In the seven years I have been in practice, what I have learned about actually running one is that to keep the clinic operating smoothly, all employees must be in tune, like a fine orchestra. Physicians might sit atop the theoretical educational hierarchy, but solving issues involving clinic flow, efficiency and quality care for all patients — including the uninsured and underinsured — let alone routine practice pressures, requires everyone to work together. Twelve physicians might practice at Retina Consultants of Houston, but we rely on our technicians and excellent support staff to run it proficiently.

CLINIC FLOW

A well run practice never confuses efficiency with speed.

While each patient deserves your and your staff’s undivided attention, some need it more than others at that particular visit: a patient who develops acute endophthalmitis following cataract surgery, for example, requires more staff time than a patient coming in for a routine postoperative visit following successful retinal detachment repair. Not every patient needs the same technician work-up and documentation. Have a system in place whereby your staff and you know how patients are to be triaged. For example, streamlining postoperative and procedure-only visits will be recognized and appreciated by your patients and staff. Achieving efficiency comes through allocating your finite time, energy and resources appropriately. Teamwork and delegation are key.

A WORD ON SUPPORTING STAFF

I strongly prefer to use a scribe whenever interacting with a patient. It’s not easy in my clinic to give my full attention to the patient while documenting the visit in real time. But, despite my reliance on scribes, I do not cede my responsibility for the content. It is imperative that what is documented is accurate and reflects the patient interaction. This often requires me to review and edit the encounter once a scribe has finished entering the patient encounter, especially following a change in status or a new patient visit. I make every effort to get the charting correct at the first visit as subsequent encounters will be facilitated by a clearly documented plan.

In our 12-physician practice, each physician and his or her scribe assumes total responsibility for their own records. It is up to individual doctors and the scribes to get it right in the medical record.

Our office has been using scribes for seven years; our interested technicians are trained to assume that role. It is generally more efficient to have someone else document while we focus on the patient. I can more fully describe the pathology, the diagnosis and management plan with the patient and the family. Technology is all well and good, but patients deserve to have the human connection.

INSURANCE ISSUES (ARGHH!)

I wish my clinic could function in a bubble. I wish it didn’t matter what insurance, if any, my patients had — I’d prefer that the terms co-pay and deductibles didn’t exist. Unfortunately, I, along with most of you, don’t practice in a bubble. Insurance issues are particularly pertinent when a patient needs surgery or an intravitreal injection. The process of insurance-verification is a monumental task. Again, delegation is critical. However, it is critical to have sufficient oversight and regular educational updates for those responsible for submitting and verifying insurance coverage. This is not a task to trivialize.

Nor is it a task your practice should do on its own. During this verification process, patient involvement is a must. Sometimes achieving insurance approval for a given management plan, even if, or in some cases especially if, an involved pharmaceutical has FDA approval, will require the patient calling the insurance carrier to lobby for his own best interests. Most patients are aware of the paperwork and challenges associated with interacting with insurance carriers. So, make the patient your ally, united towards the goal of optimal visual outcomes that are as efficient and safe as possible.

An even more pressing issue is helping the underinsured or noninsured patient with an acute surgical problem, like a fovea-threatening rhegmatogenous retinal detachment. Where I practice, the doctor’s fee is relatively small compared to the hospital fees; these can often surpass $10,000 for a straightforward, sutureless pars plana vitrectomy. These patients face the risk of the hospital sending their case to collections if they can’t pay, even when the physician has totally written off his or her portion of the debt. In such cases, association with an ambulatory surgical center is invaluable, as the ASC fee may be much less than the hospital’s. It is worth knowing the fees that ASCs in your area charge for specific surgical procedures.

MANAGE GRACEFULLY

If you are outside the exam room of a returning patient, know who the patient is before you walk through the door. Have a system in place, such as a printout, a tablet or a computer screen with the EMR opened to the patient’s information. Review his current information before you say hello. This information used to be readily accessible in the day of paper charts; it remains one of my biggest struggles in the era of electronic medical records. The best solution I have found to date is to make notes at the top of the patient charts in the demographic section. This simple act can carry substantial meaning for the patient and family.

If appropriate, touch your patient. A simple gesture of touching the patient’s shoulder before or after an intravitreal injection can go a long way to allay anxiety and forge a connection. Since at least the 1980s the scientific community has had evidence that a simple, affectionate touch in newborns, termed kangaroo care, can have a multitude of positive effects on subsequent outcomes. I believe the same is true in many instances of doctor-patient relationships, especially when an invasive procedure is part of the encounter, such as retina surgery or an intravitreal injection. Of course, don’t forget to wash your hands before and after doing so!

While the broad media seem to enjoy broadcasting the promises of new therapies, it is equally ready to magnify our perceived shortcomings and transgressions. Prominent cases of alleged fraud and abuses of the system hurt our entire global retina community; New York Times articles highlighting specific ophthalmologists abusing the system detract from the good work the vast majority of us do. But while it is important to be aware of these media reports, put your patient’s interests first. Treat her as you would want to be treated.

There is no denying the frustrations inherent in delivering patient care that we face daily. Still, I try to focus on the issues I am able to directly affect. I agree with the meditation specialist and author Sylvia Boorstein, who says much of our happiness can be influenced by managing gracefully. It is a privilege to care for our patients’ eyes and I am honored to be a part of our global retina community. OM

About the Author

Charles C. Wykoff, MD, PhD, practices at Retina Consultants of Houston and Blanton Eye Institute, Houston Methodist Hospital, Texas.
Contact him at: ccwmd@houstonretina.com