Curbside Consult with Dr. Jayne 3/21/11

It’s officially spring and there was a full moon over the weekend to boot. I’m not sure what I was thinking when I decided to work this one.

One of the downsides of being a CMIO type is that I’ve had to give up any semblance of a “normal” practice. Most of what I do these days is emergency department coverage or urgent care. One of the things I enjoy doing, though, is Locum Tenens work. If you haven’t heard of that, basically it means that you’re for hire to anyone who’s willing to meet your terms. Sometimes Locum work is fun, because you can take an assignment at an exotic location or practice in a way you normally don’t, like with the Indian Health Service or the military.

In my case, though, I usually Locum in my own metropolitan area. Folks like to hire me because I’m proficient in several EHR systems and can hit the ground running. (Thank you, moonlighting shifts during residency! Thank you, best of breed strategy!) In addition to the variety, this lets me see under the hood of other systems and experience for myself how other practices are using technology to perform patient care.

You might think it would be a competitive intelligence issue — that practices would be reluctant to use someone like me because I might steal their secrets. Frankly, they’re just happy to get someone who can jump right in and they don’t have to pay extra hours for training time. Most of the time it’s fun, but sometimes it’s very humbling.

Musings of a Mercenary Doctor

Training and staff proficiency makes a huge difference. There’s one group where I cover acute/sick visits. The physician shift splits two nursing shifts, so each physician works with two different nurses. I only work there once a quarter and it’s a large group with multiple locations, so I haven’t met everyone.

Recently I had the Jekyll and Hyde day. My morning nurse was spectacular – every patient history was nearly 100% complete, all medications were reconciled, and needed labs and diagnostic studies were pre-ordered based on standing orders. We rocked through 38 patients, too good to be true.

Remember that scene in Titanic where the crew in the crow’s nest shouts, “Iceberg! Dead ahead!”? Well, someone should have shouted that during shift change.

I spent the next couple of hours absolutely treading water and gasping for air. The semi-retired nurse who was staffing me apparently thought free-texting everything was a good idea, effectively sabotaging any smartness of the EHR workflow to select the right documentation forms or to share information between today’s symptoms and the patient’s previous notes.

Instead of reconciling medications she just entered new medications, creating duplicates. No tests were pre-ordered, making for a backup in radiology after I sent three patients simultaneously just to get the exam rooms clear for new patients. Although the volume had slowed significantly, it felt like we couldn’t get ahead. I kept focusing on the fact that at least I got to get in my lifeboat and go home at the end of the day.

Shirley is super-nice and does phone triage better than anyone I’ve worked with in a long time. She knows exactly how to counsel patients and is excellent with procedures. By late afternoon, the other physicians were gone except the two of us doing evening coverage.

According to my colleague, because she’s well-liked and is close to retirement, no one has the heart to either tell her that her misuse of the EHR is sabotaging the docs or that she needs retraining. Although they grouse about her at every provider meeting, they’ve decided they’re OK with it because they don’t want to hurt her feelings or rock the boat. The younger nurses don’t want to work nights and weekends and they can’t afford to lose her.

One of the great things about being a mercenary is not having to deal with office politics and being able to push the limits a bit. I decided to ask her how she thought the shift was going. She admitted being aggravated because she’s “not good with computers” and said she’d been frustrated since their go-live last year. I decided to dig a little deeper and see what I could do to help.

Turns out she’s semi-retired and works evenings and weekends because she helps care for her grandchild during the week. It also turns out that the practice did all the staff training last year during the morning, while many physicians were on hospital rounds, so they wouldn’t have to cancel patients. She never had formal training on the system. They asked one of the 21 year-old medical assistants to let her “shadow” and “learn the system” one afternoon.

Are you kidding me? I can only imagine what that was like for Shirley, trying to catch up after the fact and trying to learn from someone a third her age who was also learning the system.

I asked her if I could show her a couple of small things that might make her life (and selfishly, mine) easier. In just a couple of minutes between patients, I taught her how to reconcile medications and worked with her 1:1 on the next few patients. By the end of the shift, I had fantastic med lists and she felt like she had accomplished something. We spent a few minutes talking about how the logic of the system works and what happens downstream when you free-text. She honestly had no idea the havoc she was causing.

I cornered the other physician when we hit a lull. He was surprised. He had no idea Shirley hadn’t been trained. The docs had abdicated any responsibility during the EHR implementation, leaving it up to the office manager. He didn’t know about her work situation or what was behind it. I could tell he felt bad for complaining about Shirley rather than figuring out a solution. I told him what I showed her and what Shirley was now able to do.

In short, I spent about thirty minutes training/mentoring her rather than doing her job for the rest of the shift. I was happy, she was happy, and you can bet the next physician she staffs will be happy. As I finished my notes and the last few patients were trickling out, the other doc was showing her how to access his medication favorites list so she could use it to enter medications on new patients.

I hope he’s able to help his partners understand the situation and get her the training she needs (and deserves). I ended up seeing over 60 patients that shift, but the most important “care” I delivered didn’t have an ICD-9 code attached to it. Even on hectic days with systems that don’t always work the way we want, remember to look out for each other.

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