Letters

Open access worth the effort

To the Editor:

We, too, have made the switch to open access at our rural clinic in eastern Kentucky with surprisingly similar results to Dr. John Giannone's ["Open Access as an Alternative to Patient Combat," January 2003, page 65]. We have seen provider productivity increase as patient satisfaction has increased. Providers and staff like the system, and staff retention has improved. They no longer have to tell parents all day long that we cannot see their sick child. Our system works in an office with busy obstetric care and pediatric care components.

As our patients' out-of-pocket costs and time constraints increase, they almost universally welcome the offer to be seen the same day they call. With open access I am never overbooked and have more time to spend with my patients, a system change that improves face-to-face time!

I feel the key has been to constantly tweak the schedule as we learn about the system. My telephone nurse and I talk several times a week to review future schedules and make adjustments based on historical data from the last 18 months. That is critical.

William L. Melahn, MD
Morehead, Ky.

No quick fixes

To the Editor:

As doctors, one of our greatest faults is adapting to our profession's problems instead of addressing their causes. In essence, we're treating the symptoms and not the disease. Dr. Jodie Escobedo delegated reviewing and OK'ing prescription refill requests to her staff because it was requiring more than an hour of her time ["Rethinking Refills," October 2002, page 55]. Physicians didn't have this problem 10 or 20 years ago. Why now?

More people do take prescription medications these days, but insurance companies are discouraging it by raising co-pays and requiring preauthorizations. We've also seen an increase in paperwork intended to improve care, lower costs and reduce liability risk. But at what price?

We can't do our paperwork between 9 a.m. and 5 p.m. because now we have to see more patients to cover the additional overhead. As a result, we have to hire more help to delegate the refills and authorizations and also to verify eligibility and benefits, make referrals, and bill and collect from the insurers. I could just pack in more patients, but I can't possibly make up the difference.

Let's flash to the not-too-distant future: "Mrs. Smith, the nurse will see you now. Oh, Dr. Jones? He went bankrupt and sold his practice to the nurse practitioner." Think that's too farfetched? Just sit back and watch. Oh, yeah. I forgot. We're doing that already.

Cary D. Douglass, MD
Austin, Texas

The career path less traveled

To the Editor:

I can fully relate to "Choosing Between Clinical Practice and Administration" [January 2003, page 39] by Dr. Carrie Nankervis. I am a residency-trained and board-eligible preventive medicine physician who pursued this specialty because I desired to practice medicine based on science and not solely on "what worked in the past." But to accomplish this, one is often led to an administrative position.

But I, too, loved direct patient care, so I became board-certified in family practice. I immersed myself in clinical practice so much that I literally burned out. I love my patients and my patients love me back, but this healthy relationship became pathologic because I failed to spend quality time alone and with others who were just as important to me as my patients. I have since returned to the saner world of preventive medicine. Here I can maintain the balance to complete life's necessary daily activities.

These stories highlight several things. First, physicians need to admit we are humans with basic needs like sleeping, eating, paying our bills on time, raising our children, strengthening our marriages, etc. We are not machines; we cannot go non-stop. Second, our brains are not computers and we cannot hold every byte of information forced into them. We need the help of other health care professionals and technology to improve the delivery of care.

We as a profession need to rethink how we "raise" physicians; we need doctors who are healthy and well- balanced, not impaired either psychosocially or physically.

Camille Dillard, DO, MPH
Dolgeville, N.Y.

A typical day off

To the Editor:

I can't agree more with Dr. Sanford Brown regarding his Practice Diary entry "Doctor's day off" [November/December 2002, page 69]. I live and work in a rural community in southeast Idaho. My day off starts with 30 to 90 minutes of rounds. Then I spend an hour or two at the office catching up on paperwork, run some other errands and return to the office to answer some messages before the next day's work accumulates. Plus, I'm still on call for my maternity care and hospitalized patients. It's not much of a day off, but it's much less busy than a typical day in practice.

Clay I. Campbell, MD
Montpelier, Idaho