If you or a loved one has ever been hospitalized, by day two or three of your hospital stay, you likely remember the doctor visiting you every day but not staying more than seven or eight minutes or 10 to 15 minutes max. It may have felt like he or she was just “dropping by and laying eyes on you.” A month or two later, you get a bill with the doctor visit charge for that hospital day ranging from $200-$300. You wonder: How the heck could a max 15-minute visit be worth that much? Let me explain. Before that doctor ever entered your room, he or she logged into an electronic medical record (EMR), which is basically an electronic file of all that has happened to you since the time you stepped foot in the ER. He or she would have reviewed all the relevant notes (Doctor’s notes that can be five pages long, nursing notes, respiratory therapy notes, other allied health professionals’ notes) and information that has been entered into your file. This includes your presenting symptoms to the ER, your vital signs, the impression of the ER doctor, every lab and diagnostic test that was done on you, and the notes and recommendations of any consultants that the ER doctor spoke to. Your doctor will then spend a few minutes trying to make sense of all of that information and consolidating it to come up with a picture of what may be going on with you. The doctor will have to decide which pieces of information need to be honed in on and what pieces of information are unimportant. He or she has to decide which borderline lab test can be considered normal and which borderline lab test may actually be relevant enough that it needs to be repeated. They may then start looking up any old files that exist on you in the hospital system. In our hospital system, they can go back up to five or six years. Once your doctor finds that file, he or she then has to decide which are the important pieces of information in that file. Were any of your labs or diagnostic tests that are currently abnormal also abnormal previously as in six months ago? The doctor will also have to check and see which consultant saw you the last time you were in the hospital so that the same consultants may be called upon again if needed for continuity of care. And this is all before ever stepping foot in your hospital room. Then comes the part where the doctor comes and meets you in the hospital room. The doctor talks to you and verifies that what is in the records is actually correct and that there isn’t more to your story that you may have forgotten to mention initially or that may have mistakenly been left out of another person’s notes. The doctor then asks you about how you are doing currently and whether you are improving from when you first came into the hospital with the treatment being given or if you have had no improvement or if your symptoms have worsened. After that, the doctor does a physical exam and gives you an overview of the plan for that day, including any new medications and tests that they might be ordering before leaving the room. Once the doctor steps out of the room, the visit is still not completed! The doctor will then sit down at a computer and start writing a “note.” This note is a detailed documentation of the visit with the patient and a summary of the tests and treatment plan. Insurance companies continue to require greater and greater levels of documentation and details in order to reimburse the physicians as well as the hospital for your care. After this documentation, the doctor will start placing orders for any additional tests that they want to order and also enter into the EMR any orders for new medications or to discontinue any of the existing medications. After this, the doctor will typically try to find your nurse so that the important pieces of your plan of care are verbally reported to the nursing staff in addition to being in the EMR so that the medications can be administered, and testing can be done in an expeditious manner. Sometimes after this, the doctor may also need to talk with the social workers or case managers for discharge planning to make sure you will have the equipment and appropriate home health care orders and any physical therapy orders that you may need after discharge. This could involve signing forms and doing some paperwork to get your insurance to pay for home health care services. After all of this, the doctor has to find the right diagnosis codes to attach to the bill so that the insurance company reimburses the doctor and the hospital for providing care to you. At times, if the care is more complex, the doctor may make a phone call to one or more of the consultants on your case to discuss findings and relay important information. At times the doctor may need to call your family members to update them on your progress and answer their questions as well if the patient has requested this. This doesn’t even include all the times the nurses and other health professionals page your doctor to report changes in your condition — i.e., pain, vomiting, etc., new lab results and clarification of orders. This is what goes on into a “visit” that to you as a patient may just appear as a seven or eight-minute chat. Realty is that a lot of work and coordination of care is invisible to the patient as it happens outside your hospital room. For the hospitalists (doctors who see hospitalized patients exclusively), there is no such thing as an eight-minute visit. It is up to the public to decide how much value they are willing to place on the coordination of care and detail-oriented collaborative work from these doctors that often takes place outside of their hospital room. Kausar Javed is an internal medicine physician. Source
