I arrived at the office to find my staff cheerily smiling and expressing excitement about the day ahead. As I perused my schedule, it was moderately full but there was some space left over for addition of patients who called with acute problems that would need to be seen. As I looked more closely at the schedule, I could see that my staff had done a great job of mixing/alternating more difficult/complex encounters with healthy/wellness visits in order to allow me the ability to catch up time lost on those visits that might run longer because of the complexity or additional problems elicited from that patient. Furthermore, all the patients for the day were documented as having been contacted to confirm their office visit. I was also excited about the fact that all of my usual staff (the “A-Team”) were working today as there had been no call-offs due to personal illness, illness of a child, car breakdown, or PTO. My A-Team knows our patients best and how to keep my day moving so that I can stay on time as well as where best to fit in particular individual patients calling with acute problems.
I began my day with Mr. Smith, a hypertensive with whom I have been struggling to get his blood pressures to the goal of < 130/80 on multiple medications. As I entered the exam room and greeted him, he was smiling and had brought in his twice daily home blood pressure readings as I had requested. I asked him if he was having any problems with side effects from the new medication as I tapped my ID Card on the card reader and, to my surprise, was immediately logged into the EMR without delay. Mr. Smith told me he was doing well with the new medication and the blood pressures he brought in were perfect. Additionally, as I reviewed his readings, he relayed to me how he had begun dieting and exercising as we discussed on his last visit and had lost 5 pounds.
My next patient was Mrs. Thomas, a diabetic with poor sugar control that was largely diet-related as well as unwillingness to monitor blood sugars. I had entered the room expecting our usual battle about seeing the dietician and modifying her eating and increasing her activity. As I tapped my ID Card and was, once again, immediately logged into her record, she removed her log of blood sugars from her purse (to my surprise) and began to tell me how she had seen the dietician and joined a gym and her weight was down 10 pounds and blood sugars were much better. She was enjoying her daily exercise and was thankful for my persistence on getting her to see the dietician.
Mrs. Phillips, my next patient, was in for her yearly wellness visit. Despite the fact that my agenda was always full with discussing health maintenance items with her because she refused all attempts at immunizations and cancer screenings, she always came to these wellness visits with a long list of musculoskeletal complaints and questions generated by television commercials she had seen. To my surprise, she had no items on her agenda and after discussion, agreed to a Pneumovax. Furthering my disbelief was the fact that by the time the visit was over, she was allowing me to schedule her for a mammogram and colonoscopy.
The rest of my morning proceeded in the same fashion. Patients with difficult to manage diseases were showing meaningful improvement and patients themselves were taking responsibility for their illnesses and making lifestyle changes that I had previously been unable to convince them to make. I had several successful smoking cessations and multiple patients had begun a diet and exercise program. Before I left each exam room that morning, my office visit note was completed and I was on-time, in large part due to the fact that the EMR was running smoothly without the typical delays and glitches with which I had become accustomed. My staff, too, were having a good day as the telephones were not swamped with calls from patients, pharmacies requesting prior authorizations, and nursing homes reporting problems. We completed the morning session on time and were able to enjoy a leisurely lunch and start our afternoon session on time.
My first patient of the afternoon was Mr. Wright, who had recently been discharged from an outside hospital after a complicated and lengthy hospital stay. I was concerned about having to request and review hundreds of pages of medical records from this outside hospital, but was surprised to find that after I logged into the EMR, we had a Health Information Exchange with the outside hospital and I was able to review his surprisingly complete and concise hospital stay records. He was recovering nicely and all of his post-discharge medications were accurate and in order.
My second patient was a woman who had called the office with 2 days of nasal congestion, concerned about a possible sinus infection requesting antibiotics and was worked in to be seen. I entered the room fearing the difficult discussion about responsible use of antibiotics and the inevitable patient dissatisfaction that ensues. To my surprise, after evaluation and discussion with her that this was simply a cold and conservative therapy was recommended without antibiotics, she expressed gratitude for my insight and stated she was “relieved” to know that this was not something more serious and even though she was leaving my office without any prescriptions, she was thankful for having been worked into my schedule for the day.
The rest of my afternoon session went similarly well. I saw several patients in follow-up from referrals to see a specialist and was delighted to see that the consulting physician’s notes were complete and in the chart without need for me to have staff contact their office requesting they fax them over. I did have one patient with a rash that I was concerned may represent a vasculitis and was going to require prompt evaluation and biopsy by Dermatology, who typically have a several month wait to get into their office. However, when I had my nurse contact the Dermatologist’s office, we were told to send the patient right over to their office and they would see them now. Another patient was suffering from persistent sciatica despite my attempts at conservative therapy and I felt that we needed to proceed with MRI but his insurance was one that often required a lengthy approval process, costing me and my staff extra hours of work and prolonging the patient’s suffering. However, after entering the order and symptoms/diagnoses, I was given an automatic approval number immediately and scheduled his MRI for the next morning as, to my surprise, there was not the usual 2 week delay to schedule this test.
As I was in with my last patient, I was reflecting on how well my day had gone. My schedule had been well planned and organized, patients arrived early and were able to be roomed on-time to be seen and they had all of my requested items including blood pressure readings, blood sugar readings, and medication bottles to confirm what they were taking. To my delight, they were all taking their medications as prescribed. Additionally, they had all taken active efforts on their own to improve their health through diet, exercise and lifestyle changes. They seemed genuinely grateful for their care and my day was without all of the usual frustrations including interruptions for telephone calls, missing documents, delays in care secondary to managed care requirements, and frustrations caused by a usually slow EMR with frequent glitches including sudden shut-downs resulting in loss of painstakingly entered patient data. Furthermore, my staff was all present and likewise having a wonderful day and were actually enjoying their day at work.
As I listened to my last patient telling me how thankful she was that I assumed her and her husband’s care since they moved to town, as they were impressed with both my level of knowledge, thoroughness, and bedside manner, I became aware of a strange noise coming from outside the exam room door. The noise continued to get louder, making it difficult to hear what my patient was saying. It sounded like someone crying? Then it morphed into what sounded like a dog barking. Despite how loud this was and the fact that I was unable to hear what my patient was telling me, she continued to talk. Suddenly, I sat up in bed, became aware that I was home and that the new puppy my wife had gotten just (6 days ago) was barking because she needed to be taken outside to go to the bathroom.
As I lay back down to go back to sleep, I thought about my day ahead and the likelihood that it would mirror the day I just “experienced.” It seemed so real…with the exception of a well-planned and efficient schedule, patients taking responsibility for their own health and well-being, lack of interruptions, timely access to testing and specialist care without managed care interference, happy staff, and especially a smoothly running EMR without glitches…okay, also the part where the patient told me how knowledgeable, thorough and pleasant I am. But one can dream, can’t they?