A Short Story - A Day in the Life of a Family Physician in 2007
By Richard Gebhart, M.D., MAFP President, 2003-2004

Once upon a time there was a family physician named Dr. Jones. On the day of this story, Dr. Jones arrives in the office at 8:25 a.m. He feels refreshed after a mid-week day off. Grabbing a cup of coffee, he sits at his desk and turns on the computer. While waiting for it to come online, he inspects a small stack of mail - mostly throw away items. Only a single letter from a consulting physician is found regarding a mutual patient. After reading the letter, Dr. Jones circles two paragraphs of the two-page letter and attaches a note instructing staff to scan the circled items into the patient’s electronic health record.

Turning to the computer screen, he reviews his clinic’s list of hospitalized patients. Surprisingly, Joe Anderson is listed. A couple of clicks on the computer shows that Joe’s pneumonia, which Dr. Jones diagnosed last week, has worsened. But, his vital signs have improved once hospitalized and Dr. Jones’ partner has Joe on an appropriate antibiotic. Picking up the telephone, Dr. Jones calls Joe’s hospital room and chats for a couple of minutes. Joe is feeling better and thanks Dr. Jones for keeping in touch with him. This reiterates the importance of system which allows patients to have a medical home and maintain long term relationships with physicians.

At 8:35 a.m., Dr. Jones opens his email. Only a handful are directly from patients. He is pleased, and recalls he was the one physician who was opposed to establishing email with patients. His fears about being overrun with them have not materialized. That’s because many patients are able to answer their own questions by accessing educational materials via the clinic’s web site or by using the patient information kiosks located in the former waiting room. Also, several of the emails can be answered directly by staff. The emails Dr. Jones handles personally can usually be dealt with quickly and efficiently. Since he is adequately reimbursed for email consultations, he is able to increase his patient load, without having to see all of them in the office.

The first patient email highlights several new symptoms. Dr. Jones advises the patient to make an appointment to evaluate this problem. The second email is about Dylan, an eight-year old diabetic. Dylan is enrolled in an online educational program to improve compliance with diabetes care sponsored by his glucometer maker. He has completed an online questionnaire and read educational updates. This month has gone well for Dylan. He has had no illnesses and only two minor hypoglycemic reactions recorded just before lunch. His blood sugars, which he downloads from his glucometer, appear well controlled. Dr. Jones responds with an encouraging message and advises Dylan to make an appointment to have labs drawn in a month. He rewards the child for his efforts, by electronically okaying 30 minutes of free online computer game time on the hottest game website. A third email is referred from the staff. A young women with symptoms consistent with a simple UTI, meets criteria for treatment according to the ICSI guideline. Dr. Jones orders an antibiotic and relays the prescription to the woman’s pharmacy. A couple of messages from consultants are read and the information is entered into the patient’s medical record at the clinic.

Next, Dr. Jones opens the first of two emails from the clinic’s administrator. Her message to the physicians says the clinic continues to show a positive cash balance. Revenues are up over 6% from a year ago and overhead remains stable. The second email outlines the clinic’s outcome and quality measures from the last quarter. Patient satisfaction is extremely high and clinic’s outcomes are in the top 15% locally and the top 10% for family medicine in the nation. Dr. Jones reviews his own specific outcomes and patient satisfaction data for the month.

An email from the AAFP announces that CMS has agreed to pay family physicians multiple patient management fees for patients with multiple medical problems. It is expected other payers will follow suit. The email notes CMS is continuing to recognize savings and improvements in care outcomes since family physicians whole-heartedly embraced changes first outlined in the 2004 Future of Family Medicine Report.

Feeling pleased and eager to begin the day, Dr. Jones sees his first patient at 9:00 am. George is an elderly man who recently received a diagnosis of CHF while hospitalized. Inpatient records are immediately available. Although patient education was started in the hospital, George seems bewildered with the new medications and worries that they may not be compatible with his other prescriptions. After entering the new medications onto the EHR, Dr. Jones asks for a medication interaction check. He shares the information with George. An examination is completed and Dr. Jones feels he will continue to improve. Questions are answered and Dr. Jones enters the data he has collected by interview and physical examination into the clinic CHF template. Based on the current treatment guidelines, Dr. Jones completes the several prompts the EHR generates. Although familiar with the guidelines, Dr. Jones has not asked George about his pneumococcal vaccination status. George has not previously received this and the vaccine is ordered by Dr. Jones. Follow-up labs are ordered with a click of the mouse and the documentation of the visit is complete. The final minute of the visit with George is used to review the signs and symptoms of early CHF and to introduce the concept of team care utilized by the clinic. After vaccination and lab work, George will continue CHF education with the clinic’s CHF nurse. George seems impressed when told the nurse will call several times a week.

Leaving the patient room, Dr. Jones checks the computer terminal at the nurse’s station. There are several messages for him. Medication refills are authorized by a click of the mouse and immediately the information is sent to the pharmacy. Several patient messages are acted upon and information on how to handle them are instantly transferred to the staff. Time is available between patient visits to personally handle one of the messages, much to the patient’s delight. The rest of the morning continues in the same manner. Office visits are smooth and efficient, with the EHR providing needed information, supporting improved communication and adding efficiency to the office visit. Documentation of office visits by using templates and voice-activated dictation has allowed Dr. Jones to complete everything immediately at the end of the patient visit.

At 11:00 a.m., another patient, Sue, arrives with new RUQ post-prandial abdominal pain and nausea. Suspecting gallstones are the cause. Dr. Jones orders an in–office ultrasound. The images are transmitted electronically and the radiologist calls within 10 minutes confirming gallstones. After informing Sue of the results, Dr. Jones asks the surgeon to see her. Within 30 minutes, Sue and surgeon are discussing the treatment of gallbladder disease. Dr. Jones recalls that with open access scheduling Sue was able to see the doctor of her choice on the day she called. In the past, patients were seen in the ER, urgent care, or added to the schedule as a work-in.

Noon arrives and Dr. Jones has completed 12 in-office patient visits and by 12:10 p.m. all messages are answered. A 50-minute lunch hour is available and Dr. Jones takes a walk. He also has time to read the newspaper. He notes a story on how tort reform legislation, passed a few years back, is making a difference for physicians. Non-economic caps and the arbitration process has allowed many physicians to offer services they had once discontinued due to high malpractice premiums.

At 1:00 p.m., a diabetic group visit begins with 12 of Dr. Jones’ type two diabetic patients. The clinic dietitian and the diabetic educator are ready. They meet in a private, comfortable room designed specifically for group visits. Diet education and a review of oral medication and instruction about exercise are the group topics. Dr. Jones spends time reviewing the labs all 12 patients had drawn within the last hour and makes the appropriate changes in the patients’ care plans. He completes documentation and submits charges for the 12 patients and participates in the last 15 minutes of the patient discussion. The information is generated into a patient registry so Dr. Jones can track how well he is managing his diabetic population.

At 3:00 p.m., Dr. Jones completes a screening colonoscopy and between 3:30 and 5:00 p.m., completes three exercise stress tests. Assisting him is a 3rd year resident from the local FM residency. Online medical resources help Dr. Jones teach the procedure to the young physician in training.

By 5:15 p.m., documentation is completed and messages are answered. Dr. Jones is ready to leave the office. He stops briefly at the nursing home to evaluate a patient at the request of the geriatric nurse practitioner. He is home by 6:00 p.m. for supper with his family. His wife and kids are happy, his patients are happy and Dr. Jones is happy.

The End.

*Writer’s Note: Now read this short story again. Replace Dr. Jones’ name with your name. Does it sound good? This can be achieved if we all work together to embrace the concepts identified by the Future of Family Medicine Project. This is YOUR future!