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Doctors And Work-Life Boundaries: Keeping An EMR In Its Place

I’ve had a longstanding policy in my office that routine prescription refills will only be addressed during regular office hours. No evenings; no weekends; if you need a refill of your long-term chronic medications, you need to call during regularly scheduled office hours, five days a week. You can leave a message if you like, but you should not expect us to call in the medication until the office is open.

The main reason for this policy has always been medical: prescription medication requires appropriate monitoring. From the moment I hung out my shingle, I’ve made it my habit always to write enough refills on your medication to last until the next time I need to see you. In all likelihood if you need a refill, what you really need is a visit.

The logical reason for the policy is the need to consult the medical record before authorizing refills. And when those records are contained on bits of dead trees on shelves in the office, there’s no way I can access them if I’m not physically there. I’ve been known to drive out to the office at decidedly odd hours for the express purpose of consulting those records so that I can provide appropriate care to my patients. That has always been the bottom line for me, and always will. Read more »

*This blog post was originally published at Musings of a Dinosaur*

Getting Sick “After Hours” Costs Billions

During a recent emergency room shift, I treated a 12 year old boy for a swimmer’s ear. During the visit, I learned he was from the South and was in the area visiting relatives before starting school in a couple weeks. It turns out he’s been battling this pain for a couple weeks and his mom is convinced it’s because of all the swimming he’s done this summer. Instead of rushing him to his own pediatrician at home, she has been “riding it out” to see if the pain resolved on it’s own.

This was true music to my ears! Most parents rush their kids to the doctor at the first sign of ear pain, even though the current recommendations are to not use antibiotics in this age group unless the pain persists or worsens past the first few days. So, if his exam were abnormal, my decision making process would be much simpler.

What wasn’t music to my ears was learning I was the second physician to see the boy that week. The grandmother took him to see her physician when she had a scheduled appointment a couple days earlier, “just for a curbside” and learned that he did in fact have “an ear infection”. No medications were given or appointment facilitated with a pediatrician or other physician. This was truly just a curbside. The family was left with no alternative but to use the ER.

The ER often ends up being our only option when visiting an area out of town, isn’t it? If staying at a hotel, many do have a cool option that provides a physician call service so a physician will come to you, as I learned a couple year’s back in Disneyland. And, some cities do have free-standing urgent-care centers that can help with these sorts of non-911 situations. But, by and large, the ER is it in most areas and for most people.

What a backwards situation! The majority of sick people have situations that do not need the ER yet find themselves having to because there are simply no other options. Think about how much time and money would have been spared for this family and the system had that first physician just seen the child as an office visit and written the same prescriptions I wrote 2 days later during the ER visit. Think about the healthcare savings to the system and personal savings to families if we had the same theoretical options to the hundreds of thousands of annual after-hours urgent care visits our system sees each year but is current seeing in the wrong setting!

In the big picture, seeing a basic sick visit after hours in the ER is like trying to crack a nut with a sledgehammer. It makes about as much sense, too. The truth is we just have no place for the after hours regular sick people, which, by the way, are the majority of people who get sick after hours, especially if their doctor is in another state!

It’s really not a shock ER wait times are so long…ERs are over loaded with patient’s just like this boy. Until we find a better system, better take along your iPod and a good book should you find yourself heading to the ER. You’ll be in very good company waiting to be seen so may as well come prepared for the wait.

*This blog post was originally published at Dr. Gwenn Is In*

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