This is the second in a series of workplace analysis pieces. The first is here

My boss pulls me aside one day to ask me why I took a whole appointment just to do an evaluation on a patient. He tells me that I should “Be wise with my time, and the clinic’s time,” and that I should try to keep my evals short because “patients are here to get treated, they want that wealth of care, and you want to give them some relief, right?”

The way billing works in my profession is pretty simple, there are timed and untimed units. Timed units are usually treatment, so every set interval of time spent doing a kind of treatment is a timed unit. A diagnostic evaluation of a patient is unbilled. A 40-minute treatment usually means I bill 3-4 units. Thus, If I do a fast evaluation, I can bill an untimed evaluation code, as well as timed treatments. The faster my eval, the more timed codes I can get on top of it.

Obviously, my fucking boss wants me to cut down my evaluation times then that I can stack units. This makes my job less fun (what can I say? I like a puzzle, injuries are puzzles) and way more fucking dangerous. Why?

Well, I’m a frontline healthcare provider, so patients can come in and see me without seeing a doctor first. Plus, doctors don’t do a good physical screen anymore. They’re great for a lot of things, but when it comes to backs hurting, they just don’t have the training to try to pry apart the normal from the sinister. Something like 1-2% of patients who breeze in the door with a musculoskeletal or balance complaint actually have something much worse, an it’s my job to figure that shit out in an exam.

Let’s keep looking at backs, shall we? Here’s a scary thought, if you’re a younger person (<45 y/o) symptoms consistent with an L1-2 disk herniation or nerve root irritation are just as likely to be something I can help you rehab as they are a fucking tumor.

Last month, I caught a neck pain patient who was slowly getting a spinal cord injury from some arthritic changes in his vertebrae. It took me an extensive interview to catch one piece of evidence in his subjective history, that he was having occasional bouts of sudden weakness in his legs. Then I had to finely finesses neurologic testing. Were I to have rushed like my boss asked, I might not have caught that shit, or would have caught it too late. His primary care doc (who I like, and is cool) didn’t.

Beyond this, a short eval makes for shitty care. Someone with knee pain and history of ankle sprains on the same side warrants a good ankle evaluation, someone with hip pain ALWAYS warrants a lower back eval, since the two occur together so commonly (shit, they probably warrant a thoracic spine eval as well). A dizziness eval with multiple possible contributors to the problem can take me a whole session (if not more) to pin down all the details, and trust me I’m good at this shit.

So there you have it, capitalism means faster evaluations, since you can bill for more shit if you half ass it. Faster evaluations mean more missed really bad stuff, and just worse care in general. Also they’re less fun for me, and I like fun.