Guest Post: Talk to the docs

By Howard Rodenberg, MD, MPH, CCDS

Last year I went the Niagara Falls Comic-Con with my son and had the good fortune to meet David Newell, better known to most of us as Mr. McFeeley, the Speedy Delivery Man from Mr. Rogers’ Neighborhood. Mr. Newell could not have been a nicer guy. He spent 20 minutes talking with my son about his college plans, providing encouragement, names of books and authors he might find interesting, and even giving out his email address so they could stay in touch. For hours afterwards (and sometimes even now) the kid will gush with “I have the email for Mr. McFlippin’ Feeley!” He even acknowledged me as Best Dad in the Universe for a half-hour or so. It was a great morning.

The question Mr. Newell always gets is if Fred Rogers really talked the way he did on television. (The answer is yes, though with an undercurrent of expectations…evidentially the staff and crew of the TV show definitely knew it when someone screwed up.) But according to Newell, Mr. Rogers’ gentle, kind, and caring tone of voice reflected the real person underneath.

That got me thinking about how doctors talk and if their words reflect their underlying psyches as well. This is assuming, of course, that they have an underlying psyche, which is why we’ll probably exclude podiatrists right from the start.

Given this premise, is it any wonder that surgeons tend to be loud and boisterous? That internists speak like funeral directors? That ER docs are obsessed with why the guy was found naked in the parking lot behind the state capital with a cat in a bag? (And if ER docs talk about anything clinical, the operative words are “train wreck?”) Cardiologist’s don’t talk, but pronounce from on high. Urologists sputter their words like a narrowed urethra. Psychiatrists can’t go a sentence without using the word “feel” and can’t name the state bird of Minnesota or a Canadian dollar coin. Pediatricians babble and coo. Ophthalmologists talk normally but squint while they do so. Plastic surgeons can’t talk because the botox has pulled their faces tight.

What’s more important to us, as CDI folks, is what doctors talk about. It’s only occasionally patient care, and less than you would think about golf, cars, and hospital gossip. What we mostly talk about is money…ours and other people’s…and getting hassled by those who can’t do our jobs.

If part of CDI specialists’ job is to educate physicians as to the importance of accurate and complete documentation, it would make sense to address CDI issues in the context of those things they care about most. However, that’s not what we do. We try to talk to doctors about physician profiling and quality measures. We talk about coding accuracy and the intensity of resource use. And then we wonder why nothing takes. Our efforts often come to naught because these subjects just don’t matter to most physicians.

Let’s take physician profiling. We get all kinds of metrics on physicians; length of stay, readmission rates, severity of illness versus charges and costs. But can you name the last physician you know who got fired because of a poor physician profile? Doctors leave on their own for family reasons or better jobs, and are sometimes asked to leave for behavioral issues or because they simply can’t multitask or manage patient loads. But nobody ever gets fired because of a poor physician profile. Knowing our length of stay is a day or two worse than our colleagues doesn’t scare us one iota. We know we won’t be fired unless we put someone’s money at risk, either through poor patient satisfaction or care bordering on malpractice. (I would like to say that hospitals and healthcare systems are all about quality, but in reality many of them are all about warm doctor bodies bringing patients into the place and then moving them out without putting any revenue on the line. Quality is a happy result of those efforts to avoid penalties and maximize reimbursement.)

Accuracy in coding? I’m a doctor. I know what I’m talking about. All my colleagues know what I’m talking about. The fact that people who don’t take care of patients don’t know what I mean is their problem. ICD-10 is not in my job description. The hospital pays for coders. Let ‘em code. Unless it’s my CPT and E/M codes, in which case see physician conversational topic # 1: Money.

Improving hospital reimbursement? It’s all going to administration anyway. I’m going to work harder so they can hire more people to give me more problems? Did you see that they put up a million dollars for a Consultant in Culture Change and we still can’t even get a working coffeepot in the doctors’ lounge?

Well, if these don’t work, maybe we can use peer pressure to promote our CDI goals. After all, no doctor wants to be performing at a level below their peers, right? If we just point out the problem children where they’ve lost the faith, like the Israelites wandering in the desert, they’ll want to come back around on their own. And this might work if physicians weren’t like the octopi that escape from all manners of bottles and jars. We can always find some opening to explain why your data means nothing, and make you feel bad for coming to the conclusion that we’re a bunch of slackers. We’ve been practicing our excuses ever since we missed two days of our pediatrics rotation with a vicious hangover after looking for the perfect vodka tonic one Tuesday night in Kansas City. Or so I’ve been told.

(Granted, there will be some physicians who are genuinely interested in what you have to say. Mostly these are doctors who are administrators or who want to be administrators. You know, like me.)

So, when I talk to doctors about the money aspect, I tell them up front that this does not put money into their pockets but it gives them leverage to make changes in the hospital. Several months ago surgeons were grousing about not having enough OR nurses. At the end of the meeting, I was able to chime in that improving documentation gives them leverage to say, “we’re generating these dollars, can you give us some staff in return?” And I think the money argument works quite well in smaller community hospitals, where the facility’s life and death can literally hinge on a relatively small amount of money.

The biggest area of self-interest CDI professionals can leverage is in decreasing the hassle factor. I start each and every CDI talk I give with some variant of “My job is to keep people like me off your back.”

I explain that good documentation keeps CDI, utilization, quality, etc., away from you and your patients. I give the doctors and mid-levels six or seven pieces of information that will solve 75% of their problems, and tell them over and over again that it’s all I need them to know, and that the CDI team will take care of the rest. I try to do this every time I talk to anyone, even if it’s the kazillionth time they’ve heard it. We want to help you make UM and QA and, yes, even CDI go away, and let you get on with patient care.

These messages…especially the one about eliminating the Hassle Factor…are the messages that seem to resonate. But non-physicians are often intimidated and unable to speak frankly to doctors, both by force of physician personalities and by a medical hierarchy that puts some at the top and others clearly down below. So CDI programs skirt the edges of the pachyderm enclosure and won’t confront the elephant in the room. Which, I suppose, is a shameless plug for more physician advisors like me.

One other thing. I also tell physicians that I’ve adapted our queries to be quick and painless. I’ve structured our formats to reflect how I call an attending from the ED at 3 a.m., I’ve got 15 seconds to get you to say what I need you to say before you hang up on me. Unless there’s some guy naked in back of the state capital with a cat in a bag. Then I’m going to tell you the whole story, and we’ll laugh especially loud if it’s the governor.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.