Posted by: notdeaddinosaur | August 11, 2011

Huddle of One

There’s nothing new under the sun, or in medicine. I’m not talking about monoclonal antibody targeted chemotherapy; I’m talking about taking care of patients, and specifically about running a medical practice. Not even the incursion advent of all our fancy new electronics has (or should have) a fundamental effect on how we take care of our patients.  The latest thing to come down the pike is the so-called Patient Centered Medical Home, a collection of policies, procedures, and practice re-structuring (webinars, templates, guidelines, etc. all available at low, low prices, of course) that essentially makes large group practices function like a solo doc from the patient’s point of view.

Because the buzzword of this new model is “teamwork”, we’re all supposed to begin the day with a brilliant new concept called the “huddle“:

The team huddle is promoted by many clinicians and practice coaches as an innovative approach to support medical home transformation through visit pre-planning, team building and communication, and workflow redesign.

Radical!

One problem: how do I do that all by myself? I mean, here’s what I generally do every day:

  • Make sure to arrive at least 30-60 minutes before the first scheduled patient
  • Look over the schedule to get a sense of the day, who’s coming, who may need extra time, any new patients
  • Double-checking that rooms are re-stocked with key supplies (ie, three paps on the schedule; wasn’t the speculum drawer low the other day? Couple of well baby visits; enough needles for all their shots? Better top up the bin from the supply closet.)
  • Looking over the charts (now electronically; previously the paper ones — adding pages, seeing whose insurance info needs updating, etc.)
  • Go over all the above with staff whenever they arrive (usually after me)

I’ve always just called it “getting ready for the day,” an organizational strategy for business management that’s called “being prepared” in most other occupations. But now it has a new name: the Huddle. Complete with instructional videos, for chrissakes.

As far as “patient-centered-ness” goes, I’ve used a somewhat different set of concepts from Day One called “Customer Service”. Having people instead of machines answering the phone, same-day appointments, personally communicating test results; all Disney-level customer service, now re-named things like “Open Access”, have been integral to my practice from the git-go.

Why is it happening? One of the oldest reasons in the world, of course: money to be made. I’m sure there are too many doctors and medical practices out there who, sadly, need this kind of help. Sadder still, they have to be force-fed it under the guise of running a “more efficient” practice.

Whatever happened to good old common sense? Next thing you know they’ll be all over us making sure we wash our hands. (Joke intended.) Seriously, though. This whole thing about co-opting perfectly sensible things from other industries for medicine — checklists, for example — and carrying on as if having re-invented the wheel is getting old.

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Responses

  1. The Patient Centered Medical Home is really the Adminstrator Centered Medical Home. The entire mess is designed to reduce time that the doc has to spend interacting with patients, and turn her into a glorified team leader/social worker/data entry clerk. All the medical care will be provided by a rotating cast of NPs and PAs. Patients generally hate it. That the AAFP fell for this load of crap is pathetic beyond words.

  2. “The Huddle” reminds me of WalMart. Put your artificial smiley face on.

  3. All the things you do when you come in 30-60 minutes early in terms of getting reading for patients could be done by a well-trained, Certified Medical Assistant (one who’s been in a CAAHEP accredited medical assisting program and then certified by sitting for the national exam). I’m out of the field for many years now, but I can definitely tell when assistants have studied and been trained in both front and back office medical assisting vs learning on the job but no foundation of a 2-3 year college program. (Making sure supplies are in the drawers is surely not a good use of your time, e.g.)

    Just an aside.

  4. Hope you won’t have to sing the Walmart song….But seriously all this twaddle about the “medical home” and “huddle” and the medical “team” (yeah, sure it’s a team till the fecal matter hits the fan, then guess who’s responsible) is just another example of people who don’t do what we do trying to tell us how we should do it. And they are making money by the ton. It is also, as southern doc pointed out, a load of crap. And don’t even get me started on the AAFP.

  5. That video you link to is hilarious!

    The poor doc leading the official “Wednesday Huddle” starts off with “Well, I know lots of you haven’t read the bulletin/agenda, but can anyone think of something they’d like to talk about”!!!! A classic unnecessary, time-wasting meeting. All those (on the time clock) people should be out taking care of patients, not standing around having a Huddle that they can document and then document that they documented it so they can keep their NCQA PCMH certification.

    I disagree with you about the point of the PCMH: it’s actually intended to force lean, efficient, cost-effective small practices function like bloated, administrative-heavy large groups

  6. Times sure have changed. This post just made me think back to the family doc I had when I was a child. He had his exam room and waiting room in his home. He could walk from his exam room to his kitchen and grab a cup of coffee in between patients. You never ever had an appointment; his office opened up at 1pm every day (each morning he took care of his hospital patients across the street). Everyone would wait on his front porch for his wife to open up (she was his secretary). We’d all wait our turn – first come, first served (quite efficient). If we noticed someone was a lot sicker than we were, we’d tell them to go on in to see the doc first as they didn’t look so good! There was no MA or PA or nurse in the office; just the doctor. He’d check your vitals, ask what was wrong, mumble a few things, do a quick and thorough exam, and write out a Rx in scribbled handwriting (which I sometimes could read.) If you needed tests at the hospital, his wife would call over to set it up for you, and she’d write you in for a follow-up visit on a particular day, and would take your payment. It was a simple, efficient operation. He’d have visiting hours until everyone was seen; didn’t matter how long it took. You’d drive by in the evening and still see patients in his waiting room. There was never a time limit on a visit; you could spend all the time you needed in there. Occasionally, he’d stick his head out to the waiting room and announce, “Folks, I’ve got a baby coming at the hospital and I’ve got to go. If you want to wait for me … well, hard to say how long it will take.” Some folks would get up and leave after that and others would stay to wait for him, looking out the bay window towards the hospital and they’d announce “Here he comes!” when he come back from the hospital later on. He also did house calls back then if you were too sick to come to the office. I don’t know how he managed it, as he was one of the few family docs in the community. I think of how complicated medicine has gotten now, all the regulations, rules and insurances, etc., and I wonder what he’d have to say about it – but I’m sure it would be entertaining. He retired in the early 1980s and got out before things got so crazy. Teamwork, conferences, etc. – he didn’t have anything like that; just he and his wife and I don’t know how they managed it.

  7. I routinely arrive 30-60 minutes prior to my first patient. I open the office 90% of the time and go over phone calls, emails, and plans for the day. I have a list for my first MA to do when she comes in to keep things moving. Starting early or on time keeps the day mostly on time, outside of emergencies.
    I heard about the golden days of medicine, prior to HMOs and pretty much any insurance plans. Nowadays calling to the hospital is not a direct option for tests. Prior auths with prior auth certification numbers and 10-20 min phone calls with the prior auth for the insurance are the only way to get CTs/MRIs done. Labs must be done at capitated national labs, such as Quest and Labcorp. Many plans do not pay for us to draw blood on the same day as an office visit, and the $3 for drawing blood from the few plans that pay often is not worth it.
    I keep an open access with 2-4 slots blocked each day for same days. I add on same days prior to reg hrs, at lunch, and at the end of the day. Same days usually are easy and keep the patients from going to Walgreens for the Take Care.

  8. Fortunately we don’t have this crap in EMS. At least not yet, but I expect it soon. I have no doubt that someone is making a lot of money off of this idea, but I also doubt that it is the doctors or their practices.

  9. Dear H of 1 Love the comments

    Here’s an idea what if we make the patient an active participant in the patient centered model-
    Still smoking? why I it wll kill you–
    still over weight, see previous comment..
    How about the drinking? see previous two comments, colonoscopy/mammo/etc as required? see previous three comments

  10. You’ve got “huddles,” we’ve got “timeouts.” Both of which exist to retain consultants more than provide good care – buzzards feeding on the carcass of the doctor-patient relationship. Thanks for keeping it real.

  11. Who writes this drivel? Huddle? Teamwork? Here’s a novel idea…let docs do what they do best and keep the government out of it. Personally, I panic when I see the word “teamwork” because it always means I’m going to get screwed.

  12. “let docs do what they do best and keep the government out of it.”

    Sorry to knock down your strawman, but this doesn’t have anything to do with the government. It’s entirely the creation of the incompetent primary care professional societies.


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