Yesterday I had a brief shadowing experience… and I’ve been thinking to myself ever since… if I have to do anything like this ever again (in that environment, with those kind of patients/problems) I will absolutely DIE!
I’m wondering, for those who’ve done a wide variety of shadowing and have been in both office and hospital settings… are they all the same? surely they can’t be… I don’t know that I see myself in an office situation… I haven’t really envisioned that… and my hospital experiences start next week… so I can’t speak to that yet…
I can’t imagine that they are the same… I guess I’m just looking for reinforcement at this point.
Thanks!
Andrea
What was so horrible? yeah I have shadowed a lot and volunteered in the hospital. I do not know what you are trying to say…difficult patients?
I’m trying to be vague…
The highlights would be…
randomness in patients
expectations of patients for you to do illegal or unethical things
dealing with serious patient personal issues (that IMO should involve authorities of some kind)
MOUNDS and MOUNDS and MOUNDS of paperwork (FAR more than I expected - which was a lot)
hours spent on the phone/at computer writing prescriptions for everything from valium to acne soap.
if this is what everyone is dealing with everywhere, it’s no wonder drs are leaving the medical field in droves.
I even went so far as to ask the person I was working with… have you ever felt that the bureaucracy kept you from adequately taking care of a patient… and when the person said yes… I was floored… that it would be THAT bad as to keep me from doing my job…
I’m stunned… I really am…
anyway… looking for another perspective.
Of course this is the norm of today and that is why adcoms want us to shadow/volunteer in clinical settings so we do get a realistic view of what medicine will entail…sorry you had to find out this way.
While I can’t speak from experience yet (I’m working on setting up several shadowing experiences), I can say this: Don’t judge anything based on just one experience. There are a wide array of different specialties that are clinic-based rather than hospital-based, each of which would give you an equally wide array of experiences. Every practice will be different, some subtly so, some wildly so. Some differences are based on clinic administration, including those based on advice from legal counsel. Some are based the vagaries of the individual doctors. Some are based on the specialty itself. Some are based on the geographic location of the clinic and the patients who use its services. Go in to each shadowing experience aware of certain realities of life in America today: any practicing doctor who has any relationship with insurance companies or the government is going to be swamped with paperwork, red tape, and regulations, far more than is necessary and far more than is good for the doctor, the health of the patient, and healthcare in America in general. It sounds like you went in to your first shadowing experience expecting Dr. Kildare or Marcus Welby, MD (am I showing my age, or what?) and wound up with a cold dose of reality. Administration conflicts and paperwork and red tape frustrations will be just as bad (if not more so) in a hospital setting. As far as your seeming disappointment (if not disgust) with less than stellar patients, as a doctor, you have to meet a patient where he is. You tread a fine line between being non-judgemental and counseling patients to make changes in their lifestyles. Life is messy. And a doctor who can’t deal with the mess, who perhaps even disdains his patients, should perhaps be in research or some other area with no patient contact.
so, why again does it have to be like this?
I agree that it has a lot to do with the physician… I never understood how medicine could have anything to do with making a quick buck…
but I don’t understand how you could compromise your ethics (or at least my ethics) by not doing your patient justice by shoving them out the door…
and if it is like this everywhere… for every specialty and in every situation (both office and hospital)… how did it get this way?
Now, I can honestly say that the area that I was working with yesterday probably isn’t the best fit for me… and since I had no idea I would even be shadowing when I went in there… I didn’t have any expectations… I was mainly expecting to just talk with the physician… and while I can say that I’m grateful for the opportunity (on multiple fronts)… WOW!
If you have a patient that wants a script for codeine or some other controlled substance, shouldn’t you see them in the office? Or what if they want to change the prescription they have… shouldn’t you see them in the office? What if they present to you with multiple problems (which is bound to happen)… everything from general issues to depression or family problems, or multiple musculoskeletal issues… wouldn’t it be best to help them deal with all of those things by referring them? So isn’t it doing a HUGE disservice to that patient by not addressing the problem?
I am… 100% behind “holistic” care… and when I say holistic, I mean taking care of the whole person… not necessarily homeopathic or natural medicine (which can also be good)… but if you’re going to say that you do that… shouldn’t you do it… despite insurance companies and red tape?
I think if I found out anything yesterday, it was that all of my suspicions and nasty thoughts about what goes on “behind closed doors” is true… I can’t ever say I’ve been a huge optimist about what really happens… it’s never been romanticized in me… I’m just hoping that it’s not like that everywhere… that maybe… maybe… I can have a little optimism… because if I have to be reduced to that… doing a disservice to my patients in the name of the almighty dollar… then I can’t do it… I really can’t.
sounds like you were in the office of an overworked, burnt-out primary care physician who is tired of hassling with insurance companies. I’m not excusing it, just observing.
I can’t answer your questions but I can speculate. Why would you prescribe codeine over the phone? Maybe you know the patient and you’re pretty confident the request is on the level because you’ve worked with them on similar issues in the past. OR maybe you know the patient and you are pretty sure the request is NOT particularly on the level but you’ve tried and tried to deal with it, gotten nowhere, and don’t feel like confronting the patient yet again. (I have a relative who is addicted to prescription narcotics and I know first-hand how draining it can be to work with someone like this.) No, it isn’t right, but it’s human.
The agenda behind everything you observed is time. Most primary care docs I’ve spoken with readily concede that they do not give patients the kind of time they’d like to, or that they think patients need. They are being driven by shrinking reimbursement and increasing overhead… in many offices now, appointments are scheduled for just ten, not even fifteen, minutes. There is usually a practice manager advising the physicians of how they’re doing on “billable hours” so they know if they are breaking even or (hopefully) making some money.
No, it isn’t all about making money. But I didn’t go into this to give away my time and expertise, either. I have a friend who’s an internist and for the first year she was in solo practice, she didn’t give herself a paycheck - at one point she said, with some desperation in her voice, "It’s like I’m the welfare agency for my employees!"
As I’ve spent more time with more different primary care physicians, one thing I’ve observed is that often they aren’t getting reimbursed as well as they should be, because the coding and billing procedures are so arcane that many docs just throw up their hands and don’t try to “get” all of it. They’re their own worst enemies - they are shortchanging themselves by not knowing coding better, but they understandably ask, “When am I supposed to find out about that?” A good office manager can help guide a practice out of the red ink, but a good office manager is REAL hard to find and usually harder to afford!
“Time is money.” If what you want is to sit down and talk to a doctor, you need to ask to see him/her outside of office hours, because s/he is just not going to be able to sit still and talk when there are patients to be seen. Offer to bring in lunch, or breakfast to have before office hours start for the day. Maybe if you get a chance to have this sort of a conversation, you’ll get a little bit different perspective on what you’re seeing in patient encounters.
I know I probably sound like I am defending the status quo, and I don’t mean to be. I don’t want to end up talking to patients with one hand on the doorknob, either. But I am prepared to say things like, “Your appointment today is for us to devote full attention to your diabetes. If you’ve got concerns about anxiety, we’re going to need to set up a different time to do that so that I can give you enough time to really talk about it.” And I will know that I will mean all of the following: 1, I have other patients waiting; I don’t have time to add another problem onto your visit. 2, If you schedule a separate appointment I will be able to collect a second co-pay and bill for a separate visit, and will therefore get a higher level of reimbursement. 3, most importantly, I really DO need to devote adequate time to one issue in order to provide you with good care. All of these things are on the mind of your ordinary overworked primary care physician.
Quote:
I’m trying to be vague…
The highlights would be…
randomness in patients
expectations of patients for you to do illegal or unethical things
dealing with serious patient personal issues (that IMO should involve authorities of some kind)
MOUNDS and MOUNDS and MOUNDS of paperwork (FAR more than I expected - which was a lot)
hours spent on the phone/at computer writing prescriptions for everything from valium to acne soap.
if this is what everyone is dealing with everywhere, it’s no wonder drs are leaving the medical field in droves.
I even went so far as to ask the person I was working with… have you ever felt that the bureaucracy kept you from adequately taking care of a patient… and when the person said yes… I was floored… that it would be THAT bad as to keep me from doing my job…
I’m stunned… I really am…
anyway… looking for another perspective.
Hi there,
I am concerned as to what were your expectations in a shadowing experience? Medicine does involve paperwork and it does have to be a money-making profession. I would love to be able to treat people for free but that will not pay my malpractice and office expenses. Gone are the days of Marcus Welby and Joe Gannon.
Are all of my days wonderful? No but overall, I enjoy what I am able to do. The paperwork is off the scale but it is very much a part of the job. If you don’t handle it, you don’t get paid. If you don’t get paid, you don’t practice for very long. Am I going to quit surgery because of paperwork? Not in this lifetime.
There is a very large amount of uncertaintly in the profession. It requires a very long training period with little guarantees on the other side. One of the challenges of primary care is that you have to be able to manage what comes in through your door. I guess that is why I chose to become a specialist. A good primary doc is worth their weight in platinum but it is very difficult to do primary care well. The best folks work very hard and very long hours to do their best for their patients. Often, it isn’t possible to handle everything that a patient presents with.
Better to find out on this side as opposed to later after you have invested a couple of hundred thousand in medical school.
Natalie
Mary, could you define “coding” as in “coding procedures” for the class? I do not know this term.
adennis, you really struck a chord with me, I remember about a year ago, my own doctor left his door cracked while he was on the phone trying to wheedle some reimbursement or another out of an insurance company. I felt so bad for him, and a little guilty that I had complained in the past about not being seen on time, etc., knowing how he was driving himself to fit in as many patients (i.e. billable procedures) in a day, just to make a living.
Matt
Quote:
Mary, could you define “coding” as in “coding procedures” for the class? I do not know this term.
Mary, correct me if I’m wrong. This is what I know of “coding procedures” (from 12 years of public accounting for a large # of medical practices): It is the standardized method by which doctors are reimbursed by insurance companies and Medicare. Each type of office visit (new, return, etc) and each procedure (PAP, shots, etc) is assigned a specific code. These codes are standardized in that they are the same no matter which practice you’re talking about or even which state they’re in. This ensures that the insurance co or Medicare reimburses the doctor for the correct amount of money. This assumes that everything is coded correctly in the doctor’s office. It’s tons of paperwork. And while I’m not certain whether the one who does the coding has to be certified or not, because it is so volumous and “arcane” as Mary put it that doctor would in all likelihood require that employee be trained in it resulting in a larger payroll since the doctor would probably pay higher wages for the employees skills. It is another layer of red tape that serves to put a financial and emotional drain on the physician
Lisa, that’s right. But the doctor can’t just delegate knowledge of how to code an office visit to someone else, even if that someone is specially trained. The doctor also needs to know how to chart a visit to make sure that the notations in the chart match the code circled for the visit (for example, a brief visit vs. an extended visit vs. a complicated visit - each of these carries a different reimbursement and requires a different level of detail in the accompanying doctor’s note).
Next time you go to the doctor, you’ll notice that at the conclusion of the visit, s/he will circle one or several things on a sheet - these are the codes. If I saw my mom (not that I would do that) for a blood pressure check, I would still have to consider everything else that is going on with her and so I’d circle as diagnoses: hypertension, hyperlipidemia (high cholesterol), and the appropriate codes for lymphoma, skin breakdown secondary to radiation treatment, etc. etc. etc. In other words, even if she just came in to get a BP med refill there’d be a LOT to at least quickly ask about; my note would need to reflect that; I’d charge for a complicated visit because all these things would need to be taken into consideration.
Each office has a code sheet that’s customized for that practice - in primary care I’ll have all the major bread and butter diagnoses like hypertension and diabetes; Natalie’s code sheet would include lots of office procedures and diagnoses related to surgery (e.g. inguinal hernia); a gastroenterologist’s office would have a lot of diagnoses specific to stomach, liver, intestines etc. But the codes are universal and they rule the life of every physician in the United States who hopes to be reimbursed for her or his work.
Oh, and if this doesn’t sound stressful enough for you yet, insurers can and do argue with the physician about coding. And if you’re a Medicare provider, you could be charged with fraud if they think you’re trying to bilk them with dishonest coding. Even if you’re making a mistake as opposed to trying to commit fraud. While arguing with private insurers means you don’t get paid, you can go to JAIL for defrauding Medicare. Honest upstanding physicians worry about it.
Mary
…accurate coding is not only important for insurance companies, but also for public health. Public health professionals rely on all sorts of data (number and type of office visits, hospital discharges/ ambulatory care/ cancer registry data/ etc…). These data are indirectly or directly used for various purposes. Here are some examples:
-in epidemiologic studies to study disease trends
-to provide support for and/or argue against a govt. policy
-to provide a baseline for the treatable pool in the pharma industry
-to provide an onus for further research, especially if data shows a tremendous unmet need
-in calculating national trends for diseases and/or procedures
Although there are biases and limitations associated with using coded data, public health professionals do rely on them because it’s the best we have! Medical professionals have many responsibilities and coding correctly is something that should be taken seriously because its uses do have considerable public health implications.
Hey Andrea,
What kind of doctor was this (MD, ND, DO)? I shadowed a primary care MD and while I loved parts of what she did, I knew I needed to specialize. I also saw some of the same issues you described, but what really struck me was the work level. Five to six patients per hour running 2 sometimes 3 rooms by herself at one time. She doen’t eat breakfast or lunch!! I am prepared to work hard, but at a sustainable level, for Pete’s sake!
That with a different Pharm rep in the office every hour. Plus calling patients back that call with issues. Then there is the pharmacy that can’t seem to get anything right and look at that memo we just received from (insert HMO here), “I am getting a pay cut” she says and hands me the list of what she was getting paid compared to the new list effective next month.
Docs either take the pay cut or don’t take the insurance and subsequently lose the patients. It’s like being strong armed by the mafia. Ahh… the things we do for love…because it won’t be for the money.
DRD
I’ve encountered some of the same things in shadowing. It can be discouraging, but I highly recommend shadowing a few more places, to get a better perspective. The paperwork hassle issues are universal, but the ways of dealing with them, and the attitude of the physicians varies. I think it is critical to know what you are getting into.
I did a “Pre-clinical ER elective” we have, which is essentially nothing more than shadowing a few times over the course of the semester, and each experience was very different. On one evening I was with a resident who clearly loved his job, was happy to teach me, and was wonderful with the patients. On another occasion, the resident was clearly unhappy, told me not to go into emergency medicine, and was dreadful to the patients. Talking to him, I came to believe that the reason for his unhappiness was that he had not really known what he was getting himself into. He thought emergency medicine would be all emergencies, while the reality of it today is that it is a lot of primary care for those who don’t have a physician, a lot of time on the phone with other physicians, a lot of referring. A lot of social and psychiatric issues as well. I don’t think he was prepared for that.
So, two points. One, shadow at more than one place, or with more than one doctor. Two, know the realities of what you’re getting into. I don’t know if I’ll go into emergency medicine or not (heck, thats what third year is for) but I think I have a somewhat realistic idea of what I’d be getting myself into, the good and the bad.
One other thing. There are doctors who are escaping the billing/coding, etc mess. I know of a doctor (either FP or IM) in the area who does not take any insurance. She provides a bill to her clients, and they have to file themselves. The patients are responsible for knowing what their insurance will cover. She lets them know up front of course. She works part time and handles the paperwork, which is greatly reduced, herself. I’ve heard of other physicians doing this as well. I don’t think it’s something I’d be completely comfortable with, but the point is there ARE options. If she can make it work in a community with two medical schools and all the docs associated with them, I would imagine it could work elsewhere.
Epidoc