‘Kind of a Shock': Welcome to the Bureaucracy as a New Doc

Medscape

2 days ago

When Jeremy Lipman, MD, first started working as an attending colorectal surgeon, he knew very little about how to code and bill. He would receive weekly emails from medical coders and billers about how he wasn't doing it right.
If he excised a lesion or debrided a wound, the billing team would want to know what kind of debridement he performed and how big the wound was, 'which just never crossed my mind to put into a note but were important for them for billing,' he said.
Lipman finally set up a meeting with the key players on those teams, and they went through charts and showed him what he was doing wrong and what he needed to fix. 'And that was very helpful,' said Lipman, who now works at the Cleveland Clinic, Cleveland.
How prepared a resident is for the bureaucratic tasks required of an attending doctor today — including billing and responding to patient messages in a timely fashion — is 'highly variable,' said John Andrews, MD, vice president of graduate medical education innovations at the American Medical Association.
If a new attending doctor starts at a practice setting that is closely aligned with where they received training, that doctor may learn these skills more quickly, Andrews said. However, if a physician moves from one city to another — or to a different healthcare system — 'the challenges can be greater because you may have a different EHR [electronic health record]. You may have different supports to the team that provides care to your patients,' he told Medscape Medical News .
Also, 'within a large health system, it may be a more seamless path than if you're going into solo practice or joining a small group,' Andrews added.
Time spent navigating bureaucratic challenges may be harder at first because 'you haven't developed the reflexes to do it quickly,' Andrews said. 'And so it takes some time for that to get better.'
Here are tips for new attending physicians as they navigate the great bureaucracy of the American healthcare system.
Learn the Practical Side of Medicine As a Resident
Once a resident becomes an attending doctor, all of a sudden the buck stops with them and that person must navigate tasks such as billing and Medicare and Medicaid reimbursement, Andrews said.
'…For some people it's kind of a shock,' he said. The biggest change moving from being a resident or fellow to an attending physician 'is that you suddenly have independent responsibility for navigating these systems whereas in a training program there's backup or there is an attending physician who is ultimately responsible,' he said.
To help ease this transition, Andrews said medical residents in their final months of training should 'really consciously pay attention to some of the issues that you're going to need to surmount' in your practice as an attending. For example, after seeing a patient, ask the attending doctor how they coded the visit.
Also learn from the attending physician how to work within and coordinate interprofessional teams. 'I think there's an old school model of the physician doing everything,' Andrews said. 'And the truth of the matter is in the current healthcare system; it's a multidisciplinary activity.'
'And being sort of at the head of that team and coordinating the input of people like pharmacists and physician's assistants and physical therapists and occupational therapists and whomever you may have to work with, that's an important skill that people have to learn,' he said.
Meet the Teams
When you're a resident, there is a program director who is responsible for your daily workflow, said Lipman, who serves as the director of Graduate Medical Education at the Cleveland Clinic.
However, 'Once you become an attending, you often have many people that are responsible for different areas of your work.' That can create confusion about what you're supposed to be doing day to day, he explained.
After accepting an attending position, consider setting up a meeting with the key players to ask about documentation standards and billing. 'If you have the opportunity to meet with the biller or coder from your institution to get some tips and tricks, that's great,' Lipman said. There are also billing courses available online.
It is also important to learn how to manage patient communications outside of direct clinical encounters. Find out what other team members, such as nurses and office staff, can manage. Also, ask new colleagues when they answer emails, calls, and MyChart messages, Andrews said. Find out how your new team keeps up with communication and paperwork in a timely manner, Lipman said. Such paperwork includes insurance pre-authorizations, work release letters, Family and Medical Leave Act paperwork, and disability forms.
'If they're not submitted in the right time, patients are going to lose out on disability benefits which can be their financial lifeline if they lose their employment,' Lipman said.
Figure Out What's Important
Once a new attending arrives at their position, 'figure out what the coin of the realm is,' Lipman advised. 'What is the thing that that institution is most focused on as far as a metric for your success?'
'Certainly, we all want to provide excellent patient care,' he said. '…But then there are things like research and committee involvement and education and documentation… What are the other things that become meaningful to your institution and to your leadership so you can focus your efforts in the right places?'
If different people want different things from you, try to figure out who is responsible for what you want, Lipman said adding: Do you want more time for your clinical work? Better operating room times? More leadership opportunities? Find out who can offer you those things, Lipman said 'and that's probably the person that I would defer to.'
It's also important to learn the practice's protocols and regulations and understand how they may differ by setting.
Lipman sees patients in a variety of practice settings including the endoscopy suite.
'And each of those settings has a different level of rules and regulations and how things are done and it's important to understand what those are,' he said. 'What works in one setting doesn't work in another even though it's in the same hospital and so understanding those different rules and regulations is key.'
Also, talk with your new partners to find out what's really important. 'You might be told that there are sort of 10 things that you have to do, but you can talk to your partners and they say: 'Well you know in reality it's just these three things that are super important and the other seven are not', so you have to prioritize,' Lipman said. 'They can help.'
Note that doctors who go into private practice have 'a whole separate' layer of things they must deal with compared with doctors working for larger systems, Lipman said, including making sure they are running their private practice.
Finally, new attendings may want to consider writing down the things that are important in their job currently and what they would like to see in their job 5 years from now, Lipman said.
Then when they are given opportunities or things they're being asked to do, they can reflect on whether those things align with what they have written down that are either currently or in the future going to be important to them, Lipman said.
'And if not, then trying to find ways to either say no or delegate to somebody else.'