I dread Mondays. It's not just because we can't sleep in until our balmy weekend 7am then hang in our p.j.s until noon. It's not just because the family and I have been lulled into a lovely and civilized little pancake-brunch filled existence. It's not because when the alarm goes off Monday at 6am my husband start swearing.
No, he doesn't start swearing. I do. He stumbles into the bathroom. I groan. I think about whether or not I contracted some kind of exotic illness overnight, one that will hobble me enough so that I can't work, but not so much that I can't go to Target. The kids, alerted to parents being awake and alive, begin to chirp. I groan some more, then slowly ease myself out of bed. Damn, both legs are still attached. I can stand! Damn, I can walk. Damn damn damn. So begins the chaotic roller-coaster ride of getting us all out the door.
Three pairs of pants, three pairs of socks and shoes, boots, mittens, hats, gloves, home toys, napping blankets and sleep toys, 2 iced lattes, a shower, a frantic search for my keys, another latte, Pulmicort nebs, and another latte later I'm in the car about 7:15am on the way to work. I'm biting a nail while I drive and fretting. What will await me in Primary Caresville today?
There are some certainties. There will be sick people. There will be well people: a physical or two and a pap. A well-child check or two. Maybe a presurgical evaluation to do. The phone will ring and ring and ring. I will plod through my morning, charting as I go, gulping my special brew high octane iced tea, barking orders here and there, and my schedule, always pretty open Monday afternoons, will fill up with people who were sick over the weekend, or who just realized that dagnabbit, they can't live without seeing me another second. All of that I enjoy. A lot.
The problem of Mondays, for me anyway, is the paperwork. Oh, Lawsie. It is bone-crushing. The stack of faxed crap, in fact, probably is bone-crushing once all those faxes are attached to charts. Refill requests, hospital admission/discharge paperwork, lab results, more refill requests, inscrutable notes from patients, consult letters, old charts, junk faxes, pathology reports, xray and other reports, physical therapy evaluations, order sheets from nursing homes, home health certification and recertification....It goes on and on. By Monday morning I have all of Friday night plus all day Saturday and Sunday to review, plus half of Monday (you'd be surprised how much stuff is faxed in the middle of the night). I have notes to write about calls I took over the weekend (yes, I keep track). There's mail on Saturday (at least for now) to review. There are what seem like 8000 phone messages to get through as well, which my poor nurse will present me with as soon as she's emerged from her chart igloo. Then there are my techno-savvy patients' emails to sort through...And I haven't even touched on all those new corporate/hospital directives about this and that, must go to this, sign this and return a month ago blah blah blah.
I counted once how many charts I did on a relatively slow Monday. I saw 22 patients, meaning, I got paid to see 22 patients (hopefully!). There were 6 charts sitting in my box when I arrived bright and early. Five were leftover from Friday afternoon, hitting the box after I was gone. While I got my coffee, Wonder Woman (my front office major domo) snuck into my work room and dumped 23 charts in my box. That's 29 charts before I found creamer. Through the course of the day I got another 27, plus the 22 from patient visits. That's a bare minimum of 78 patient matters in a day, but, as any physician will tell you, patients rarely have just one thing to share. Some phone messages or fax refills are easy; many are multipart, multiperson tasks.
Take something simple, like med refills. For every request I look to see how long it's been since the patient was in for an appointment. How long has it been since labs? Is the dose correct? Was the patient supposed to come back a month ago for a blood pressure recheck? I'd say probably half the time we get a refill request, something else comes up. The patient gave us the wrong dose; the patient wants something he/she got from the cardiologist, for example, and we have no record of the medication at all; patient is terribly overdue for an appointment; labs are overdue, etc. Somebody in my office starts to try to track down the patient, who inevitably doesn't answer the phone. A game of phone tag ensues...
Don't even get me started on hospital follow-ups. Friday night, while discharging an 80 year old lady from a hospital she usually doesn't go to, the hospitalist stopped the Coumadin? Didn't call me about why she might be on it which might be because she had a PE two months ago? Huh? And now said patient is at home complaining about leg swelling? That's at least three phone calls between me and my staff and the patient and the hospital.
At this point, I usually start reaching for the Tylenol.
Now, let's say I can knock off one quarter of the charts in a minute or so. They'll take at least one more minute with my nurse, then there is refiling time. So let's say, in the best possible case, 25% of my charts on a Monday take 3 minutes of processing time. 25% are only slightly more complicated, and took six minutes. 40% were more atrocious. I talked to my nurse, she made a call, left a message, got a message back, found me, we talked about it. Called the cardiologist, then called the patient, then finally called the pharmacy. Let's call that a 10 minute task. The last six charts were bears. They included forms, complicated record review, phone calls back and forth with other physicians or providers, phone calls to family, etc. (Oh, how I love talking to families. Really. But oh, how I hate watching the clock while I talk to families.)
Here's the math, only I'm warning you, I'm not good at math. Especially depressing math.
I'll subtract the 22 patient appointments from my 78 charts. That's 56 charts. 25% of those took 3 minutes:
14x3=42 minutes
Fourteen more took about six minutes:
14x6=84 minutes
About 17 took 10 minutes:
22x10=170 minutes
And lastly:
6x30=180 minutes
Total all that up? It's 476 minutes, or almost 8 hours of work for free. Completely, utterly uncompensated. You can argue that it's my job to follow up on work/labs, etc. that I generated in appointments, but nah, I don't make that much from appointments, in fact, I'm lucky to barely break even, and what I mean by that is that I rarely break even.
Now, I just paid an attorney about $1500 for 300 minutes of work. More on this in a minute.
I think one can sense that Mondays bug me. One, because I want to be at home in bed, or stretched out on my couch reading a book. Two, because it's busy. So terribly, terribly busy and I start to get neurotic about missing something I shouldn't miss, just because I have so freaking much to do. Once I finish it all at work I have to go pick up the grounchy brown bears at school and start my second shift. That makes me nervous, too. Last but not least, me and my staff are doing more work than ever for free on Mondays.
Why might primary care be doomed? Because my attorney made $1500 to talk to me on the phone a couple of times, drop me a few emails, review a really short contract. I'm not begrudging him the $5/minute he got paid. I get paid ZERO per minute of phone/email/paper pushing, in fact, I lose money because I have to pay my staff to do phone calls, afix postage, make copies, etc. Am I too "fat" (yes, personally) at the office? I have a little more than a staff of two. My office is nearly 100 years old and what it doesn't lack in charm it does lack in reliable electricity, parking, and reliable heat. My carpeting is ancient and gets cleaned periodically as cheaply as we can to within an inch of its life. I fix the toilets when they're broken. I could go on, but ah, no, I don't think my overhead is too crazy high.
I have told you why I don't like Mondays. One day sets me back 8 hours and lots of moolah. I'm not eating pancakes in my pajamas. I'm buried in a chart igloo. The silicon chip inside my head is temporarily switched to overload. (Obscure Boomtown Rats reference. Sorry. In my head resides a nerd from the 80s.)
No, he doesn't start swearing. I do. He stumbles into the bathroom. I groan. I think about whether or not I contracted some kind of exotic illness overnight, one that will hobble me enough so that I can't work, but not so much that I can't go to Target. The kids, alerted to parents being awake and alive, begin to chirp. I groan some more, then slowly ease myself out of bed. Damn, both legs are still attached. I can stand! Damn, I can walk. Damn damn damn. So begins the chaotic roller-coaster ride of getting us all out the door.
Three pairs of pants, three pairs of socks and shoes, boots, mittens, hats, gloves, home toys, napping blankets and sleep toys, 2 iced lattes, a shower, a frantic search for my keys, another latte, Pulmicort nebs, and another latte later I'm in the car about 7:15am on the way to work. I'm biting a nail while I drive and fretting. What will await me in Primary Caresville today?
There are some certainties. There will be sick people. There will be well people: a physical or two and a pap. A well-child check or two. Maybe a presurgical evaluation to do. The phone will ring and ring and ring. I will plod through my morning, charting as I go, gulping my special brew high octane iced tea, barking orders here and there, and my schedule, always pretty open Monday afternoons, will fill up with people who were sick over the weekend, or who just realized that dagnabbit, they can't live without seeing me another second. All of that I enjoy. A lot.
The problem of Mondays, for me anyway, is the paperwork. Oh, Lawsie. It is bone-crushing. The stack of faxed crap, in fact, probably is bone-crushing once all those faxes are attached to charts. Refill requests, hospital admission/discharge paperwork, lab results, more refill requests, inscrutable notes from patients, consult letters, old charts, junk faxes, pathology reports, xray and other reports, physical therapy evaluations, order sheets from nursing homes, home health certification and recertification....It goes on and on. By Monday morning I have all of Friday night plus all day Saturday and Sunday to review, plus half of Monday (you'd be surprised how much stuff is faxed in the middle of the night). I have notes to write about calls I took over the weekend (yes, I keep track). There's mail on Saturday (at least for now) to review. There are what seem like 8000 phone messages to get through as well, which my poor nurse will present me with as soon as she's emerged from her chart igloo. Then there are my techno-savvy patients' emails to sort through...And I haven't even touched on all those new corporate/hospital directives about this and that, must go to this, sign this and return a month ago blah blah blah.
I counted once how many charts I did on a relatively slow Monday. I saw 22 patients, meaning, I got paid to see 22 patients (hopefully!). There were 6 charts sitting in my box when I arrived bright and early. Five were leftover from Friday afternoon, hitting the box after I was gone. While I got my coffee, Wonder Woman (my front office major domo) snuck into my work room and dumped 23 charts in my box. That's 29 charts before I found creamer. Through the course of the day I got another 27, plus the 22 from patient visits. That's a bare minimum of 78 patient matters in a day, but, as any physician will tell you, patients rarely have just one thing to share. Some phone messages or fax refills are easy; many are multipart, multiperson tasks.
Take something simple, like med refills. For every request I look to see how long it's been since the patient was in for an appointment. How long has it been since labs? Is the dose correct? Was the patient supposed to come back a month ago for a blood pressure recheck? I'd say probably half the time we get a refill request, something else comes up. The patient gave us the wrong dose; the patient wants something he/she got from the cardiologist, for example, and we have no record of the medication at all; patient is terribly overdue for an appointment; labs are overdue, etc. Somebody in my office starts to try to track down the patient, who inevitably doesn't answer the phone. A game of phone tag ensues...
Don't even get me started on hospital follow-ups. Friday night, while discharging an 80 year old lady from a hospital she usually doesn't go to, the hospitalist stopped the Coumadin? Didn't call me about why she might be on it which might be because she had a PE two months ago? Huh? And now said patient is at home complaining about leg swelling? That's at least three phone calls between me and my staff and the patient and the hospital.
At this point, I usually start reaching for the Tylenol.
Now, let's say I can knock off one quarter of the charts in a minute or so. They'll take at least one more minute with my nurse, then there is refiling time. So let's say, in the best possible case, 25% of my charts on a Monday take 3 minutes of processing time. 25% are only slightly more complicated, and took six minutes. 40% were more atrocious. I talked to my nurse, she made a call, left a message, got a message back, found me, we talked about it. Called the cardiologist, then called the patient, then finally called the pharmacy. Let's call that a 10 minute task. The last six charts were bears. They included forms, complicated record review, phone calls back and forth with other physicians or providers, phone calls to family, etc. (Oh, how I love talking to families. Really. But oh, how I hate watching the clock while I talk to families.)
Here's the math, only I'm warning you, I'm not good at math. Especially depressing math.
I'll subtract the 22 patient appointments from my 78 charts. That's 56 charts. 25% of those took 3 minutes:
14x3=42 minutes
Fourteen more took about six minutes:
14x6=84 minutes
About 17 took 10 minutes:
22x10=170 minutes
And lastly:
6x30=180 minutes
Total all that up? It's 476 minutes, or almost 8 hours of work for free. Completely, utterly uncompensated. You can argue that it's my job to follow up on work/labs, etc. that I generated in appointments, but nah, I don't make that much from appointments, in fact, I'm lucky to barely break even, and what I mean by that is that I rarely break even.
Now, I just paid an attorney about $1500 for 300 minutes of work. More on this in a minute.
I think one can sense that Mondays bug me. One, because I want to be at home in bed, or stretched out on my couch reading a book. Two, because it's busy. So terribly, terribly busy and I start to get neurotic about missing something I shouldn't miss, just because I have so freaking much to do. Once I finish it all at work I have to go pick up the grounchy brown bears at school and start my second shift. That makes me nervous, too. Last but not least, me and my staff are doing more work than ever for free on Mondays.
Why might primary care be doomed? Because my attorney made $1500 to talk to me on the phone a couple of times, drop me a few emails, review a really short contract. I'm not begrudging him the $5/minute he got paid. I get paid ZERO per minute of phone/email/paper pushing, in fact, I lose money because I have to pay my staff to do phone calls, afix postage, make copies, etc. Am I too "fat" (yes, personally) at the office? I have a little more than a staff of two. My office is nearly 100 years old and what it doesn't lack in charm it does lack in reliable electricity, parking, and reliable heat. My carpeting is ancient and gets cleaned periodically as cheaply as we can to within an inch of its life. I fix the toilets when they're broken. I could go on, but ah, no, I don't think my overhead is too crazy high.
I have told you why I don't like Mondays. One day sets me back 8 hours and lots of moolah. I'm not eating pancakes in my pajamas. I'm buried in a chart igloo. The silicon chip inside my head is temporarily switched to overload. (Obscure Boomtown Rats reference. Sorry. In my head resides a nerd from the 80s.)
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