Ep 2 A Day in the Life, Doctor

Andrew Johnston MD: 0:00

It's a relationship and one provider won't work for all patients.

Heather Johnston: 0:11

This is doctor patient, a podcast that examines all the aspects of the patient provider relationship. I'm your host, Heather Johnston, MD, a real life doctor and patient. Have you ever wondered what your doctor's day is like You see a small piece of it when you're at your visit, but what's happening the rest of the time? This is important because the doctor patient relationship is a two way street. We want a certain quality and level of care from our doctors, we feel frustrated when they run late, seem distracted or are short. But in order to reciprocate kindness and patience back to a doctor, you should understand a little bit about where they're coming from and what their life is like. My guest today is Dr. ANDREW JOHNSTON, an internal medicine doctor and the Site Director at the Open Door Fortuna Community Health Center in Humboldt County, California. He has been practicing for 32 years. We chatted about what his day is like and what challenges he faces in his efforts to deliver quality care.

Andrew Johnston MD: 1:10

I wake up around 4am and get ready for work, I try to get to work by between 630 and seven in the morning, I start seeing patients at 830. So that gives me some nice quiet time to go over things that are in the electronic medical record inbox, my task list. And that's filled with things like telephone calls, lab resultsv to review, prescription refills, documents that gets scanned in from the hospital system, or consultants, all kinds of different messages you get from staff and some messages from patients from the online portal, where people can send you messages about questions they have about their health issues or other things. So there's always something in there, always, that's just a ongoing quantity of work. So getting to work early gives me time, I like to have at least an hour hour and a half is great. Before people come in that I can nibble away some of those things. Try and get through all the prescription refills before I start seeing patients maybe going over test results, things of that nature. Then, for seeing patients that's from 830 to 12 and then from 1 to 5, between 12 and 1, sometimes you're seeing a patient in there might not finish the morning till 1215 1220 rarely 1230 You take about five minutes to eat something that's lunch, and then you're working on that list, that inbox list or you're dictating your notes from the patients that you saw that previous half day.

Heather Johnston: 3:01

During the lunch hour

Andrew Johnston MD: 3:02

During that hour, yeah. I try to dictate the notes, before I go on and see the next patient. If I take an extra four minutes to dictate it right then and there, it's still more efficient than doing it at the end of the half day or the end of the day. So that's sort of the typical day, and then at five o'clock, you're done with patients. What I'll do, then if I have notes still to dictate, I'll dictate those before I go home 95% of the time. 5% of the time, I might leave a few for the next morning, coming in early and getting them done then. Sometimes towards the end of the day, not not at five o'clock, but maybe between 530 and 630 if I'm still there, I can build up this feeling of just feeling like I've got to get out of there. And I might have a lot of work to do. But I just think I just can't sit here and do it anymore.

Heather Johnston: 3:57

Well you've already been there for 12 hours.

Andrew Johnston MD: 4:01

Yeah, but that doesn't really, it's not so much that thought it's not the thought of, Oh, I've been here for 12 hours, poor me, it's it's not that. It's just a feeling of feeling like you got to get away from it. So there are days where the longest is probably being there 15 hours, like getting there at six and maybe staying till nine. And usually that's on a Friday where things just pile up and I'll have a set number of things that I want to complete Friday before the weekend starts. I don't want to start my weekend Saturday by waking up and doing certain work related things. So I'd rather stay a little later on Friday. Most of the time. I'm leaving there probably about seven o'clock. So it ends up being on average, maybe between a 12 and 13 hour day in the office.

Heather Johnston: 4:54

So the day that you described seems really tight. What happens if a patient has an unexpected problem or something that they didn't necessarily come in for like I'm here because my blood sugars have been crazy, but by the way, I can't feel my left foot.

Andrew Johnston MD: 5:10

The easy answer is well, you'll you'll run behind more. But part of the answer too is having the capability to think on your feet to adjust to the situation. I'll go into an exam room, knowing what a patient's problems and issues are, having a vaguely preformed plan of things that I need to address and how I might want to address that. And then yeah, you go in and you're thrown a curveball, something horrible has happened that they need to talk about or something serious is going on that you need to evaluate further, completely unexpected. Well, then, you may not need to do all those other things you were thinking you would do, so you, you adjust. You adjust and adapt, and yes, it is part of the reason also why we we run more behind; is that you can't some things you just can't cut corners on.

Heather Johnston: 6:06

So of that day that you described, what's the hardest part of that day?

Andrew Johnston MD: 6:11

Probably deciding when to go home. Deciding how much of that inbox does one do or do I do before I say, Okay, put in a good day's work. I feel good about going home now.

Heather Johnston: 6:29

But is the idea that you're never really finished the list because the list is always growing?

Andrew Johnston MD: 6:34

That's my personal situation. And I think some of that has to do maybe with my own inefficiencies. There are a few providers we have in our office who have a much, much smaller list that they are oftentimes, it's down to just a few things. Whereas I could have 100 things in this folder, 50 things in another folder. So some of that may be there's different reasons for that. So I think that depends a little bit on the individual.

Heather Johnston: 7:07

What do you think a patient's role is in making a visit go efficiently? In other words, what should a patient do to get the most out of their visit with you?

Andrew Johnston MD: 7:23

I'd say be prepared. If you have several things that you want to go over, write them down so you have a list. You have medication, prescription pill bottles? Bring them to the appointment. I don't think people have any idea how often the medication lists are just wrong that we have. It could be the wrong dose, the wrong milligrams, a medication that stopped 18 months ago, but it's still on their list. So to bring all their pill bottles to each appointment, have a list, if there's a few things that they want to go over, if there are things that they're supposed to be monitoring at home, and they're writing down reports about their blood sugar, their blood pressure, something like that, bring that into, so be prepared. And it's really helpful too if when you walk in, and this is partly on us as providers, if we ask them, what you know what's on your list today, things that you want to go over, not us kind of directing the whole interview part and then at the very end, after you're done as a provider with your interviewer you've done whatever exam you need to do and kind of wrapping that up, then they say, Oh, well, just a couple things. In, in your mind at that point as a provider, you're already moving on, you know, three patients down the road as to what you have to do. You're gone, you're out the door, mentally. And then they say, Well, I really wanted to talk to you about this. Happens all the time. And part of that's our fault for not saying when we walk in there. How are you doing? Are there some things today that you want it to go over? I've got a few things I need to talk to you about.

Heather Johnston: 8:58

Are you suggesting that that should be first, like before you address your things?

Andrew Johnston MD: 9:02

Yeah, yes, I think ideally, it would, it would be a conversation of maybe a conversation starter of okay, so I'd like to talk to you today about your high blood pressure and your diabetes and your depression. Is there anything you want to, apart from those things, anything else you wanted to bring up today? And they might have a backache or bad headaches or some other situation completely unrelated to what you think they may be there for. And then you know, you've got your three things you wanted to talk to them about, they may have two or three and then very quickly, sort of triage that list and figure out you may be able to do all of those or you may end up saying Well okay, well we'll leave extra why on your own list or their list will leave extra why maybe to the next appointment.

Heather Johnston: 9:55

What's your stance on internet research before seeing a doctor?

Andrew Johnston MD: 10:02

I think it's really, it's dramatically, dramatically changed things, whether it's before seeing someone, or after seeing someone. Dramatically change things in the last 20 years, where I think we're viewed with much more suspicion and doubt, as to the legitimacy of our suggestions or recommendations. It's made things, I think more difficult, I would be hard pressed to say it's made anything better. It's introduced a whole new layer of really what comes down to negotiation. I feel much more like a used car salesman now, I think in part because of the internet. It's a strange thing.

Heather Johnston: 10:48

Yeah, I think so too. I have mixed feelings about it. On one hand, I appreciate the idea that somebody will do a little more legwork to be prepared for a visit, like, Hey, you told me I had migraines, I read a little bit about it, I have these five follow up questions from what I read, I feel like that could be a helpful thing, to have somebody reading a little more, because they might not even know the questions that they have about what they're going through without reading something. Also, I think for a lot of patients, it's a stressful time to visit a doctor. Not everybody feels empowered to ask or to question. Some people forget their whole list because they forgot to bring it on paper and they just can't remember. It's like, it's like how your blood pressure is always higher at the doctor, because most people do feel a little nervous there. And so I guess in a perfect world, I wish people could, you know, if they had a ton of questions, they could read a little bit about it. But obviously, on the other hand, there are terrible pitfalls, where people may not know where to go for information. How do you know what site is legitimate? How do you know what you're reading is right? Do you ever recommend that patients read anything online?

Andrew Johnston MD: 12:09

Sometimes, but I'm very targeted with the places I may suggest they go look. And I think that the COVID pandemic has been a great example of people looking at things online, reading it, thinking, while I read it online, it's got to be true, because it's right there. And you can read it on the internet, as though it's the New Encyclopedia Britannica or something. And so I think, when to go back to your question about appreciating people putting in that effort, I don't really look at it the same way. I'd rather that if they have questions about it, they ask.

Heather Johnston: 12:52

I think this really touches on something that I think about so much, and is really one of the reasons why I actually am starting this entire podcast, which it just comes down to the basic relationship between a patient and a provider. Like, do you trust your provider enough to forego internet research and ask them what the answer is or what their opinion is? And I just think so many people don't feel that they have that, whether it's because their health insurance keeps requiring them to change physicians or their physicians or leaving or changing groups. And so you're not with somebody for a long time. Or perhaps you have been with someone for a long time, but you can never get through. And the doctor never calls you back themselves anyway, it's somebody else in the office you don't even know, that you don't have any relationship with at all. And it gets really tricky I think for patients to feel trusting. I get that, I really do.

Andrew Johnston MD: 14:06

On the surface, I would say I think it's a lot worse now than it was 20 years ago. But it may also be something that just wasn't really discussed 20 or 30 years ago before the Internet where people could look things up. Because now what happens often is we may recommend a certain treatment direction or certain evaluation direction. And people give you the response. Oh, okay, thank you. I'm I'll do my research and get back to you. Whereas 30 years ago, there was none of that. There was no research to do.

Heather Johnston: 14:43

But also I certainly remember when I was in medical school, this is in the 90s being taught about the different kinds of relationships you can have with your patients. And we talked a lot about how things used to be a lot more of a patriarchal model. Like, the doctor's in charge, you don't question them, you're going to do what the doctor says. That's the relationship you have. But that over time, that was really changing so much more into a more partnership based model, where you have dialogue with your patients back and forth. And so it makes me think a little bit about that. And I think some patients want it one way or the other way. But the issue is, if you don't, I mean, it's a relationship, right, you got to develop some trust in there.

Andrew Johnston MD: 15:34

It's a relationship and one provider won't work for all patients.

Heather Johnston: 15:40

That is true.

Andrew Johnston MD: 15:41

I agree with with what you said. And that takes time to build that. Sometimes you may feel that trust, quickly, in one or two visits. Sometimes it takes time, unfortunately, with how they schedule patients and appointments, all the stuff that has to be done in an appointment, unrelated to what a provider is doing with a patient. That time is so minimal, that it can take a number of visits to build up that trust.

Heather Johnston: 16:15

So does it bother you? If you say something to a patient? Like, I'm really recommending X? And they question you about it? Like, well, I don't know, that's a little bit different than something I heard or read or that my doctor told my aunt something completely different. Do you mind it when patients do that?

Andrew Johnston MD: 16:38

No, I don't, I don't mind at all. And when it first comes up with a patient on a particular problem, I look at it as a way to explain something to them, to educate them about it, hopefully to get them to trust me as part of the whole relationship building. So no, I don't get offended, or I don't mind or take it personally or get my feelings hurt. It's not like that at all.

Heather Johnston: 17:05

So if you have 15 minute MyChart messages per day to answer, why doesn't your clinic arrange it so that you have one less patient per half day to see, so that you can answer those?

Andrew Johnston MD: 17:12

Okay, so most clinics, and I would say patient practices too, they have their operating budget. Their budget is based on an assumption of a certain number of patients being seen each day, and a certain amount of compensation that you're going to get for that. That's what you base your whole budget on. So we know for example, as an FQHC, that we get X amount of dollars from the state Medicaid HMO plan that's active in our county. And we know how many patients we need to see a day to maintain that budget. If they take away one patient, for, I think we have about 80 providers a day to do MyChart messages, that's 400 Less visits a week, 1200 less visits a month, 12,000 less visits a year. We'd be laying people off if we did that. So I think that kind of circles around to the what I think is the main problem is just the whole payment system that sets up all this other stuff. It would be great if I had one less patient to see every day, and I could dedicate that time to calling patients back. I rarely call patients, rarely. I'm usually sending a message secondhand through my medical assistant. Someone calls up, they have a question about XYZ, I'll send it to my medical assistant, please let them know ABC. It's rare that I'm picking up the phone to do it. Because I just don't have the time with everything else that comes in through the day.

Heather Johnston: 19:09

Would you like to do it?

Andrew Johnston MD: 19:11

Yeah!

Heather Johnston: 19:12

In an ideal world?

Andrew Johnston MD: 19:13

Well, I've started doing it more on my administrative time when I'm supposed to be doing other things, not direct patient care things. So now those other things don't get done because now I'm thinking, Well, it's nice to call patients and they're they're so grateful for it. They really are appreciative of it because it doesn't happen that often. So yeah, I'd like to but it becomes an issue of time in a day and other stuff that you're expected to do.

Heather Johnston: 19:42

In those 30 years you've been practicing what has changed the most in your eyes about direct patient care, how you interact with patients?

Andrew Johnston MD: 19:56

Probably the amount of time to spend with someone. Everything is just so much more rushed now than it was then.

Heather Johnston: 20:03

Time is short in a doctor's office. How a doctor chooses to use their time has implications for the quality of the care that they deliver, and how much trust they're developing with their patients. A handful of studies have looked at how long doctors spend with their patients for an annual checkup, and the average is about 15 minutes. 15 minutes! That's about how long I spend walking my dog if I'm in a hurry that day. Or I could listen to three songs in 15 minutes, or maybe I could do the dishes in that time. To think that that's how much time I should spend seeing a patient for their once yearly visit sounds crazy, right? It's just not enough time to dig into issues and have discussions about them. It's also why doctors tend to examine you while you talk, because we don't have enough time to do these things separately. Tune in later this season for episodes on ways that some doctors are pushing back on this. And we'll also do a deep dive, at least more than 15 minutes worth, into the health insurance industry and how it's affecting the doctor patient relationship. Thanks for listening today. To catch up on more episodes and to get new ones delivered directly to you. Subscribe wherever you find your podcasts, Apple, Google, Spotify, iHeartRadio and more. If you'd like to be a guest or have an idea for an episode, let me know at www.drpatient podcast.com That's drpatientpodcast.com. Here's the disclaimer. Even though I am a doctor, I'm not your doctor. These stories, my comments and all discussion is purely reflection about what's working in the healthcare system and what isn't. Don't use any medical information that you hear in these episodes to diagnose or treat yourself. If you have a question about your health, get in touch with your doctor or local health clinic.