Avoiding the Shoals of Contracts and Codes
"I saw this guy in coverage today that I wanted to steal from his regular doctor," one friend said.
"To have him come to me for primary care. You know? He was just such a nice guy—we had a great chat. If all your patients were that nice, it'd be the perfect job."
I laughed. "I've had people like that. I smile every time I see them on my schedule." I thought of a sweet 70-year-old I had seen that day for recurrent nosebleeds. She was anxious to have themstop before she went to Europe with her son. We'd talked about my trips to Europe with my mother, about Italy, about grown children traveling with their mothers. As she was leaving, she'd smiled and said shyly, "You're nice . . ." In that moment, all the years it had taken to get there felt worth it.
"It's so weird having such an open schedule," my friend went on. "We didn't have this much time for new patients when we were residents."
"I know," I agreed. "It's neat—you feel like you really have time to talk."
"Sure. But I find myself doing these ridiculous things, just because I have time. I feel like I need to do all the health care that people haven't had in five years. Someone comes in for sinusitis, and I have an empty schedule so suddenly I'm reviewing their whole family history and giving them a tetanus shot and trying to check their prostate. They're like, 'I just wanted antibiotics!'"
I nodded. "I did a Pap smear yesterday on someone who came in with an earache."
He giggled. "Poor people . . ."
"It's kind of like an assault."
"Leave me alone!" I imagined such a patient saying.
In contrast to the hospital, where almost everyone had something seriously wrong, in the clinic half the challenge was figuring out who was not sick. And a good part of the remaining half involved reassuring people who were really sick that their bodies just needed time to heal on their own.
"I felt bad enough when I came in here!"
Meantime, I was learning a new kind of medicine. Residency had trained me brilliantly to think of things to worry about; I was not so adept at deciding which of those I needed to take seriously. Much of my training had been in the hospital, where we were dealing with urgent issues and often doing lots of tests at once, in hopes of identifying the problemas soon as possible. The rhythmof clinic medicine was different; few problems were emergencies, and it was usually better to approach the evaluation one step at a time. Furthermore, in contrast to the hospital, where almost everyone had something seriously wrong, in the clinic half of my job involved figuring out who was not sick. And a good part of the remaining half involved reassuring the people who were really sick that their bodies just needed time to heal on their own.
Though the approach was different, the
learning curve was as steep as it had been in residency—those packed years of specialty training after medical school. A lot of the time I felt the way I had then: excited, exhausted, and thrilled to finally be doing something I'd been learning about for so long. I wasn't yet efficient at clinic medicine, so the difference between a too-quiet schedule and a toobusy schedule was only a few patients. I could turn on a dime from feeling restless to feeling overwhelmed. My practice grew quickly, though, as did my skills. I was startled to realize one afternoon that I'd comfortably seen more patients in half a day than I'd seen in my entire first week at the clinic.
Some weeks after my first day, a young woman who looked vaguely familiar came in to have a physical exam. She smiled brightly and toldme that her back pain had gone away just when I had said it would. Glancing down at her chart, I realized that she had been my very first patient on my very first day. It seemedmuch longer ago inmymind than on the calendar; I couldn't imagine having been quite so nervous over a simple problem just a month or two earlier. She looked around the room and admired a photograph of a rose from my front yard.
"Looks like you've settled in," she said.
"I have," I replied, realizing how true that was.
Seeing patients was easy to get used to, but the financial and administrative side of medicine was considerably more challenging. During my first week, I had a long and baffling meeting with the people from a department I had never previously heard of: Coding and Compliance. The coding and compliance staff had the unenviable task of teaching me in a few hours how to bill for the work I do. This had barely been addressed duringmy four years of postgraduate specialty training, much less in medical school. I'd had eight years of medical education, and nobody had acknowledged that this was a business as well as a calling.