Dr. Head Coach
My Day Off
It was just a couple of days after Christmas when I arrived at the office late afternoon to drop off a stack of work and pick up another stack. As I walked into my tiny backroom office a nurse practitioner who works a few days a week for us said, “Oh, what are you doing here on your day off? I thought you had the whole week off? Must be nice.” I slowed to a stop, adjusting the white coat I was wearing because I had just come from the hospital, and gripped my stack of superbills a bit tighter. “It is a day off clinic for me but…. “ My voice trails off but then I decided to say, “Yes, it’s been great to have some more time with my family this week than usual.” Any further conversation is halted by the home health nurse calling me back. I pick up my huge stack of superbills waiting for me to review before year end - a task that will take up most all the family time left this year - and wave goodbye to the nurse practitioner.
I am a primary care physician and owner of my busy private practice with a couple physician partners. Our aims are patient centric. The medical center is open every day of the year for both urgent and scheduled care visits, serving patients of all ages. We employ physicians, nurse practitioners and physician assistants. Our team includes other very important members: medical assistants, x-ray technicians, phlebotomists, schedulers, triage nurses, office manager and a small army of staff to manage all the third party payor demands and billing. Every member has a job and every job is important. I count on the front desk to greet patients warmly, check them in promptly and get them to the team of clinicians. I rely on my lab staff to process blood and urine samples.
A physician, and especially a physician practice owner, leads the team. But since we all know it’s the practice of medicine and every encounter brings new challenges, my job is most analogous to the head coach. In football, the head coach manages all the assistant coaches and players. The coach is an expert at developing and training athletes. The coach chooses coordinators for the team that are good at their specialty, offensive or defensive. Sometimes the coach needs a sub specialist, like a kicker to secure a field goal. If the coordinator’s offensive plays do not work against the opponent, the game will be lost and it’s the head coach that takes the heat.
The head coach of a football team gets some of the credit for winning a game, but most of the blame for losing. That is the definition of job stress right there. The coach is always thinking about the team, watching videos of recruits, analyzing plays and researching the other teams. Even on days “off” and in the off season the coach is hard at work. The 32 hours of clinic visits printed on the office schedule (the game time), is less than half of the actual time the doctor head coach has her heart and head in the game.
On that day “off” from the clinic after Christmas, my pager woke me up at 6 am. Two more babies were born the night before, making the total four at two hospitals. Three of the four had complications so my physician assistant could not help me round that day. I texted her that I would take care of all the newborns and headed off to the hospital. One baby was small and struggling with low blood sugars and feeding difficulties. Another required several hours of help breathing after birth and needed supplemental oxygen. As I tried to leave one hospital I ran into one of the many nurses who come to see me as a patient, along with her whole family. Thirty minutes later I had heard all about her husband’s declining health, the grandson she was worried about, and my most common complaint…. I can’t get an appointment with you until the end of the month. “Are you taking a long vacation?” I empathize with her frustrations and explain that I do work full time and I will have someone contact her to work her in sooner.
On my way to the next hospital I got a text from a nurse for my patient who was just discharged from the ICU on Christmas day. She has a new diagnosis of colon cancer and an adult son with spina bifida at home. I called the nurse and we discussed her new ostomy and how to help the son. As I pulled into the hospital parking lot a notification from my clinic facebook page pings my phone. There is a negative review left online by a patient who had to wait over an hour to be seen. I make a note to look that up later to see how it can best be addressed. Maintaining a favorable online presence is very important to a private practice.
At the next hospital I inform a mother taking suboxone that contrary to her impression from the OB, her baby was at risk for opioid withdrawal and would need to stay for a minimum of 3 days for observation. She was devastated. Because I didn’t have to get to the clinic, I was able to sit down and process that grief with her. Forty minutes later she dried her tears and felt comfortable with the plan which shocked her an hour ago. While logged into the hospital system I set up some follow up appointments for the babies being discharged. I see urgent messages from staff and patients via the portal so I quickly answer ten of those. In the hospital inbox there is a message from a rheumatologist. As a coach I train my clinicians to recognize the atypical and ask for help when they need it. After he asked me to look at a “weird rash” I identified Gottron’s papules characteristic of dermatomyositis. Since an appointment with rheumatology is a three month wait, I coordinate plays and call in favors to other coaches who trust my experience. In this case the rheumatologist gave the patient a sooner appointment and me some advice on additional tests and treatments to take care of her in the meantime.
No time for lunch, but I grab a granola bar while I head to the office. I promised the supervisor for the medical assistants I would train two of our staff that day how to download and direct messages from all the hospital systems to our EMR system. In private practice we see all insurances and go to all hospital systems. Thus, our team works with a handful of EMR systems, none of which communicate with each other. Two hours later, after many interruptions from the pager, the hospital and other staff, we finished that training. I then accompany my office manager while she terminates a medical assistant whose careless mistakes have put patients at risk. Despite the many positive contributions from this employee over the years, she has to go. When my patient develops septic shock from an e coli bladder infection because the lab staff forgot to check their alerts, it’s my name that will be “in the newspaper”, not the linebacker who missed the tackle.
My day “off” is only half over. I haven’t seen any of my children or my husband all day. I am still wearing my workout clothes, but never made it to the gym as I had hoped. On my way back to my desk my administrator stops me to tell me that another physician assistant called in sick. She begs me to work for a few hours to absorb some of the many urgent care patients piling up. The other clinician working that day is new and needs extra time to see patients. Since I am an experienced coach I can analyze plays and come up with strategy twice as fast. The office manager quickly puts 10 patients on my schedule for a two hour period, which is as many as the other clinician will see all shift. I also discuss a contract issue with the office manager about a physician we are recruiting. We have been short staffed for months and it’s wearing on us all. Finally, I text my husband to tell him that I will not be home as I had planned. I hope to make it home by dinner, which he will make for our family.
This brings me to the point at which I walk to my desk and the nurse practitioner asks me if I’ve been enjoying all my time “off” for the holidays. As head coach I am always playing the long game. It’s not a “clock in and out” job. It’s not shift work, it’s a calling. I spend late nights pondering my patients and partners. I spend hours educating staff and reviewing “plays” from the less experienced team members. I review and sign off on charts and catch many mistakes before they cause a problem. I scope out new recruits and make the tough decisions to get rid of anyone who may prevent us from winning the game. Winning, in this case, means providing timely, patient-centered care based on best practices. Winning is helping our patients navigate this complex and unwieldy healthcare system. Winning is making sure the critical game-deciding plays are executed perfectly. After all, a lesser trained clinician can throw an algorithm based cocktail at every cough that walks in and be right most of the time. But it takes an experienced head coach to find the cough that is a pulmonary embolism or the rash that is dermatomyositis. That play matters. It’s a life or death, win or lose outcome for that one person. Someday that one person may be you, or your loved one.
All our loved ones deserve physician-led team based care. If the defensive coordinator suddenly decides he can win a football game all by himself, the offensive game will suffer and the special teams will be off target. We can not win for our patients without a head coach, and those patients deserve to have a physician head coach... the standard of care!