Work: A New Job

This is tardy. Apologies.

I have this new job. I've had it since last December, actually, but I just started last week, after several wonderful weeks of summer. My job is with Group Health Cooperative, as a family doctor in the Burien clinic.

"Burien," most people say, "why on earth would you go to Burien to work?"

It's my dream job. That's what I thought when I took it, that's what I think now. What's happening there is what should be happening all over the nation. We're practicing a new model of primary care, the "Medical Home," with a goal to be the model clinic on which others build their own practices.

But I can't really help my colleagues spark a health care renaissance until I learn where the bathrooms are, so I'm taking it slow, and I'm grateful that others are dedicated to transitioning me to my job in a humane, rational way. It's a complicated system.

I started last week with several days of orientation: benefits for a day, the electronic medical record (EMR) for two days, and a day of finding the bathrooms and learning how things work in my clinic. On day five, last Friday, I saw my first post-residency patient. Practicing on my very own license.

Yikes.

The support is wonderful, though. The co-op has a great consultation process, using secure email, through which I can ask specialists to comment on the care I'm giving. A quick question with the chart "attached" (we all use the same medical record), and within a day I have recommendations to help guide the care I'm giving. It's great, and helps me to continue learning at a rapid pace.

I've been seeing patients at a slower rate than my much more experienced colleagues, and for this I am grateful. I use the extra time I have to get used to the logistics of delivering care in a new place that is part of a big, complicated, but effective network of resources. It's not always intuitive how to get something done. I use every minute I've got learning how to be more thorough and more efficient.

One of my big challenges--one I'm thrilled to take on--is to integrate technology (our EMR) into visits in a way that engages patients and doesn't shut them out. Often, even with paper charts, the visit can become a kind of one-on-one between doctor and chart, with patients pushed aside while doctors dig for old notes, labs, and results to try to make sense of the patient sitting in front of them. In residency, I had many moments like this, me looking for a mammogram result while the patient looked at me looking down into a mess of paper.

I could easily make the same mistake, though at least it would be a paperless offense. What I've learned though shadowing one of my partners is to use the EMR with the patient to be more thorough, cover every concern the patient brings, and finish the work of coordinating and documenting care before seeing the next patient.

For those readers who don't have to chart for a living, I'll just say that's a huge accomplishment. The norm in primary care is "batch and cue," meaning a doctor finishes seeing a patient and puts the work generated by that visit into a cue--or a pile--to complete at the end of the morning, the day, or even later.

Trouble is, how do we remember everything that happened in the visit? We don't. We start forgetting things the moment the visit ends, and if we don't get to the work (making notes, writing orders, reviewing results) quickly, important things fall out of our heads, and things get left undone. Not good for patient care. Not good for clinic employees. Not good for families of clinic employees.

"Today's work today" is the buzz I've heard among the new model folks. What I'm learning at Group Health is even more immediate: something like "this moment's work this moment." Whatever our patients bring to discuss, we can work on it now.

We have powerful tools available to help us accomplish this, and I hope to write more about these tools and my experience as I learn (I'll bundle these under the label "work").

For now I'll say this. I am happy.