The extra stuff

The basic stuff is most important. You have a problem that concerns you enough to come to the ER. Maybe it's a cut, or a cough, or some sort of pain. I happen to have the training to be able to quickly listen to you, examine you, and make a diagnosis. My real job, as a contractor who is staffing the emergency department of the hospital, is to decide if it is safe to send you home or if you need to be admitted. For some problems, I might need to do a test (or twenty) to confirm my diagnosis. No biggie, I work at a facility that can do it all. Most of the tests I order are just to cover my ass against litigation, or to try to support my clinical impression that you should be admitted. The admitting docs like to make really sure that you need to be admitted, and my clinical impression alone isn't usually sufficient. So those additional tests are the first layer of extra stuff.

That basic decision-making process only takes a couple of minutes at most. What follows is more extra stuff which takes much longer. You see, I have to document my findings in the medical record. A simple note isn't enough, because "the government" has decided that they will only pay me if I document certain things. So I have to ask you various things that I don't really NEED to ask you to make my diagnosis, and I have to examine parts of your body that have nothing to do with why you came in. We have special forms we use to help us make sure we have done all that extra stuff, that a company charges us extra for. Lots of little boxes to check off. So if you are wondering why I'm looking in your ears or asking you how much alcohol you drink, now you know.

I only need a pen and a stethoscope, really. I travel light. The stethoscope is to listen to your insides. I could put my ear to your chest, like I do with my daughter, but the stethoscope allows us both a to have a little more dignity. Plus, it looks cool. The pen is to write your prescription when I send you home, to justify my bill to your insurance company, and to protect me from your potential lawsuit.

I might need a pair of sterile gloves, or an ACE wrap, or a suture kit to fix your problem. Of course, I can't just go get these things off the shelf, because we have to charge you for them. So they are kept in a big electronically-controlled bin with dozens of little drawers that pop open when the item is requested under your account number. What do you have to type into the machine so that the "ACE wrap" drawer opens? "Elastic" or "bandage?" The staff confers while I wait.

If I've ordered any tests, the results will soon be available on my computer. Of course, in order to protect your privacy, I have to log in with my super-secret password each and every time I want to check. Hmmm, not back yet, so I'll go see another patient. When I return, I have to log in to the system once again, because it's been more than two minutes since I last logged in. In those two minutes, some sinister person might sneak into the nurses' station, sit down at my desk, and learn that you have a urinary tract infection. Ha, not with our top secret security system, they won't!

Once I have all of your tests back and I have discussed the plan with you and written your prescriptions, it's time to document more stuff in your chart. Again, to cover my ass. Prescription given....check. Patient informed of need to follow up....check. Diagnosis and labs discussed with patient....check. Discussed with Dr. _____, will see patient in the office in _____ days. X-rays discussed with radiologist. Even though there are typed X-ray and laboratory reports that will become an official part of your medical record, I still must write it all down myself so that your attorneys can see that I actually reviewed it and the insurance company can see how complex the case was. Then I sign and date my note, the lab order sheet, the medication order sheet, and all of the prescriptions.

So what could take only a few minutes takes much longer because of all that extra stuff. Don't worry, I know that you had a lot of extra stuff that you had to sign when you checked in too, so I don't expect any sympathy. We can share our frustration with all of that extra stuff. Did that visit seem to take longer than you expected? If we could eliminate some of that extra stuff, maybe we both would be happier. Unfortunately, the "powers that be" only seem to create more and more extra stuff each year that puts up walls between us. The patient-physician interaction is getting smothered in a sea of bureaucracy.