I am working on a letter to my hospital district. The district fired me on Tuesday, gave me a three month severance check, and asked for my keys, pager, hospital ID and I cleared my desk. My first patient cried when I told him I couldn't see him because I had been fired; his wife died last week.

Comments on this letter are appreciated.

The letter so far:

First of all, I would like to extend my heartfelt thanks to the hospital district and the hospital medical and other staff and nurses for the last 9 and a half years. It has truly been wonderful working with you and endlessly educational. Thank you very much.

I do wish to discuss the direction that the hospital district is going in. I do not agree with the current plans and wish to add my two cents. This had become an ethical dilemma for me and I am grateful to the district for giving such a clear end to the dilemma.

There are three parts of the current plan that I have difficulties with. One is a quota of patients per day, the second is seeing patients for one problem per visit and the third is templates. I would like to explain my viewpoint and offer some other options. I was planning to offer them to the hospital CEO and COO at our followup meeting, but that is not to be.

Regarding quota, patients are not objects that one can produce or process as in a factory. I think that it is unreasonable to say that providers need to see a certain number of patients, just as if they worked in a factory and had a quota of objects. Instead, I would suggest that the district look at billing and RVUs (Relative Value Units). I did not make the "patient number goal" last year, however, I went far enough above the RVU goal that the district paid me 10000 bonus at the end of the year. The meeting with the coders was highly encouraging. They said that my charting was excellent, they could follow a clear narrative and that, in fact, I was not billing high enough. I do bill higher than the average but it is because I like and attract complex and unusual patients. I like them and they sense that. I have excellent relationships with many otherspecialists outside Family Practice who I can call on when I think I have something unusual, a "zebra". The one additional element that I need to continue my work is time. In order to do these complex visits, I cannot see a person every 20 minutes. Last year I saw 14-16 patients a day. I did not see as many as Dr. J but I did pass the RVU (Relative Value Unit) goal, though not by as large a margin as he did. The district needs a diverse selection of doctors and Dr. J and I have very different styles. Patients will choose what they want. I would advise you to focus on RVUs, not numbers of patients. Providers and patients will be much happier.

I understand that congress has passed a law saying that rural health clinic physicians HAVE to see a minimum of 18 patients per FTE (full time equivalent). Now that I have been dismissed I have been reviewing the law. I would interpret the law differently than our local hospital district and would use the ideas presented by the state of Alaska at:

Secondly regarding "one problem per visit". To me this is both unethical and impossible. It is reasonable to defer some problems, especially if a patient has an urgent visit for a cold or urinary tract infection. However, if that patient has a documented breast lump and has not followed up, I would feel entirely remiss not to mention it. Also, the average primary care patient has 5 chronic diseases. This was documented in a study 6 years ago. If, for example, a patient has hypertension, diabetes, moderate kidney failure, congestive heart failure and a toe infection. I CANNOT ethically treat one thing. If I treat the toe without thinking about the kidney function, I could worsen and hasten their kidney failure. They could end up on dialysis or die. All patients over 70 have some reduction in kidney function based on age alone, so it is a common problem. I choose Family Practice as a specialty because I wanted to care for the whole patient and I am deeply offended by the stated "one problem per visit." Another example is a recent patient who was new to me and in for back pain. She was hoarse. Fearing that she wouldn't return to have it addressed, I worked on both at once. She has seen the Ear, Nose and Throat specialist and has vocal cord polyps and is scheduled for surgery. They do not think it is cancer. She thanked me at the next visit and said she'd never had such a thorough visit. I can't feel bad for spending that time, no matter what the district goals are. Our county's largest population is age 50-70. Some are exceedingly healthy and many are not. If you were 70 would you be willing to come for 5 separate visits for 5 separate chronic diseases? I don't think I would, unless forced to by congress or medicare. I think county health will worsen under this policy because patients will get frustrated and just not come in for their diabetes. I do think that this is a national issue as well.

Thirdly regarding templates. My template is "Why are you here?" I work from that. In the three years that I have worked with the computer A4 system, it has infuriated me, but about three months ago I finally got to where I was actually satisfied with my notes. I had figured out how to get the narrative written where it was easy to track and follow. The coders confirmed that they could follow it. I do fill out the templates, but only after the narrative, and I find the template questions virtually useless. If I were to use the templated questions instead of really just listening to the patient, I wouldn't pick up half the things I pick up. The coders also spoke up and said that the narrative is much more important than the template and preloaded computerized sentences for which one just checks a box. I can thank the district for my much improved typing skills; I'm very fast now. I do see irony in the 18 patient a day, 20 minutes per visit. We were told that the computer system was adopted to make us more efficient and so that we could "finish the charts in the room", but now it seems that there is pressure to be done in 20 minutes. I am told that some providers fill in their notes partway BEFORE they see the patient. Personally I find that concerning. Nor would I be willing to see a provider who had their nurse fill out the template. Sorry, but I want to talk to the provider.

My plan for earning adequate RVUs to support the district and clinics had multiple ideas. I would like to share these with the district. Perhaps you could use them for other providers.

1. Group visits. I approached our COO and CEO two years ago but was told there wasn't space. I attended an excellent training session at the AAFP Conference a few years ago.

2. Consults. I have discussed consulting with Dr. RC, pulmonologist in S. She said that there is a board certified family practice physician in S. who reads echocardiograms and is excellent, because it is his area of interest. My areas of interest are end of life issues, memory loss/dementia, I still really enjoy delivering babies and have worked with perinatology and high risk pregnancies for 18 years and lastly, unusual cases. For a consult, a patient requires a referral from their primary care provider, but then the RVUs for the visit are higher than the regular visit RVUs. I am sure that other providers have areas of interest. I've asked Mr. B, PA, lung questions for years, since he also is trained as a respiratory therapist.

3. Cesearean sections. It is clear that we do need another person. I called the head of the perinatology group with whom I have worked for the last nine years and asked if they would consider training me. They have been my consultants for high risk obstetrics patients since the start of 2000. I called this week and spoke to Dr. S. and I will probably be able to visit next week, since my time is currently more open. They are short on fellows this year so said that it would be a good time for me to train. It's a bit challenging as a single mother, but I'm sure we can work it out.

Again, my thanks to the district. My new clinic phone number is 3------2. My goal for opening the doors is September first.

Yours truly
Lizardinlaw, MD

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