My Name is Doctor Bottleneck
Written for a now defunct medical website in 2020
Hello, my name is Doctor Bottleneck. My role is the opposite of a company CEO or a small business owner, even though I am clinically responsible for the care of my patients and the financial impact thereof.
In the business world, CEOs set policy and delegate tasks and responsibilities. They watch the big picture and get into the nitty gritty only if there seems to be a problem or a need for change because of new opportunities.
My role is to literally touch everything that happens to my patients, even if I’m not the doctor ordering a test or responsible for what to do with the result.
This, on paper (for those who still find that analogy relevant), sounds like a good idea: One medical professional maintaining an overview of each patient’s care. Theoretically that would seem to lead to better, more cost effective care.
Each primary care doctor is directly generating perhaps a million dollars in direct practice revenue. (This is only a guess, because I don’t know my own numbers or even an official average.) Then, with the new ways of counting actual cost per patient compared with a theoretical assumed baseline cost, we are more or less held responsible for the financial impact of clinical decisions made by other doctors far beyond our control. So, if we each have 1,500 patients with average annual health spending of $8,000, we could have something to do with $12,000,000 worth of healthcare decisions every year.
But there are two problems with this:
FIRST, doctors see patients all day long and generally have absolutely no time set aside in their schedules to read our own incoming test results or incoming specialist reports, answer questions or even refill prescriptions - all those things are done outside our patient schedules during uncompensated overtime.
What makes these duties even more cumbersome is that our current EMR “workflows” require that absolutely everything that goes into each patient record is electronically signed off by the primary care physician. And given the current level of sophistication of our software, scrolling through a seven page discharge summary or consultation note that may contain medication changes or followup suggestions takes multiples of the time it used to take to do the same thing on paper. In addition, papers were often sorted by support staff and prioritized. In electronic records, the provider is the first and only person who sees anything that comes in. It is then up to us, again in spite of the clumsiness of our software and the lack of time for doing this work, to delegate followup actions to our support staff.
SECOND, doctors know almost nothing about the financial impact of everyday clinical decisions.
We are starting to be held responsible for the total cost of our patients’ care with little or no knowledge of what the real cost is of tests and procedures at the hospitals and specialist offices around us. This is a whole new area for us and I see little progress in spreading this kind of information to primary care providers. If anything, I see this as an emerging area of confusion and resentment between medical administrators and clinicians.
So, even though the world seems to need doctors to maintain a fairly detailed overview of the clinical and financial aspects of our patients’ total healthcare, the world severely underestimates how much time that takes - or should take, if we are going to do it right.
I think it’s high time we have a serious discussion about the best use of a doctor’s time. How many hours per week does it take to manage our patients’ healthcare and how much is that worth? How much time are we wasting right now on perfunctory electronic signatures? To what extent are we allowing workflows that feed the computer but suck the life blood and enthusiasm out of the medical providers who feed it what it wants without getting back from it what they need?
And I don’t like he name Doctor Bottleneck. I want to be Doctor Real.
My mom worked for our family osteopathic doctor, Dr. Lee, who later did whatever it took to change to an MD. That’s beside the point but what I loved was that no matter what you came in for, he did a mild adjustment that felt so good and set the scene for an enjoyable visit whatever the visit was for. He was my GP through childhood, set my broken ankle when I was pregnant and delivered my son. He was my doctor until I left the area. I had it in my mind that he was so excellent because he was Chinese and also mixed in what was probably Chinese medicine, so when I moved, I specifically sought out a Chinese doctor, and since I’d had a functional heart murmur all my life, found one whose sub specialty was cardiology. Oh my goodness, he was young and as modern as Dr. Lee had been traditional, but again he was an excellent, excellent doctor and again, he stayed my doctor until I moved out of state.
So anyway, that was in the 50s, 60s, 70s and 80s. Boy did I digress. Just reminiscing all that personal care with doctors who knew me and cared for me so well, when they had private practices and before technology turned patients into commodities to be seen and done with in 15 minutes.
What I started out to write was that my mom, a country western singer before marrying, ,had had one year of business college demanded by her father, and so when she quit the music industry (she was small potatoes but successful in her small way), she went to work for Dr. Lee as a front office ‘nurse.’ That is, she handled setting appointments, and doing all the paperwork that comes in a doctor’s office. Later on, Dr. Lee trained her to be a back office nurse, to take BP and give shots (she gave THE best shots…she said the secret was to push the stuff (sorry I forget the technical term) in the needle, slowly into the muscle, not hard and fast. I wish whoever trained the young man at Walgreens where i got my last Covid shot had trained him as well. I have never been bruised by a shot until that one. Blood all over the bandaid and a bruise as big as a fist that after 6 weeks is finally fading. I documented my bruise weekly and plan to send the pics to the pharmacist there, telling him to never let that kid give shots again.
My mom was then able to work where most needed on any given day depending on who else was working in the office. Dr. Lee got to doctor his patients. He also made house calls.
Anyway, the thing is, and think you often refer to it, back in the day, someone else did the job of all the paperwork and administrative work that doctors are now expected to do with EMR’s. I’ve read that AI might help take over this task to allow doctors to doctor again. I sure hope so.