Re: access

[Guest guest]

I think a lot about how others are doing "unfettered access". Does that mean a

patient can call you at 3:00 a.m. and you'll see them? How about as you are walking out the door to meet

someone for dinner? How do you live your life with kids and family and friends when

patients know they can call anytime? My patients CAN call me 24/7, but I can't always see them in

the office since I have little kids, a mom to take to the dentist, etc. is not always available to watch the

kids and mom, he has a life, too. I need to get a lot of sleep as well.

Hints? Suggestions? Ideas?

To: practiceimprovement1 Sent: Monday, October 13, 2008 4:12:56 PMSubject: access

this is a snippet from JAMA which excerpted it from the ls of Internal medicineProving once again that we as IMPs are on the right track when we do open access,/ unfetterd access-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

I think the questions you ask are what all of us would ask when we first take on UNfettering our access. But unfettered access is not burn out modeFor one thing when you stop the rules and barriers to you you will get fewer calls.

I forget all the theory behind that .There is some guy named uh Senge I think, he wrote something called the fifth discipline I think.,and I think I he called it the tragedy of the commons but what it boils down to is that when we or anything ,makes itslef so scarce then people want it more. People try to access us more and more becasue they actually can less and less. When you stop the rules like " we only do new patients at 1 pm " or we only do physicals at 8 30 and 1 " and offer anyone who wants one an appointment that day for any reason at all that they want one for, you " obviate the demand " for later. Especially think about it when patients get what they need like all their refills and when they get what they need at a visit they are simply not going to call you later

The fear of the 3 am demand for sore throat care comes from all of us feeling so put upon If that really happened ,a 3 am call about sore throat then that patient just needs a can we talk for a minute let me see you must be hurting pretty bad do you have to get up for work in a couple of hours what are you thinking is going on ,conversation . There is usually some fear or pressure about work or maybe ther e is that mother in law in the background telling him he has X horribleness.BUt we have all been trained for so long to get all worked up and start saying what we CAN " T do first.,becasue we have been battered in our trainign and other practices to wan tto shoot the damn phone.

The whole point of who we as iMPS practice is to be good to patients in ways that are accessible but of course to have a life What is most useful is for you to think of ways to say what you CAN do . I can see you X, OH let me see how I can help, not to throw up the barriers first becasue we have been taught to protect ourselves We have been so trained to TRAIN PATIENTS well they aren't dogs you cna't train them You a re the one with the education.

Unfortunatley someone on t he list serv said recently " they will take advantage of you in a second " about patients well THEY will not take advantage that is rough thinking but it is what we come out of our training with ,THEY a re looking for someone to help them and are used to being sent here and there, told to wait, and then when they get in the room " their " doc not knowing who they are

When we as docs have room to breath and slow down and stop viewing the patien as the enemy but as someone else who has kids and has just as busy a life as we do then we can offer unfettered access andi t works

The other IMPS are not lying NANcy This stuff worksThe more barriers you throw up the more the barriers get battered .Lower the barriers and you will find that an occaisional call while at you kids' soccer game means nothing When you say to the paitetn ouch that sounds awful can I see you in the morning that works,

When you say what you CAN do ,people hear that you care, and few expect you to drop what you are doing .THEY do not know you a re at soccer game they are just trying to find out when you will be around They are just asking (ok once before I did this practice someone called me at 9 am on Christmas and said Are you in the office today? No,I said " it's christmas " Beats me , they seemed sane.)

There maybe some folks who really want you to do a new patient physical at 9 pm but that is pretty rare and frankly that poor guy has a tough schedule.! so just say what you CAN do.Of source you have a schedule you stick to and have a life. And of course there will be the occasional time that you just can't get in there or someone just can't wait but it is not common " Course it is always when I go away...

One patient recently I have seen her through, well, she started here fairly well, age 62 teaching ,had some allergies, then she got a bizarre ischemic optic neuritis and then she had a spontaneous csf leak undiagnosed in the local ER and I sent her to portland and she had a cribiform plate repair and now she is happily retired and just fine and I saw her mother at home til she died etc etc and she was in recenlty and I say , so, I say, being a good IMP, and asking about confidence ,I say MAry, are you confident you can manage your health problems and she says " I am since I know I can get you anytime "

That accessibility make s huge difference for people But accessibility doe s not mean I am rushing in here every two seconds to see stuff I umm have never seen anyone on a saturday becasue I live half an hr away form my offcie....

Once or twice I have offered though since I am no longer afraid ,I offer " I am going to be in FArminton this afternoon I say, if you want.. " and they usually say oh no don't bother on saturday I will call y ou if I get worse "

Does that help you NANcy? One problem is money- since we are all feeling so beset by the crap with insruacne etc we mix up our anger issues over insruacne and regulations and evil " reimbursement " issues with taking care of p eople .I do. Very hard to keep them separate The patient can't help it that they are poor and have medicaid that will pay you 19.00 for a visit.

I think a lot about how others are doing " unfettered access " . Does that mean a

patient can call you at 3:00 a.m. and you'll see them? How about as you are walking out the door to meet

someone for dinner? How do you live your life with kids and family and friends when

patients know they can call anytime? My patients CAN call me 24/7, but I can't always see them in

the office since I have little kids, a mom to take to the dentist, etc. is not always available to watch the

kids and mom, he has a life, too. I need to get a lot of sleep as well.

Hints? Suggestions? Ideas?

To: practiceimprovement1

Sent: Monday, October 13, 2008 4:12:56 PMSubject: access

this is a snippet from JAMA which excerpted it from the ls of Internal medicineProving once again that we as IMPs are on the right track when we do open access,/ unfetterd access

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax

[Guest guest]

I think I agree with Jean!? Before my physician daugther joined me in June, I

had been on call for 2.5 years. Three calls after 10 PM in that time, one call

after midnight and several weekend visits a year, especially during ski season.

With open access(advanced access). I begin most days with at least 80% of my

schedule open and so can see everyone who needs to be seen, and have enough time

to do refills and ongoing care, even in acute visits-when the patient feels up

to it.

Since everyone knows I will also see them the next day at the latest, few calls

for the reasons states below. Occasionally, I do get the injured or sick

walk in at 5 PM, and if they are my patients I will see them.

Most people have my cell phone number, since I leave it on my answering machine,

and they do call me at times, but I can control it. The more certain the access,

the less likely it is used.

________________________________

From: on behalf of

Sent: Tue 10/14/2008 7:51 AM

To:

Subject: Re: access

I think the questions you ask are what all of us would ask when we first

take on UNfettering our access.

But unfettered access is not burn out mode

For one thing when you stop the rules and barriers to you you will get fewer

calls.

I forget all the theory behind that .There is some guy named uh Senge I think,

he wrote something called the fifth discipline I think.,and I think I he

called it the tragedy of the commons but what it boils down to is that when

we or anything ,makes itslef so scarce then people want it more. People try

to access us more and more becasue they actually can less and less. When you

stop the rules like " we only do new patients at 1 pm " or we only do physicals

at 8 30 and 1 " and offer anyone who wants one an appointment that day for any

reason at all that they want one for, you " obviate the demand " for later.

Especially think about it when patients get what they need like all their

refills and when they get what they need at a visit they are simply not going

to call you later

The fear of the 3 am demand for sore throat care comes from all of us feeling

so put upon If that really happened ,a 3 am call about sore throat then

that patient just needs a can we talk for a minute let me see you must be

hurting pretty bad do you have to get up for work in a couple of hours what

are you thinking is going on ,conversation . There is usually some fear or

pressure about work or maybe ther e is that mother in law in the background

telling him he has X horribleness.BUt we have all been trained for so long to

get all worked up and start saying what we CAN " T do first.,becasue we have

been battered in our trainign and other practices to wan tto shoot the damn

phone.

The whole point of who we as iMPS practice is to be good to patients in ways

that are accessible but of course to have a life What is most useful is for you

to think of ways to say what you CAN do . I can see you X, OH let me see how I

can help, not to throw up the barriers first becasue we have been taught to

protect ourselves We have been so trained to TRAIN PATIENTS well they aren't

dogs you cna't train them You a re the one with the education.

Unfortunatley someone on t he list serv said recently " they will take advantage

of you in a second " about patients well THEY will not take advantage that is

rough thinking but it is what we come out of our training with ,THEY a re

looking for someone to help them and are used to being sent here and there,

told to wait, and then when they get in the room " their " doc not knowing who

they are

When we as docs have room to breath and slow down and stop viewing the patien as

the enemy but as someone else who has kids and has just as busy a life as we

do then we can offer unfettered access andi t works

The other IMPS are not lying NANcy This stuff works

The more barriers you throw up the more the barriers get battered .Lower the

barriers and you will find that an occaisional call while at you kids' soccer

game means nothing When you say to the paitetn ouch that sounds awful can I

see you in the morning that works,

When you say what you CAN do ,people hear that you care, and few expect you to

drop what you are doing .THEY do not know you a re at soccer game they are

just trying to find out when you will be around They are just asking (ok once

before I did this practice someone called me at 9 am on Christmas and said

Are you in the office today? No,I said " it's christmas " Beats me , they seemed

sane.)

There maybe some folks who really want you to do a new patient physical at 9 pm

but that is pretty rare and frankly that poor guy has a tough schedule.! so

just say what you CAN do.Of source you have a schedule you stick to and have a

life. And of course there will be the occasional time that you just can't get in

there or someone just can't wait but it is not common " Course it is always

when I go away...

One patient recently I have seen her through, well, she started here fairly

well, age 62 teaching ,had some allergies, then she got a bizarre ischemic optic

neuritis and then she had a spontaneous csf leak undiagnosed in the local ER

and I sent her to portland and she had a cribiform plate repair and now she

is happily retired and just fine and I saw her mother at home til she died etc

etc and she was in recenlty and I say , so, I say, being a good IMP, and

asking about confidence ,I say MAry, are you confident you can manage your

health problems and she says " I am since I know I can get you anytime "

That accessibility make s huge difference for people But accessibility doe s

not mean I am rushing in here every two seconds to see stuff I umm have

never seen anyone on a saturday becasue I live half an hr away form my

offcie....

Once or twice I have offered though since I am no longer afraid ,I offer " I am

going to be in FArminton this afternoon I say, if you want.. " and they usually

say oh no don't bother on saturday I will call y ou if I get worse "

Does that help you NANcy? One problem is money- since we are all feeling so

beset by the crap with insruacne etc we mix up our anger issues over

insruacne and regulations and evil " reimbursement " issues with taking care of p

eople .I do. Very hard to keep them separate The patient can't help it that

they are poor and have medicaid that will pay you 19.00 for a visit.

On Tue, Oct 14, 2008 at 8:42 AM, nancy blake <nancycblake@...

> wrote:

I think a lot about how others are doing " unfettered access " . Does that mean a

patient can call you at 3:00 a.m. and you'll see them? How about as you are

walking out the door to meet

someone for dinner? How do you live your life with kids and family and friends

when

patients know they can call anytime? My patients CAN call me 24/7, but I can't

always see them in

the office since I have little kids, a mom to take to the dentist, etc.

is not always available to watch the

kids and mom, he has a life, too. I need to get a lot of sleep as well.

Hints? Suggestions? Ideas?

________________________________

>

To: practiceimprovement1

<mailto:practiceimprovement1 >

Sent: Monday, October 13, 2008 4:12:56 PM

Subject: access

this is a snippet from JAMA which excerpted it from the ls of Internal

medicine

Proving once again that we as IMPs are on the right track when we do open

access,/ unfetterd access

--

If you are a patient please allow up to 12 hours for a reply by email/

please note the new email address.

Remember that e-mail may not be entirely secure/

MD

ph fax

--

If you are a patient please allow up to 12 hours for a reply by email/

please note the new email address.

Remember that e-mail may not be entirely secure/

MD

ph fax

[Guest guest]

I think I agree with Jean!?.

This is your first time?I am an acquired taste, they tell me...-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.

Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

I think I agree with Jean!?.

This is your first time?I am an acquired taste, they tell me...-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.

Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

I think I agree with Jean!?.

This is your first time?I am an acquired taste, they tell me...-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.

Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

I hear what you're saying Jean. i agree, most patient's would not and do not abuse access. I have given nervous, new parents my cell phone #, and other patients as well. I do not mind the calls at the kids scoocer games, that doesn't bother me. And I recently was out on a Saturday, alone without kids (!) and a patient called. It's a 3+ hour wait at the Urgent Care. I told her meet me at the office, saw her for 5 minutes, everyone is happy.

My medical assistant, Michele, doesn't say "no" to patients. She says, let's see what we can do. She says let's talk about what works. Maybe the whole concern I have is getting this place up and IMPing, which we are pretty good at, but not completely, because of the access. I have someone cover for me once a year or so, but otherwise I am 24/7. Maybe I AM doing the right thing and don't even realize it...

To: Sent: Tuesday, October 14, 2008 10:54:12 AMSubject: Re: access

On Tue, Oct 14, 2008 at 10:29 AM, <Jim.Kennedy@ uchsc.edu> wrote:

I think I agree with Jean!?

.. This is your first time?I am an acquired taste, they tell me...-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax

[Guest guest]

Of course not, just had the usual issues reading through your note.

________________________________

From: on behalf of

Sent: Tue 10/14/2008 8:54 AM

To:

Subject: Re: access

On Tue, Oct 14, 2008 at 10:29 AM, <Jim.Kennedy@...

> wrote:

I think I agree with Jean!?

.

This is your first time?

I am an acquired taste, they tell me...

--

If you are a patient please allow up to 12 hours for a reply by email/

please note the new email address.

Remember that e-mail may not be entirely secure/

MD

ph fax

[Guest guest]

So yeah I hear you saying " to get the practice up and Imping " but then you say you are, sofirsttell me why you do not think you are " Imping " Why do YOU think?' and then tell me why you are. Offlist or on. Either (People will tell us if they want us to get off list becasue we annoy them)

I would ask two for instances-1.Are you having a balance of patients- are supply and demand in balance? or are you not full, or are you too full and sorting that out?2. Are you using HYH? that part is crucial (well to me . I know ,I will bring on someone saying but I am an IMP I just do not use HYH-- OK,OK but how you gonna prove it ? Good intentions do not make a plan)- wherein you get empowered patients that have confidence that they can problem solve, measuring your feedback on access and efficency and seeing if the patients with many docs know who is in charge, seeing if YOU know and are not surprised by, the measures they self report as issues on HYH.

And being obsessed is good . obsessed and driven towards quality and safety and the prusuit of happiness Or well 2 of those 3Damn I was gonna be mature today but I guess it doesn't suit me..

I hear what you're saying Jean. i agree, most patient's would not and do not abuse access. I have given nervous, new parents my cell phone #, and other patients as well. I do not mind the calls at the kids scoocer games, that doesn't bother me. And I recently was out on a Saturday, alone without kids (!) and a patient called. It's a 3+ hour wait at the Urgent Care. I told her meet me at the office, saw her for 5 minutes, everyone is happy.

My medical assistant, Michele, doesn't say " no " to patients. She says, let's see what we can do. She says let's talk about what works. Maybe the whole concern I have is getting this place up and IMPing, which we are pretty good at, but not completely, because of the access. I have someone cover for me once a year or so, but otherwise I am 24/7. Maybe I AM doing the right thing and don't even realize it...

To:

Sent: Tuesday, October 14, 2008 10:54:12 AMSubject: Re: access

On Tue, Oct 14, 2008 at 10:29 AM, <Jim.Kennedy@ uchsc.edu> wrote:

I think I agree with Jean!?

.. This is your first time?I am an acquired taste, they tell me...

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax

-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD

ph fax

[Guest guest]

I do not use HYH. I think because many of my patients do not have internet, nor will

be very open to using Internet (not secure enough, blah, blah,blah ) as well as I like

the personal touch. I use AC, and the summary page has all their meds, problems, specialists, tests

and such. I review it pretty much at each visit. I know we can do HYH on paper in the office, but

my patients have a hard enough time just filling out their "why are you here?" 2 line form. I could educate

them, sure, and may consider HYH.

I just realized that my biggest challenge is that to survive financially, here in a dead zone, I need

to see about 15 patients a day. HYH will be quite time consuming at first, don;t know if

\my completely disorganized mind can handle it right now.

To: Sent: Tuesday, October 14, 2008 4:53:29 PMSubject: Re: access

So yeah I hear you saying" to get the practice up and Imping "but then you say you are, sofirsttell me why you do not think you are "Imping" Why do YOU think?' and then tell me why you are. Offlist or on. Either (People will tell us if they want us to get off list becasue we annoy them)I would ask two for instances-1.Are you having a balance of patients- are supply and demand in balance? or are you not full, or are you too full and sorting that out?2. Are you using HYH? that part is crucial (well to me . I know ,I will bring on someone saying but I am an IMP I just do not use HYH-- OK,OK but how you gonna prove it ? Good intentions do not make a plan)- wherein you get empowered patients that have confidence that they can problem solve, measuring your feedback on

access and efficency and seeing if the patients with many docs know who is in charge, seeing if YOU know and are not surprised by, the measures they self report as issues on HYH.And being obsessed is good . obsessed and driven towards quality and safety and the prusuit of happiness Or well 2 of those 3Damn I was gonna be mature today but I guess it doesn't suit me..

On Tue, Oct 14, 2008 at 12:27 PM, nancy blake <nancycblake@ yahoo.com> wrote:

I hear what you're saying Jean. i agree, most patient's would not and do not abuse access. I have given nervous, new parents my cell phone #, and other patients as well. I do not mind the calls at the kids scoocer games, that doesn't bother me. And I recently was out on a Saturday, alone without kids (!) and a patient called. It's a 3+ hour wait at the Urgent Care. I told her meet me at the office, saw her for 5 minutes, everyone is happy.

My medical assistant, Michele, doesn't say "no" to patients. She says, let's see what we can do. She says let's talk about what works. Maybe the whole concern I have is getting this place up and IMPing, which we are pretty good at, but not completely, because of the access. I have someone cover for me once a year or so, but otherwise I am 24/7. Maybe I AM doing the right thing and don't even realize it...

From: <jnantonucci@ gmail.com>To: Practiceimprovement 1yahoogroups (DOT) comSent: Tuesday, October 14, 2008 10:54:12 AMSubject: Re: [Practiceimprovemen t1] access

On Tue, Oct 14, 2008 at 10:29 AM, <Jim.Kennedy@ uchsc.edu> wrote:

I think I agree with Jean!?

.. This is your first time?I am an acquired taste, they tell me...-- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax -- If you are a patient please allow up to 12 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD 115

Mt Blue Circle ph fax