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21 March 2012

From the doctor's perspective

I started to summarise a bit about the NZ Health system in this post.  But I've been thinking a lot about how I might describe MY experience working in it for a few weeks.  Of course, it's only been a few weeks, though I've seen LOADS of patients already.  This is a very busy practise.

The first thing I've noticed is how overall, I am much more relaxed and able to enjoy the encounters with the patients I am, compared to previous jobs I've had.  I recall the words of Ray Anton, the CEO of Clutha Health First, during my phone interview.  He said, "we want your brain to be focussed on taking care of patients, not all that other stuff."  "All that other stuff" is the stuff that has threatened to make me leave clinical practise entirely.  "Stuff" like diagnosis coding, procedure coding, E&M coding, worrying about whether the patient can afford a medication or a visit or a procedure and fighting with them to come in once a year to get their prescriptions renewed.  "Stuff" like documenting to support the coding and documenting to satisfy the lawyers of potentially litigious patients.  I spend so much less time documenting now.  And yet, I document sufficiently (there are some here who don't, for sure).  The subsidies for primary care are on a capitation basis so it really doesn't matter the complexity of the visit. The patient's copay is almost always the same.  So I'm not worried about how many "bullet points" I need to justify billing for what I know I did.  Instead of spending a couple of hours at the end of the day dictating notes or filling in templates in the EHR, I am usually done with the note as soon as I've done seeing the patient.  I look up a diagnosis that seems to fit in the EHR and I put it in.  The only extra "coding" work comes when it's an accident case, and then it's coded on time (so if there's a cast or a dressing change or whatnot that takes longer, it gets billed for more).  Granted, my learning curve is still quite steep with all the different forms, drug names, etc that I'm required to look up or go ask the nurses about every 15 minutes.  But everyone is VERY patient with me.  It seems they are grateful that I'm here and don't mind answering my incessant questions.

As for litigation, it is virtually impossible to sue a doctor.  I think I mentioned that before. It's virtually impossible to sue anyone!  I think in SOME cases that can go too far and there are doctors who get lazy.  In fact, even in other areas, it seems, there could be a bit more concern for safety. A colleague (who is a kiwi but just moved back from years in Canada) told me he was hiking and there was a sign on the track that warned of some loose ground, holes, or something.  He thought MAYBE these pitfalls might be marked but they weren't.  Whoever put up the signed figured that was sufficient warning, even though there might be unexpected holes or loose rock on a track that someone might fall into without knowing they're there.  When they say "at your own risk" they really mean it!

Anyway, the majority of my time is spent actually listening to and examining patients, figuring out what they need and finding a way to provide it.  It's the last bit that is slowing me down at the moment because it requires a lot of learning about the system, what's available in the clinic or the hospital, what can be done urgently in Dunedin, and whom to refer to and how to do it.  I spend a lot of time looking up drug names in the drug book.  I'm working making a list of important numbers, as well as units conversions because it's sometimes hard to work out quickly whether someone's cholesterol levels REALLY are in an acceptable range.

One interesting thing is that patients are required (and expect) to come in every 3 months for prescription refills if they are on chronic meds.  They don't fuss about it AND it give us ample opportunities to catch any problems early and review whether they have good BP control, etc.  Occasionally a doctor will make an exception and let a patient call in for refills but patients know those are exceptions and don't push for those exceptions.  So, although people will come with lists, if you are seeing them every 3 months, the lists are usually much shorter.

I am going to stop there because my lunch break is over and I wanted to post some of these thoughts before I lose them.  I think it's a pretty good introduction to how things are going from my perspective.  Of course, there will be more!  Cheers!

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