Let me tell you about a recent morning working in my outpatient rheumatology clinic. I’ll tell you less about the medicine, but more about my process of practicing medicine. I hope to shed light on what it’s like to be a physician, behind-the-scenes. As you’ll see, practicing medicine is time-consuming; it takes much more than the time spent with the patient in the clinic or at the bedside. Or at least it does if you really want to take care of your patient.
I’m documenting this process as a way to reflect on my habits and improve the way I work. I hope that this post also stimulates discussions about habits, hacks, or tools you’ve found that help you get your work done so that we can learn from each other.
My clinic day actually started the night before, when I reviewed the schedule of patients and read the prior medical records for the new patients. For returning patients, I created drafts of my clinic notes (5 minutes each) which included the recommendations I had made during their previous visit, important events from intervening visits with other healthcare providers (emergency department, primary care, other specialists), and new items to address during the visit on the following day (this all took 43 minutes).
My day started at 7:30 am and involved seeing three new patients (60 minutes each) and four returning patients (30 minutes each). During clinic time, in addition to conducting thorough histories and physical exams, I reconciled all of their medications, renewed their prescriptions, sent new medications to their pharmacies, and created referrals to physical therapy. I did this, without a break, until 12:30 pm, with barely enough time to fill my water bottle before our weekly case conference.
After the conference, it took me 15 minutes to dictate each of the new patient visits, and 10 minutes to complete each of the notes for returning patients.
Later that week, I edited my dictated notes (5 minutes each), reviewed the bloodwork I ordered from 6 of those patients and an X-ray that I ordered for 1 patient (5 minutes each). For those with normal results, I wrote letters that my staff mailed to them; for those who needed a change in their management, I emailed my nurse and asked her to call the patients directly to inform them about their results and to review the changes that I recommended (5 minutes each).
For one patient, I had to email his gastroenterologist who is treating him for an undefined inflammatory bowel disease to discuss what additional treatments the gastroenterologist would recommend, and to check whether this treatment could also be used to care for his underlying rheumatic disease (7 minutes).
A patient with SLE appeared well on the exam, other than having active arthritis. However, bloodwork showed a decrease in complement levels and increasing proteinuria (indicating lupus activity), so I had to email with her nephrologist about augmenting her current treatment (5 minutes) and then ask my nurse to call the patient with this information and with new prescriptions (5 minutes).
Another patient with rheumatoid arthritis, on TNF inhibitors, had a history of multiple skin cancers. When I saw him in the clinic, he told me he had had a biopsy of a suspicious lesion but had not yet received the results. I later called him to get the results of this biopsy (his third squamous cell cancer!) and reviewed the literature on the use of RA drugs in the setting of skin cancer. I reviewed the American College of Rheumatology’s recommendations for treating RA, in which they recommend against the use of biologics in patients with skin cancer and RA. There is an inherent increased risk of skin cancer in patients with RA regardless of treatment, but TNF inhibitors may increase this risk further; tofacitinib at higher doses may do so as well, however, tocilizumab has not been shown to increase the risk of skin cancer) (30 minutes). I called him and suggested switching to tocilizumab (5 minutes) as an alternative, then asked my nurse and pharmacist to help with the PA for this drug (5 minutes).
A patient with a history of an ankle fracture had not recovered after prolonged treatment with casting and physical therapy. He had seen two different physicians at two different institutions and had had 3 different imaging studies. I had to obtain and review the records from his prior treating physicians (at two different hospitals with two different, incompatible medical records, 30 minutes) and review his images with our musculoskeletal radiologists (fortunately the patient was smart enough to bring the discs with him, 10 minutes).
All in all, to take care of these 7 patients that I saw last week, I spent 5 hours of face-to-face time in clinic, and an additional 5 hours documenting the clinical encounter, coordinating care with other physicians, obtaining and reviewing outside medical records, reviewing scans with our radiologists, writing PA’s, reconciling medications, researching, and communicating with nurses and patients. My experience with the amount of time spent in clinical care after the patient has left the clinic is similar to that reported in other studies. Much of this additional time I spent documenting on our electronic health records, which have been suggested to contribute to physician burnout.
My boss always reminds me that a week has 168 hours–plenty of time to see patients, do research, apply for grants, submit manuscripts, teach, and get promoted! But if every hour of clinic requires an additional hour of work, the math becomes much more complicated in the end. It’s no wonder that many of us take our work home to complete at night and on the weekends…and why plans to do regular exercise or meditate often fall by the wayside.
Despite these challenges, I still love my job, my patients, and the opportunity to teach and improve the lives of others. I hope that by writing down what it’s currently like to be a physician, I can highlight areas for improvement and begin to sketch a map of where we should head in the future.
Patient details have been changed to protect privacy.
What habits, hacks, or tools have you found to help you get through your workday?