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Subject:  Re: OT: Career crisis Date:  10/16/2005  1:06 PM
Author:  xraymd Number:  212641 of 312945

Greetings, blkmagwom, thanks so much for your input. As it turns out, I am a fast typist (I was actually a PROGRAMMER prior to leaving for medical school in 1994!). What is much harder for me is the wending through a byzantine set of modules, each of which has its own little rules for data input, many of which have checkboxes or radio buttons, and many of which require clicks to shut off pop-up boxes requesting more detail. And the WORST of which is that I am now required not just to type what I used to handwrite (that's not so very hard for me) BUT that I must, at the end of the patient encounter, be prepared to SEARCH over a specific database whose search terms are different in many cases from common medical parlance to try to find codes to assign to each of the diagnoses that I arrive at that I used to be able to handwrite without those codes (we have a professional coder on staff who assigns the codes). And that impacts my accustomed thoroughness - one of the things my patients say they most appreciate about me - because for every code *I* now have to hunt down and assign, that's yet another entire branch of modules I have to make my way through even when I already KNOW the code. Heaven help me if I DON'T already know it, because it's about a 50-50 chance it will be in the database. And again, I still have to spend extra time processing this info electronically even when I find it. The big kick in the head is that the program will literally NOT MOVE FORWARD unless all codes are resolved - so I end up with sessions that don't close and patients stacking up waiting to be seen because I am fighting with the computer. Thus I have taken to saving all my documentation for the end of the day, and that's why I've been in the office night after night after night until well after 9pm. I've been asked to be not just a physician anymore. I've been asked to become a data entry expert and a coding expert. And adding further insult to injury, if I manage to match a code to a diagnosis and wish to write prescriptions based on it, I have to continually re-enter my password for every single prescription I print off from the computer - and sometimes I can't even find the desired medication in the Rx database! Is it any wonder I throw up my hands and revert to paper and written Rx's? And then I have to record what I've done for later transcription into the computer.

Can you hear the screaming from Tucson yet? :-)

The equivalent to what you proposed, regarding dictation as a form of one level of indirection of data entry into the computer, would be simply to let me do what I have DONE SUCCESSFULLY TO DATE. That is, allow me to continue paper charting and have someone else input my patient encounters on paper into the computer asynchronously, rather than MY doing it. My handwriting is perfectly legible (so I am told). I have always written down in duplicate what Rx's I've written and I have always put all of my diagnoses on the checkout ticket as well as on my assessment and plan on paper - I just never before had to find codes for every single stinking one of them (many of the codes I do know and do put). The other docs who have adapted are simply shortcutting how much information they used to capture, because they can't afford to get bogged down by the limits of the system. And they are online in front of their patients so they don't have to spend an additional half-day at the end of the day encoding the encounters. On paper, I could get the work done simultaneous with a patient visit. Online, I can either choose to spend X amount of time wrestling with the system while the poor patient in front of me grows weary of the interruption this causes - or I can choose not to cause delays in patient throughput and save the whole battle for later, which I've ended up doing. But there are just not that many hours in the day to get it all done and still have me thrive. And the management is recalcitrant - they are just not going to allow me to go back to paper charting. So it's become something of a standoff and I am going to drop over from sheer exhaustion. I am being scrutinized to see where I can "streamline" what I've already learned to do in documenting, and that's fine, but it just DOES NOT ADDRESS the issue that I don't want to be doing this in front of patients, nor does it address the issue that it still takes me 3-5 times as long to input the data than it did to write by hand my progress notes. I used to get home by 7 or 7:30pm (still a long day but way better than now). Now if I try to stay till all the work is done, I never leave before 9pm and often not even before 10pm. Something I have not even mentioned yet is that I am walking out to my car in a deserted parking lot night after night in the dark - and there is no security to call to escort me. Of course the "answer" to that is perhaps I should take all the work home with me since I can get online from home. But clearly, the real answer is to separate me from this crazy requirement to keep fighting with this system and let me get back to my prior level of productivity as I've been accustomed to operating at, with tremedous reduction in stress level.

The bottom line is that there is going to be a cost, one way or the other. The practice will lose me (and will have to find another physician to take on the work I've been doing - and they haven't been getting great bites so far) or they will have to spend money to get someone to code my encounters. The price paid, so far, is that I am thoroughly burned out and am quickly getting bitter. Not every physician is going to adapt equally to this system and I have long said that they have erred in not planning for failure. And this is a failure of colossal proportions. I miss feeling like I am both productive and rested. I miss feeling like I am an asset to the organization. I am coming dangerously close to saying "take this job and shove it" which would be a tragic outcome but is a very likely one given the degree of stress this has created, and in my view, unnecessarily. But it is what it is and I must make my decisions in light of the constraints I am placed under.

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