Thursday, May 06, 2004

Good News and Bad News

As the saying goes, I've got good news and bad news.

The good news is I saw 2 new patients in my practice today.

The bad news is I sprained my left ankle tonight at my weekly Wednesday night basketball game. It's swollen to the size of a lemon and currently propped up on a chair as I type this. No more basketball for me until I get disability insurance. I called in sick for tomorrow's afternoon clinic at Kaiser that I was scheduled to work, but I can barely walk right now. It'd be very difficult for me to see 12 patients in 3 1/2 hours like this. Heck, I can't even do that when I have two good ankles.

I was pleasantly surprised to get calls for appointments yesterday. One gentleman saw my ad in the local paper and had saved up various aches and pains to discuss. The second patient was a former Kaiser patient who could no longer afford her insurance, and was referred by one of physicians from the clinic who knew about my practice. I scheduled the first patient at 9AM and the second one at 11AM, thinking that should be plenty of time. Patient #1 arrived at 9AM, and took about 15-20 minutes filling out my forms (Registration, Medical History, Financial Policy, Notice of Privacy Practices, Guidelines for Emailing). It took about an hour, and he left at 10:15AM.

I entered his information in SpringCharts, and proceeded to write the progress note. I've decided I'm not going to try to chart while the patient is in the room. I think it's distracting and gives the patient the impression that I'm not fully focused on what they have to say. When I do finally get a returning patient, I'll bring my laptop into the exam room with me, if it's appropriate. As a medical student, I used to write down EVERYTHING a patient told me, because I didn't know what was relevent and what wasn't. I went from a clipboard to index cards as a resident, keeping one card for each patient. Some time in the first year at Kaiser I gave up the index cards and wrote on little slips of paper attached to the chart. After I started taking part in UCLA's Doctoring Program teaching first year medical students how to interact with patients, I realized that it was all about building rapport with the patient.

I remember a 1st year student interviewing a Standardized Patient (an actor playing the role of a patient). He looked calm and relaxed in his white jacket, sitting back with his leg crossed in a figure 4 position with a clipboard in his lap. As he asked his questions, he kept looking down at his clipboard and occasionally at the patient again. When he was finished with the interview, the other students congratulated him on a job well done. I, on the other hand, said that I thought he looked just like a resident in the emergency room. Which wasn't necessarily a good thing. Why was he even writing on the clipboard? He didn't have to write a progress note or remember anything about the patient after his interview. To me the clipboard or chart is a crutch, a security blanket in case the student gets stuck and can't think of what to say next. But it also gets in the way of developing rapport with the patient. And this class is all about teaching the students how to develop a relationship with a patient, in order to build trust, which in turn results in more information being shared and better care. A lot of doctors could use some of that, too, doncha' think? So now, I gently advise all first year medical students to ditch the clipboard and focus on the patient. They'll have plenty of time to carry their clipboards later.

Which brings me back to now. I try to practice what I preach, so I ditch the chart or clipboard when I first walk into the exam room and greet the patient. I only write if there is some number (eg. BP) or list (eg. medications) that I'm likely to forget. But I've learned that I am able to remember most other details after the patient has left.

By the time I was done with my progress note, the second patient arrived. I spent 50 minutes with her, and because she had no insurance, I was going to round it down to 45 minutes, and told her to pay me $60. Fortunately for me, she caught my mistake. "Don't sell yourself short, doctor!" 45 minutes at $50 per 15 minutes should be $150, with a 20% prompt pay discount that would bring it down to $120. I thanked her for her honesty, and explained that I was rather new to the business aspect of medicine. Which was rather obvious.

Later that afternoon, I worked 4 hours at Kaiser and earned $240 or $60/hr, the going perdiem rate. I realized that I probably made that much seeing those 2 patients in the morning as I did seeing 12 patients at Kaiser. So, if I can get more patients, I think this solo practice thing may just work, financial-wise. It already works satisfaction-wise. And that's good news.