You Need a Break

Gastroenterologist Patricia Raymond did something recently that you may have assumed is impossible for any physician, especially one in solo practice.

She took a vacation.

And didn't regret it.

"It was fabulous," recalls Raymond of her trip to Cancun, her first extended break since going solo. How did she do it without being clobbered mercilessly upon her return with patients, lab work, phone calls, and all the rest? How did she avoid worrying about how her patients would get along without her, about forgotten tasks, about, well, everything?

She did it by taking her office with her to Mexico. Raymond's new EMR, from eClinicalWorks, allows her access to her office records remotely and securely, so each morning she'd plug her laptop into her hotel's high-speed Internet connection and spend an hour catching up before heading out to the pool.

Raymond, from Chesapeake, Va., travels extensively. Among many other pursuits she's an advocate of work-life balance for physicians, an author, frequent speaker on the subject, and host of a program on health topics on her local public radio station.

But being away from her practice doesn't keep her apart from it. With her laptop, she can gain access to virtually everything she needs to keep up.

"I take my laptop everywhere I go," she says. "And I can always get a high-speed connection at my hotel."

Working too hard?

An ABC News poll a few years ago found that more than a quarter of Americans say they're working too hard, twice as many as 40 years ago, and that a plurality of us thinks it's not worth it.

Americans toil longer and harder than any other industrialized country. The Swedes average 32 days of vacation a year. The Dutch: 25. Even the Japanese, famous for their efficiency and work ethic, average 20 days. What do we get? Sixteen days.

"I think Americans are sick," says Louis Spikol, a family physician in Allentown, Pa. "The Europeans have got it all over us."

Yet how do you find the time to take a break? How do you square disagreements among physicians about who gets to go when? And how do you deal with what some physicians say is the biggest problem - coming back?

"The problem isn't that we aren't permitted to go," says Raymond. "In fact, most physicians have employment contracts that specify exactly how much time off per year they get. The problem is that when you actually take the time, you get punished for it."

Indeed, says Walter Gaman, a family medicine physician with seven-doctor Healthcare Associates in Irving and Frisco, Texas. "That's one thing I've never come to grips with - the first couple of days after you come back from vacation are just hell on earth. It's like you never went on vacation. You're so inundated with patients, paperwork, and everything else, and I guess the only way to ameliorate that is to book fewer patients. But sooner or later you have to face the music. You have to see the patients and do the work."

Keep the peace

Of course, you also have to make sure your patients are covered while you're gone. That can sometimes lead to ugly confrontations with partners over the timing and length of vacations, or to the use of a locum tenens physician to cover you, which costs money. Nothing can solve these problems entirely. But there are things you can do before you leave, and after you return, that will help you keep your patients covered, your office relationships peaceful, and your life at least a little less hectic.

At Healthcare Associates, the physicians have sometimes squabbled over who gets to take vacation when. The practice has a first-come, first-served policy when it comes to booking time off, but most of them wait until late spring, a few weeks before prime vacation season, to try to schedule their vacations. The fact that doctors may take as much vacation as they wish, provided they're willing to accept less compensation, can also complicate scheduling.

"We've tried over the years to do different things; we once had a big eraseable-ink calendar," which the doctors would use to reserve time, but that didn't solve the problem, Gaman says. Nothing, in fact, has completely settled all the conflicts, but the group has found that what works best is to simply get together in a room and hash it out. "Basically, we just call a big meeting about vacation and try to hammer things out around a table."

The conflicts have diminished as the group has grown. It's easier to ensure coverage for patients now that it has seven physicians than it was a decade ago when it had only three. In addition, the practice now assigns a midlevel provider to each physician. The midlevel stays at work when the doctor is away and serves as the front-line provider for patients, calling in another physician only as needed.

"She can handle a lot," Gaman says of his NP, "but she can't handle everything, so some things will spill over to the other doctors."

But that problem is diminished because the doctors try to take vacation during the practice's slow periods - summer months, when many of their patients are themselves on vacation - and never during its busy times, January through March.

Spikol has just one partner, making their negotiations trickier. But his practice participates in a call-sharing group with six other physicians. "The summer is slow, but obviously someone needs to be there, so it's just give and take," he says.

At both practices, the rules are mostly unofficial; doctors simply make an effort to be courteous to one another. If your group is struggling with disagreements over vacation schedules, though, you might want to institute more formal policies over who gets first dibs, whether busy periods are off limits, and whether and how to encourage doctors to take time off during slow months.

A locum notion

Should you hire a locum tenens physician to cover your patients while you're away? Most physicians would rather not, if only because hiring a locum makes going away more expensive.

"We've looked at having locums in the past, and when we were a smaller practice, when there were only three of us, we did get a locum for vacations," says Gaman. "We would have to. There just weren't enough physicians here. But to me, it's never really been an advantageous thing to do. It costs a lot of money."

Don DeCamp, chief operating officer of CompHealth Group, a Salt Lake City-based healthcare staffing firm, says it's less expensive to hire a locum than many doctors think.

"Many physicians want to take a vacation, but the only way they can do it is with a locum, and they think it's high cost," says DeCamp. "It's really not high cost."

The actual costs vary widely by specialty and location. But generally you should expect to pay about $800 to $1,200 per day for eight hours, says DeCamp, plus expenses such as housing. (You can try to find a locum who lives in your city, but most doctors who work as locums do so in part for the opportunity to travel.) The cost includes malpractice insurance and the physician's salary.

You can bill for his services, though sometimes this can be tricky since the locum may not be credentialed with your payers.

In any event, says Jeff Tanner, vice president of CompHealth's locum tenens division, the use of a fill-in physician is as much about keeping patients covered without draining the permanent physicians' mental health as it is about reimbursement.

"Payment is one of the key components," Tanner says. "But keeping the practice going, meeting patients' needs, and maintaining continuity of care are important, too." And partners always expecting coverage from each other "risk burning out the physicians and having them look for ways to leave," he adds.

If you do use a locum, spend some time on the selection process. You should get a chance to interview the physician in advance of his arrival, and if you don't like him, ask for someone else. (For more on whether and how to use a replacement physician, how to bill for services, and related issues, read "Take Heed When Taking Off" in the September 2004 Physicians Practice. Search for it at www.PhysiciansPractice.com.)

Welcome back, doctor

Nothing can tinge the enjoyment of a vacation quite like the knowledge that you'll be slammed by paperwork and patient overload the minute you get back. Is there anything you can about it?

One possibility is to take advantage of the remote-access features of your EMR, if you have one, like Raymond does. Her remote access has come in handy even when it comes to scheduling. Once, bad weather was threatening to prevent her from getting back into town in time to perform several colonoscopies. That could have meant those patients enduring the unpleasant procedure preparation for nothing, but because she could see it coming, she was able to have her staff reschedule the appointments in time.

But even short of that, there are ways to lessen the week-after-vacation effect:

• Come into the office for a few hours on the weekend before you're due back. That way you can catch up on paperwork, which is sure to be piled eye-high on your desk, while it's quiet. "I know that's kind of a bummer," says Gaman, since technically you're still on vacation. But it beats trying to deal with all the paperwork and get through your backlog of patients at the same time.
• Keep your schedule the week of your return clear of patients who can wait a few days. Don't schedule any follow-up visits or basic check-ups that week, because you'll be swamped with patients who got sick, or experienced something new, while you were out. If possible, you might try to see more patients the week before you leave.
• Have an advance meeting before with whoever will be covering for you to discuss potential patient issues that may come up in your absence.
• Get all your dictation done and all your paperwork off your desk before you go. Plenty more will pile up for you while you're out.
• Require, or at least encourage, staff whose workloads will be dramatically reduced in your absence to take their vacations when you do. Conversely, make sure they're at their stations the week you get back.

How much you stay in touch with the office, if at all, depends on what works best for you. Keeping a line of communication open can help lessen your first-week-back workload, depending on how much you're able to do remotely, but it might also make you feel like you never really got away.

Raymond says she didn't mind her daily log-in sessions one bit, and they made it so much easier for her when she got back.

Maybe you're the type who relaxes more easily when you know everything's OK. Or perhaps, like Spikol, you need several days of total, interruption-free decompression.

"I'm available when I'm here," he says, "but I like to take vacations where I really get away. For example, my family and I went cross-country skiing in New Hampshire. They didn't even have cell phone coverage."

Bob Keaveney is acting managing editor of Physicians Practice. He can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the May 2005 issue of Physicians Practice.