Excerpts from a Doctor's Personal Journal

Guest Post by ANONYMOUS PHYSICIAN

4/18/13 …finally certified as a PCMH with NCQA. We’re meeting Meaningful Use requirements and are busier than ever. It seems I’m staying at the office later and I haven’t seen any of the expected profit yet, most of the increased reimbursements have barely offset the added costs as far as personnel and IT, but now we can prove the quality of the care we provide…

4/25/13 …at dinner with the family I realized how chaotic my home life is, no structure like at work. I was late getting dinner ready, Thursday is my night to cook, and I didn’t have all the ingredients so I had to run to town and still forgot to buy milk. I needed to pay bills but hadn’t transferred any money to the checking account and had used up the last of the checks without ordering more…That night the twins Annie and Amy were pestering my wife Kate about soccer camp, and Glen was talking about his latest baseball game, he made the varsity baseball team as a sophomore playing first base. Kate, who runs her own business as a florist, observed that at work she has systems to track orders and deliveries, but at home we can run out of milk and no one says anything. It got me thinking…

5/16/13 …after dinner the kids had finished their homework and were starting a game of Monopoly and Kate was about to settle down with her book when I called everybody together for an impromptu family meeting. I proposed that we build a Family Centered Personal Home (FCPH) based on the same principles of the PCMH I had learned at work. I suggested we could have written family procedures and protocols for all the important stuff, and we could track our progress if we digitized and automated as much of it as possible. We would develop a team approach with everyone functioning at the top of their abilities. The kids were excited when I told them we would each need our own IPad connected with the home computer, but Kate was skeptical and wondered how it would help and what it would cost.  Eventually my enthusiasm prevailed and Kate agreed to try. I know that if we can collect enough data and use the right quality metrics we can optimize the FCPH…

8/22/13 …it’s taken all summer but I think we’re ready to begin in time for the start of the new school year. I used all the spare time I had this summer writing protocols for everything from paying bills to homework and piano lessons. I took the money we would have spent on weekend outings and invested in a new home computer and IPads for everyone. I had an IT guy at work help me modify some basic software and spreadsheets to structure our initial data collection, later I’ll need to invest in better software to help interpret the data we collect…

8/29/13 …Ready to roll! I explained tonight that the new computers are tools and not toys, we’re going to use them to track our progress. I showed each of the children how to use the preloaded spreadsheets to track their time spent on homework, chores, piano and violin practice, school attendance using GPA as an outcome metric, and so forth. I included detailed procedures for everything from teeth brushing to basic hygiene and meal prep, expectations for laundry, vacuuming, dishwashing, and lawn mowing... Glen was excited to see I’d included a program to track his baseball batting average. It’s important for children to have some unstructured time to pursue their own interests and hobbies so I built that into the detailed preloaded schedules customized for each of them. For Kate and me, we have the added responsibility of tracking household finances, kitchen and pantry inventory, transportation expenses maintenance and repair, etc. I mirrored some of the children’s software on our computers too so we can have reminders of important events like recitals and soccer games….

8/30/13 …today I introduced the family to the rest of the team, just as with the PCMH Kate and I can’t be expected to do it all, so I’ve hired some surrogate help in the form of tutors, nanny, personal trainers, gardener, and housekeeper. I have outsourced accounting, IT development and most home maintenance responsibilities. Extended family can step in to fill some functions when Kate or I aren’t available. I’ve had to forgo any retirement savings this year and we might miss a mortgage payment or two, but it will be worth it in the name of quality…

9/2/13 …I had to password protect the Intimate Relations protocol and data set on the shared server, it was generating too much interest. I need to talk to Kate about measuring quantity as well as quality as a metric…

10/10/13 …pulled Amy aside tonight and had a stern father-daughter chat, she just hasn’t been tracking her data like the rest of us. She complained it was too much work, that all the data entry was actually keeping her from performing the tasks she is supposed to track. I explained that I completely understand, and that based on my experiences at work the documentation is always more important than anything else so sometimes you have to fudge a little bit in order to get everything done. Without the data we can’t measure how well we’re doing and if we can’t measure it how can we improve? She cried and tried to argue that sometimes the intangible things in life are more important, but in the end she saw things my way and promised to try harder…

12/12/13 …During dinner tonight everyone was quiet, the cacophony of conversations we would have heard last year at this time is gone, instead everyone has their head down rapidly pecking away at their computer screens documenting their activities of the day…we don’t seem to be interacting nearly as much but the pantry is well stocked and the oil/filter in the pickup was changed on time for once…

1/16/14 …reviewed the children’s report cards from fall term and Annie’s grades have fallen. Looking through the automated reporting features of our user friendly software it appears she has been keeping up with her homework, and the chore tracking feature reveals 100% performance, everyone else is tracking around 65% to 80% with a performance incentive set at 72.3%. My personal observations make me question the veracity of Annie’s outcomes, but it’s hard to dispute the data…

2/13/14…Glen is in the front yard playing catch with Nathan his personal trainer, the twins are at the kitchen table with Brenda their mentor working on their algebra, both tasks I used to have to do. This has freed me up to do more important things… I just discovered all the tires on our mountain bikes are flat, they’ve probably been that way for months and nobody noticed, I’ll need to add a bicycle tire pressure monitoring protocol to Glen’s garage inventory and maintenance duties, maybe I should sell the bikes, we haven’t used them in almost a year…

3/27/14 …spent the first couple of days of spring break tweaking our protocols and procedures for the FCPH and letting the kids catch up on their reporting. Was surprised to learn that Glen isn’t going out for baseball this year, he says he just doesn’t have the time…

5/15/14 …Amy is still having a hard time, tonight she complained that our relationships are suffering, she observed that we haven’t played a game of Monopoly in over six months and our dinner conversations are curtailed as we all rush to finish the meal and clean up so we can complete all the documentation needed for the FCPH. It was difficult for me but I had to explain to Amy that in any endeavor like this sacrifices are necessary. At the office before we became a PCMH I used to think that my relationship with my patient was paramount and that I could effect a better outcome by getting to know and bonding with my patients respectfully. Our transformation to the PCMH taught me that I wasn’t doing such a good job. Some of my patients that I’d been treating for years weren’t following my advice and were skewing the metrics used to incentivize me so they had to be discharged from care. I explained to Amy that just as I’ve had to sacrifice any antiquated notions about relationship building in clinical medicine in order to optimize my outcomes, so too must she jettison any such unreasonable expectations as we perfect the FCPH…

6/18/15 …our household is running like a well-oiled machine, and I can prove it! We had to let the housekeeper and gardener go so we still have some issues in those realms, but everyone has very well defined roles and responsibilities… sometimes there can be a lot of finger pointing when things go wrong. I haven’t talked to Amy in weeks, there are still some discrepancies in Annie’s data and actual outcomes I haven’t put my finger on yet, and Kate seems more distant somehow. Glen no longer talks about going to medical school after college. On the computer I can show you how we’ve improved on so many metrics in the last two years, I can’t imagine trying to run a household without the FCPH…

The author is a family physician in solo practice.

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