An Interview with Christine Sinsky, MD
By Sonya Collins
“Innovations in Primary Care” is the theme of National Primary Care Week 2011. Here Christine Sinsky, MD, talks to Progress Notes about an innovative solution to a common problem doctors face. As one of the principle investigators for an American Board of Internal Medicine Foundation primary care initiative, also sponsored by the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital, Sinsky travels around the country observing new models of primary care practice.
When you're out on the road visiting practices, what have you seen that's made you the most excited?
First, my heart breaks when I see bright, well trained physicians spending most of their day on non-physician-level work. Many physicians spend a significant portion of their day doing work that in an ideal clinic would be re-engineered out of the practice or delegated to a more appropriate person on the team. When a doctor doesn’t have enough support staff, he tends to do a lot more on his own: getting supplies, keyboarding orders, typing the visit note, retyping portions of the note into the after-visit summary, then running down the hall, grabbing the note from a printer and taking it back to the patient.
Our time with patients could be more patient-centered as well. Many of us walk into the exam room, look at a computer screen, glance at the patient, and then as we ask questions, we start typing. We are furiously multi-tasking, trying to record the information, while periodically looking over at the patient. Some things get lost.
As I observe other physicians, oftentimes the patient is communicating something really important but the physician misses it, perhaps the depression or the depth of worry, because at that moment his attention is on the computer screen.
But that didn’t happen at a family practice residency program in Quincy, Illinois, where they are piloting “The Office of the Future. ” In this model there are two medical assistants always working with the same doctor, and they have developed an effective model of collaborative care, including collaborative documentation.
One medical assistant (MA) records the initial patient history during the pre-visit rooming process, comes out and tells the physician what she has learned, then they go back into the room together. The physician is able to attend directly and completely to the patient, while in the background the MA records the notes. While the doctor examines the patient, he verbalizes the findings, which the MA also records.
The physician tells the patient and MA the assessment and plan, which the MA records, along with the meds, upcoming labs, appointments and whatever else is required. When the doctor leaves, the MA stays with the patient, prints up all the instructions and reinforces the plan while the doctor goes on to the next patient who is already in an exam room with the second MA. This system allows the doctor to bond with each patient. He has a relaxed visit and a calm clinic day.
Tell us about a patient who seemed to benefit from this innovative model.
One patient I observed had underlying mental health issues and five or six complaints. Instead of frantically taking notes on the character, timing, location, and modifying factors for each of these complaints, which is what many of us do – trying to obtain and record the history according to a billing template – the doctor could step back and look at the big picture; he could explore the patient’s complaints as well as the psychosocial situation and craft a thoughtful plan.
This new model appeared satisfying for the patient and the physician, and also for the MAs, who were able to step up a little in the role they play in patient care.
I often feel that patients leave our offices with a deer-in-the-headlights look. Like, “What do I do next?” It’s hard to assimilate a lot of information. Having it reinforced by another person who is perhaps slightly less intimidating than a physician – I think that’s all for the good. And because the MA was in the room with the physician, she knew exactly what the plan was and could capably reinforce it. I can’t imagine that those changes won’t result in better patient satisfaction and better adherence to the doctor’s recommendations.
As for the doctor, when he leaves the room, he is done with the work for that patient and is ready to turn his full attention to the next person. A few years ago, after I started to dictate [to an audio recorder] while I was in the room with each patient, I felt much less stress as I moved from patient to patient. I realize in retrospect the stress I was previously under: holding all the details from an accumulating number of patients until I had a break when I could record it.
I watched the Quincy physician move from room to room with a clean mental slate. He didn’t have additional work that had to be done after each visit because the history, exam, assessment and plan had already been recorded. Because of this operational efficiency, his practice can make room that day for any patient that calls in. In other practices, where physicians spend 30% of their work output on documentation, this is not always possible. This physician was able to apply his efforts to patients who need access, as opposed to documenting the visit.
How can this model help address some of the problems facing primary care?
We have a primary care physician shortage; in this setting, it isn’t cost-effective to have a system where highly trained people are not working at the top of their capacity, and furthermore, are becoming so discouraged by the nature of their work that they either don’t stay in the field or don’t provide a good model that trainees can see.
I want to help us all see the percentage of our days we, as physicians, are spending doing the kind of work we envisioned ourselves doing when we were in med school. What percentage of the day are we doing work of highest value to our patients? Then I’d say, ‘Lets work together to maximize that time.’ When we apply our training primarily to high-value tasks, and less to administrative and regulatory requirements, I think we will all be happier.
Dr. Sinsky, a board certified internist, practices internal medicine at Medical Associates Clinic and Health Plans, a level 3 Patient Centered Medical Home, in Dubuque, Iowa. She serves on the physician advisory panel for the National Committee for Quality Assurance (NCQA) physician recognition programs, is a member of the Society of General Internal Medicine’s Patient Centered Medical Home (PCMH) working group the American Board of Internal Medicine's Board of Directors and the Institute of Medicine’s Committee on Patient Safety and Health Information Technology. Dr. Sinsky is a frequent speaker on practice innovation, redesign, and the Patient-Centered Medical Home, including for the American College of Physicians, the Institute for Healthcare Improvement, the Patient Centered Primary Care Collaborative as well as private and academic medical centers.
