'Adding Procedures, Cutting the Paperwork=--Easier Said Than Done'

 A couple of months ago, one of the partners in our practice came to me and told me they were interested in adding on a simple office procedure that we've never undertaken at our practice before.

This is a procedure that they've been trained in doing, have their certifications for, and have several years of experience doing it in other settings, including on the inpatient floors and at a practice that they worked at several years ago. Seemed like a reasonable thing -- a nice opportunity to provide some augmented care to our patients, especially in this day and age when getting patients into proceduralists and subspecialists can be incredibly daunting.

As I think I mentioned before, one of the most frequent portal messages we get from patients are something along the lines of "That doctor who you wanted me to see -- when I called they told me they were not going to be able to see me for (6, 9, 12, 18) months. Is there anything you can do? Can you beg for a favor, can you call them, or can you get me in to see someone outside your institution?"

While subspecialty care is critical, there certainly are some minor procedures well within the realm of reasonably being done by general internists, often within our scope of practice, and on our institutional certifications as being something we can do. This includes joint injections, shave biopsies, punch biopsies, freezing off superficial skin lesions, injections with long-term steroids to alleviate pain and inflammation, implanting long-term contraceptives, and more.

Occasionally, when we try to set up a program like this, we can get pushback from specialists within the institution. Often the message we get is that we are stepping on toes, stealing their bread and butter, taking away the simple moneymaking things they do in their practice that helps support them. But if the patient has to wait weeks or months to get a skin lesion biopsied or a cortisone injection in their knee, wouldn't it be better for everyone involved if we took some of this off of the specialists' hands? Think of it: if we freed them up from these minor procedures, they may be available to see more complex patients in a timely manner.

Similarly goes the argument I've made in the past about getting specialists and subspecialists to relinquish the care of patients with stable chronic problems back to their primary care providers. This just seems to make a lot of sense.

No one really needs a cardiologist to manage their stable hypertension, their high cholesterol, or their mild heart failure. No one really needs an endocrinologist to manage their stable diabetes, hypothyroidism, obesity, or osteoporosis. No one really needs a gastroenterologist to manage their reflux, dyspepsia, constipation, IBS, or fatty liver disease.

Most of the time.

Sometimes, we send these patients to specialists when we don't know what's going on, when patients are convinced that what we are doing won't work, or if we think maybe we're missing something so that we need someone else to offer an opinion or confirm our suspicions. But then return them to us, and we'll take it from there.

Maybe the pain management folks really like it when a simple joint injection patient is on their schedule, a quick 5-minute visit for a very billable procedure with very little risk. It probably doesn't take much time, or much intellectual input, and the documentation is probably all standardized at this point.

Yes, I'm sure there are plenty of folks out there in the community who make a great deal of their income off of these minor procedures, but here at an academic medical center, I bet, if you did the math, it's worth it to clear the decks of these kinds of visits from the specialists so they can handle the tougher patients, the more complicated cases.

And how do we get the general internists and other primary care doctors to take on more of these simple procedures? Already we're overwhelmed, burned out, trying to squeeze too many patients into too busy a schedule, dealing with overwhelming demands, endless paperwork and documentation, portal message after portal message coming at us in wave after wave, and endless forms that need to be filled out.

Maybe, just as we move these simple cases away from the subspecialists, we can find ways to offload much of this extraneous administrative stuff that isn't what we chose to do and isn't about practicing medicine. That way we can practice up to our licenses, manage our patients' acute and chronic problems, quickly perform minor procedures that patients need, and enlist the assistance of our colleagues for complicated cases when we've tried A, B, C, and maybe even D, and are not sure what to do next.

Maybe some of this is going to include more non-physician providers. Maybe some of this is going to be about changing expectations and moving this away from the work of physicians to platforms that can handle much of this, including artificial intelligence and other smart systems. And maybe some of this is just us rising up and shouting that we didn't go to medical school and train all these years to fill out durable medical equipment forms for surgeons who don't want to do them, or to spend hours on the phone convincing insurance companies that our patients need a medication or imaging study that we've decided, in our medical wisdom, is the right thing for them to do right now.

So, let's move everything around, shuffle the chairs a bit, rearrange things, even out the playing field, smooth out the rough edges, and get us to a better healthcare system that works for everybody.

https://www.medpagetoday.com/opinion/patientcenteredmedicalhome/118889