Setting limits ... Re: Re:Too many patient demands, what to do?

[Guest guest]

Somewhere, I'm not sure where (for Rochester residency folks, somehow I think

Betsy told me this once, but I may be wrong), I heard a great concept about

" setting limits. " Basically, people say, " you just have to set

limits and not let so-and-so get away with more. " Problem is, that is our

setting limits for other people's behaviors which really we don't control. And it

makes us reactive to the world around us.A perhaps healthier way to look

at limit setting is that we set limits for what we will accept and respond as needed

for our benefit/protection.So, in reality, we all know that we will

always " give in " a bit at least for patients. But we have to set the limit

for OURSELVES on how much and how often. Then communicate our limit to the patients

when needed. Point is that we can't control others, but we must

control ourselves and let others respond/react as they will. Then we can go to bed

with a clear mind and not be fretting, " oh, how those patients keep passing the

limits I've set for them. " We can't be responsible for them, only

ourselves.Somehow I don't think I'm saying this clearly, but I'll leave

it at that and hope the concept is helpful to someone, somewhere.All the

best --TimOn Sun, August 24, 2008

5:36 pm EDT, wrote:

I have been off for 5 wonderful daysNever theless have been

dealing with a crisis involving a neighbor patient LEnGHTY phone calls

/repetitious.I have been talking ot ER etc When patietn called today- and things

are better -I actually said i could n't stay on the phone too long becasue I had to

pee. it was true but I bet you can't use that all the time... :)Why people can't say no is worth thinking about . because I mean

it is not about saying NO it is about saying how can I help you and

offering choices.

I do avoid phone calls, and always try to keep them under 5 minutes. Basically, if it's too long, I say, " wow, lots going on with you. Talking

onthe phone isn't the best way to take care of so many things. I have to

invite you inso we can give it the time and attention these issues

deserve. " Just gottastart saying it.That tends to work.Tim

On Sun, August 24, 2008 5:17 pm EDT,

Wayne Coghill wrote:

Shehas a hard time saying " no. " And, once she

gets into the conversation, shehas a hard time gracefully ending it quickly if

need be. So our only recourse is tominimize the number of times she ends up

on the phone with a patient. And yes, thisalso makes it hard to keep up with

the schedule since there is a problem with thepatients who are always

" oh, and one more thing... "

[Practiceimprovemen t1] Re:Too many patient demands, what to do?Now

thisis an interesting topic. I would like Gordon to expand more on his

commentsre: needs of patients and layers of access. I am

also in the " what to do " phase and in analyzing what I have created

in my practice Ibelieve that I have enabled too many patients to take

advantage of my service forfree. In building a practice, and in just being a

caring person who wants folks toget more than their money's worth.. I would

spend 20+ minutes on the phone withpatients for multiple patients per day.

What should have been a 4 minute phone callwould expand with further questions

they did not ask at their initial visit, withnew problems that should be dealt

with at their next visit and even with questionsabout what their husband's

doctor told their husband to do. Moms would call and askif their daughter's

should be vaccinated with Gardisil- daughter's I don't even see.When I took

their calls, answered their questions- I was delivering hassle freeservice

with no barrier to access. It obviously does not work for the providerwho is anything but a concierge type practice.So- I am trying to

retrainmyself and my patients. I don't encourage phone call updates anymore.

I'm not evensure I want an email update- as they often turn into long involved

back and forthcommunications. I schedule them for a follow-up visit. If they

call with anyquestion that seems like it will take more than 5 minutes to

answer, I tell them toschedule a visit or use the Virtual Visit- email or

phone visit for a price. Icannot spend my time performing unreimbursed

care.My mind is aging andwhat was once a steel trap that could

multi-task and remember every bit ofinformation that entered, no longer

functions that way. I sometimes find myselftrying to multi-task- do a refill

here, a pre-auth there.. in between patients andphone calls.. but soon, I'm

sitting there staring at my desk not knowing what to donext. That approach has

led me to a significant reduction in productivity.Particularly when you

are adding in checking on billing, doing a little marketing,working on a new

logo.. etc etc. Thus, what is saving me now, is compartmentalizingthe day. I

do refills no more than twice a day -all at one time. Same for phonecalls back

to patients (except for urgent ones). I use email as much as possible forlab

notification. I am using certifiedmail for security more and more. I am lookinginto secure phone messaging with tavoca.com http://tavoca.com/> so I can leave voice mails for

folks regarding lab results and more-without playing phone tag. Technically I

am trying to create a layer between myselfand the patient so I'm not drawn

into prolonged, unreimbursed contacts with them.Even if I COULD extract myself

from a live phone conversation with them, the timeand effort of trying to

reach them is ridiculous. They call and ask me to tocall. I call them at

home- leave a message. I try them on their cell- leave amessage. I call them

at work- leave a message. I email them... That is five minutesright there.

Yes, I've tried asking what number or email I should use as their onlycontact-

but then they forget what they told me and regardless, if I don't reachthem on

first try at any number, I'm still wasting my time if there is a better waysuch as secure messaging or secure email.I am doing what Jean

suggestsalso- referrals to specialists are often handled by faxing the

specialist the noteswith a letter and asking the patient to call the

specialist or vice versa. I don't want to be cynical but I do feel that

patients take advantage of those whogive a little extra. Much like dog

training, if you let them up on the couch once,they will always get up on the

couch. I sometimes feel like my patients expect me tobe a prescription

vending machine that they feed useless tokens to rather thanreal money- not

that any form of prescription vending machine is acceptable. I am

available 24-7 to patients by phone and have been for 4+ years... itreally has

not been taken advantage of... but, there is still a cost to me and myfamily... and I have in no way come close to being compensated for it other than

thesatisfaction of providing good (sometimes fantastic) service/care to my

patientpanel. As I make more of the changes noted above, my income is

improving and I feellike I'm gaining control of productivity. But now I wonder

if I'm not going theright direction after reading Gordon's post. Gordon said:

insatiable and unreasonable demands is an inability to meet the

legitimateneeds of the patients. I know that last sentence will make many uncomfortableand possibly defensive, but step back for a second and consider theopportunity to see if an approach that better meets patient needs might solvethe phone call problem.>>I

believe my attempts at meeting theirneeds on their schedule and within their

expectations (meaning they want it free -see anecdote at bottom re: how bad

some of my patients are) has created much of theproblem. Again, using the dog

training analogy- if I am consistent with thestructure of the practice

functions- ie how refills are done, then patients thenknow what to expect and

their expectations are then met. I need to be consistent andso do they.

Certainly, I will make exceptions but not continually. If I " train "

them to utilize the tools I offer such as Virtual Visits, theybenefit by

having the increased access and even lower cost (sort of given lack ofinsurance coverage). Those that cannot accept this structure, should goelsewhere.SO, in re-reading Gordon's post now that I

haverambled on, the key word is legitimate needs of patients. So I will work

on listingwhat I believe legitimate needs are... what do you all think they

are?Myanecdote: my patient is a nurse, in a nurse practitioner

program. I would expect herto have some respect for safe and appropriate care.

She decided she no longer wantedto use transdermal estrogen because the patch

is " ugly " and called askingme to change her to oral estrogen. I have

a STRONG bias against oral estrogen andbelieve that patients need to

understand the differences. This patient is alsooverweight with an elevated

CRP already and has every excuse in the book for why shedoes not exercise or

lose weight. I suggested an appointment in the office or aVirtual Visit to

discuss the ramifications of this switch... she responds that shedoes not have

15 minutes to spend even in a Virtual Visit. She subsequently left thepractice. I did not meet her expectations. I personally would not qualify

herexpectations as legitimate. Again, I am not a free prescription vending

machine.apoligies for the rambling length.Carla

Gibson

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