“We’re short today. I need you two to answer the phones, see what the patients need, do your best to take care of them over the phone, and keep them out of the office, and out of the ER. If you have to call in something for them and tell them to call back in a couple of days, just do it.”

I overheard this speech (paraphrased above) one morning last winter from our temporary office manager, placed in the office by our Boston supervisors, to our practice’s two Registered Nurses, just as the clock flipped to 8:00 am and the phone lines began to light up. At first glance, this was no ordinary day. It was in the middle of the flu season, one of our provider’s was out of town, and another local doctor was out of the office with an unexpected illness. And the day was starting with all available appointment slots full. But in actuality, this was the dead of winter, nowhere near the peak season when our average daily population increases 5-fold, and not too atypical after all.

The desperate (or at least out-of-luck) patients were calling in at precisely 8 am because they had been instructed to do so the day before, the last time they called for an appointment and were told that same day slots are held until mornings and that the next scheduled appointments were at least 3 weeks away.

Two valuable clinical resources, experienced RN’s who are very good at their job, were going to spend the better part of the day apologizing and trying to keep patients from coming in to be seen in person which, under the guidelines of health insurance contracts, is the only way the practice could recoup the costs of having two RNs sitting at their desks answering phones. From a business point of view, it doesn’t take a Harvard MBA to understand that this is not sustainable, especially when the practice was already paying a significant share of net revenue for the management that had no option but to suggest this workaround.

From a medicine point of view, trying to manage urgent health issues over the phone with nurses, is sub-optimal healthcare. And, if there are no appointments available for urgent issues, there certainly are no appointments available for preventive medicine visits. No time to call patients and go over lab results from the previous week. No time to look for patients with chronic disease conditions that are not following through with their care plan. No time to tack on a little education and guidance to the end of each visit.

Join me on the hamster wheel, we’re just getting started:

…and no time to use an inefficient electronic medical record to document each of these visits in a way that maximizes reimbursement from the same health insurance companies (and government payers) that burden us with this system in the first place, which means…

…less money to provide for that manager’s and those RN’s salaries, which means…

…more pressure from supervisors, to see MORE patients during the day, to open up more appointment slots, which means…

…less time with each individual patient, which means…

…less focus on chronic medical issues, and more focus on the problem at hand (“treat and street”), which means…

…poor management of chronic medical conditions, which means…

…increased need for urgent care services, which means…

…increased demand for appointment slots, which means….

Trust me, like a hamster wheel, I can keep this going until I fall over in exhaustion.

And that is what happened to me last Spring.