Is your doctor in? A Big Life-lesson

I am a family physician in the middle of Missouri.  For over 10 years now, I have been exclusively committed to a practice in long term care and hospice.  Essentially, that commitment has turned out one Big Life-lesson Being on call the entire decade (Yes:  24/7). Why does it need to be that way, you might ask? It comes down to our premise question, it seems:  Is your doctor in?

This Big Life-lesson involves the relative inaccessibility of medical providers in our society. The system in which we work has some very serious shortcomings... some systemic weaknesses which hamper our providers/doctors the ability to provide excellent care…  (what we as Advanced Senior Care (ASC) now call;  Just Better Care)

This Big Life-lesson is a continuation of my experiences from multiple healthcare settings where I’ve practiced in my career: Emergency rooms, urgent care, outpatient medicine, hospital medicine, and now again this past decade as an exclusive provider for long term care and hospice.

In our practice today, it is surprising how often the system must call on me or my ASC colleagues for help because there is no way for a patient to have his/her needs met by the medical provider who knows him/her best.  They are just not Available.

Here's the problem:  Like most business/offices, medical practices are typically open in a traditional 8 to 5 / Monday through Friday schedule.  BUT, health care - particularly long-term care and hospice  -  (undeniably, a 24/7 enterprise) "office hours" only cover our patients for about 40 hours out of a 168 hour week... that’s only 24% of the time!  As anyone in this industry will tell you... it is exceedingly unlikely that all emergencies, decompensations, infections, falls, or a multitude of other misadventures... will occur during the 40-hour clinic/practice model work week.  Thus, according to my arithmetic, our sick or terminal elderly patients have a 24% chance, at best, of having their issue addressed by their primary care provider (or an informed designee/colleague) in a timely fashion (i.e. within the same business day). 

But let's face it… most practices do not have:

A:  The Horsepower (resources) ... or B:  Boots on the ground (practice Heart/vision/management)...  to be available the other 76% of the time our patients need us.   Why is that?  Here are some basics to consider and account for:

  • Vacation, medical staff meetings, widely recognized holidays, and sick time/ETO.
  • Most Primary care providers don't actually see patients for 5 full days per week – (Why? There are administrative, educational, and other sundry duties that compete with patients for time with their care provider.)
  • Many doctors, NPs and PAs split time between different clinics or locations... or they spend some of that time rounding on hospital patients, overseeing county health departments, etc.
    • In fact, a growing number of practitioners are working less than full time.
  • Unfortunately, ALL offices will indubitably suffer from inefficiencies and delays in communication (faxes, voice messages, etc.)
    • Many offices simply cannot keep up with the volume of information flying back and forth (via phone, fax, email) about patient issues.  (As my associates at ASC have heard me say many times... it is exactly like drinking from the fire hose!)
    • To keep up with the needs of long term care or hospice patients, an office really requires extra resources and staff - dedicated to the tasks of communication, documentation and information handling.
  • The effect of changes in healthcare policy, reimbursement and legislation (regardless of the intention or the originating source i.e. political party), will always cause the following chain reaction:
    • 1.  Regulatory changes in healthcare simply increase the cost of doing business.
    • 2.  Will create more administrative burden for our healthcare providers and organizations.
    • 3.  Cause the organization to slow down and even re-think and possibly re-staff to meet these new needs… once again challenging the commitment of being available and providing overall better care.

The net result and hard cold fact is:  If you are in one of these settings as a patient or as the care giving family member or patient advocate…  your patient/family member/client runs the very real risk of not having their medical needs addressed when they need it (whether that be antibiotics for an infection, orders for blood tests or x-rays, or new medications to treat pain, shortness of breath, seizure activity, or a simple itchy rash)!

At ASC, we have worked very hard and gone "back to the drawing board" many times to engineer a system with the infrastructure to handle the 24/7 needs of our patients.  Granted, it is not without cost and headaches, and not without glitches... as we are only human.  We recognize the Herculean nature of our task...  the size of the proverbial bite we took when we committed ourselves to this patient population.  (After all, it is often said that nursing home care is every bit as highly regulated as the nuclear power industry - though I cannot name a study that has vetted this claim). By focusing on this patient population, and by committing to a mobile practice model, we have afforded ourselves the flexibility to chip away at the obstacles created by our encumbered healthcare system.

We can now dedicate more personnel and resources than ever before to these complex and fragile patients.  We are blessed by a team of highly skilled, experienced, and compassionate professionals who share a heart for our patient population and our business model of providing Just Better Care.  We’ve combined versatile mobile technology (secure electronic medical records, e-prescribing, LTE-equipped devices, etc.) with old fashioned bedside care.  Each day we renew our commitment to our patients and the communities we serve as well.

So, the Big Life-lesson over the past decade of dedicated care to this patient population is:  That I (and now we at ASC) are quite often part of the safety net - the net which is suspended beneath our long-term care or hospice patients - designed to help prevent them from falling through the cracks, … 7 days a week (not just 40 business hours).  We have in fact, decided that this IS part of our calling, our practice, our business model and we are available 24/7 for Just Better Care for our patients, their care givers, and patient advocates.  Plus, we will continue to find ways around the obstacles that our imperfect healthcare delivery system creates.



That is to say… whether we are involved as primary care physician, or in the context as medical director, we try very hard to own every problem presented to us.   Because we have made ourselves available 24/7, by multiple modes of communication (phone, text, telemedicine, email... even fax if signature is urgent), we can address things such as urgently needed documents/signatures … orders, urgent notifications, or medications for patients in pain crisis, or at end-of-life… we strive to be able to say:    “@ ASC… Your doctor IS IN.”