 I suppose, but from what I know about a master's... Amosist. Amosist. Well, it's just that I had to hope. The same thing that I hoped. That I'd be practicing my specialty in a teaching hospital. Do you have a specialty? Internal medicine. Just finished my residency. I know. You hoped you'd be doing nothing but that. When they first made me head up an Amy Clinic, I wanted to kick somebody's... Well, I found out it's not all that bad. You know, you're doing something important for the whole hospital. Crucial these days. And there's a lot of personal satisfaction. The job's not that hard to master. It's got lots of built-in problems, but you can work them out all right. When you know the tricks. The place to start is with the Amosist Implementation Guide and algorithm books available from Ambulatory Care Division. I bred it. The way I understand it, then, the Amosist system is a way of treating more patients by using FURMDs, while by using specially trained medics to take care of the minor stuff, cold, back aches, so on. It's the only way we have of concentrating our physicians, whether needed the most, on the more serious cases. This is how it works here. A patient comes in, one who's obviously not in an emergency, comes to the reception desk. From here, he goes to medical records where he picks up his records folder and a blank triage note. From there, the patient goes to the triage section. Here, a screener asks the questions in the triage manual to determine if the patient's complaint looks like something that can be handled by the Amic Clinic or whether the patient should go to one of the specialty clinics. He fills out the triage note and sends the patient on his way. The screener's like a traffic cop making sure everyone goes to the right place. Then, if the complaint's something the Amosist has been taught to take care of, the patient has his vital signs checked and recorded and sees the Amosist. This is the heart of the operation. How well the Amosist and the algorithms work determine how well the system works. I know this sounds over dramatic, but how well the whole hospital works. Using these algorithms, the Amosist can take care of up to 70% of the common complaints down to issuing prescriptions. However, it is critical that the Amosists see only patients with chief complaints they are trained to evaluate. URI, gastrointestinal disorders, cough, skin rashes, ear pain, extremity pain. What if it turns out to be something he can't handle? Then it's like a computer that's fed information, it's not programmed to handle. The patient is kicked out. He's sent to you or one of the other Amosist positions. He becomes a doctor's patient instead of the Amosist. Well, so that's my job, huh? I just sit around twiddling my thumbs waiting for something the common can't handle. No, actually, Jim, I'm going to be perfectly frank with you. This was not my idea of an ideal assignment when I first heard of it. And now I'm really wondering why you need a full-time physician here. I mean the way I see it. Well, well, this system's handling things my mother could take care of. I mean, and here I am, out of my specialty, looking at cases that... Well, they're not totally routine, but they sure aren't fascinating either. I mean, I feel kind of useless. Why? Why put a full-time doctor here anyway? I wish the Amy Clinic did run itself. Amy Clinic can deal with about 65 or 70% of the walk-in business the hospital handles. But the system tells us which ones need to go directly to a doctor and which can be handled by the Amy Clinic. It breaks down this way. Of 100 patients that walk in here, about 30 will be triaged directly to a doctor. The other 70 will be directed through the Amy Clinic. Now, that 70, about 15, will need to be seen and treated totally by a doctor. About 55 will be initially evaluated by Amosus. The initial triage encounter determines which Amy patient goes first to a physician and which to an Amosus. The algorithm will require a doctor to verbally consult on about 20 of those cases and actually examine about 10% of them. With the Amy Clinic, you'll be seeing only those cases that really need your attention. And overall, you'll be making a bigger contribution to this hospital's healthcare system than any one doctor can make on his own, just treating one patient at a time. You'll be responsible for seeing that hundreds of people get good healthcare. And to do that, you'll have to make decisions only a doctor can make, setting the standards for the clinic and seeing that they're maintained. And sometimes even simple decisions aren't simple. Come on, I'll show you what I mean. Take this reception desk, for example. The problem is the same everywhere. You've got to have someone to greet patients, to get them started into the system correctly. But how to do it can vary from clinic to clinic. Here, we had to knock out a wall before this reception desk could be found by the patients. And we found out that the receptionists had to be a separate job. We've actually got several people trained for the job, including our screeners. But we never let a screener be a receptionist and screen patients at the same time. Then patients would have to wait to be screened. And that's dangerous. And you'll be dealing with people and their personalities a lot. That corpsman over there is our senior aimist. He wasn't an easy position to fill. He needed someone who was personable, who likes to work with other people. But you also need someone who can work in a highly structured job and who's intelligent. A lot of his work and that of the aimist he supervises will be routine. But it's up to you to convince him or her it's important. Well, don't the people who work here get all their training and pep talks and things like that before they come here? Well, of course there is the instruction. They'll get at the Academy of Health Sciences. There your people will be taught such things as how an algorithm works, the basics of diseases, and how to write prescriptions. Remember, this is theory. When they return to you, it's your job to teach them the practice. Well, I didn't know about that. How am I supposed to do it? Well, you'll find out the ways that work best for you, but I can give you some suggestions. Come on. In the first place, you'll find your people will do better at the Academy if you'll prepare them with a good medical vocabulary. I have them study this notebook combined with a few hours of classroom work. They'll have a good head start by the time they get to the Academy. Plus, and this is where some good psychology comes in handy, I try to convince them that what they're going to learn makes them professionals, experts, that they're getting specialized knowledge that'll set them apart from most corpsmen. Okay, but what about after they get back from the Academy? Well, that's when you get into the difference between theory and practice. The Academy will teach them how to feed information into the algorithm and come out with the appropriate action, but you'll have to make sure they get the right information to feed into it. And that means, one, gathering the right historical information about a patient, and two, examining a patient correctly. The Academy will only spend about two weeks with your people. You'll have to spend about 12 weeks teaching them the things the Academy just can't. Let's finish our coffee and then I'll show you something. Hi, Specialist Jennings. What's the problem? Hi, Doctor. Eddie here's got an earache. Eddie, this is Dr. Lewis. Dr. Lewis, Eddie Davis. Mind if we take a look? You mind, Eddie? How would you describe that ear drum? Well, the bony landmarks are fine. There's an air fluid level. Not inflamed? No, sir. Thanks. I agree with you. That's all, Eddie. Now, what would you say about that boy's ear? Serisotitis. Right. You can make that diagnosis on the basis of your experience. Our corpsman in there can make the same diagnosis with the help of his algorithms, but only if he decides the color of the ear drum is normal. If he called it inflamed, the algorithm would give a different result and the treatment would be different. That's why I was asking him about the inflammation. It's your job to make sure all examinations have reproducible results. And when someone says inflamed, he's talking about the same appearance everyone else on your staff is talking about when they say inflamed. In other words, we've all got to be speaking the same language. Right. And you can standardize that language with special classes and videotapes available through Health Services Command. It's the same thing getting a patient's history. You can't just ask someone if he's been exposed to a strep throat. To the patient, that might just mean exposure to any type of sore throat. While you're talking about exposure to a strep throat that's been culture proven. I can understand that. The aim is to stand the patient, have to be speaking the same language too. Right. But more than that, they've got to be speaking the language of the algorithms. And you're the one who decides what that language is. You don't make up the algorithms, but you make any changes in them. And it's your responsibility to make sure everyone on your staff takes a patient's history and examines the patient the same way. The best way to do it, the way I've done it at least, is to examine every patient a student aim assist examines for about the first three weeks. Check everything they do. Go over the history, examination and algorithm with the aim assist. Make sure what he found out was correct. That he used the right language and that he followed the algorithm properly. And take back frequently to make sure your staff is maintaining whatever performance standards you set. There are other methods you can use. Have frequent in-service training sessions. You can bring in lecturers. Just remember to make sure that they understand that a lecture they give to an aim assist should be different from a lecture they might give to your physicians. The lecturers shouldn't be too sophisticated. And they should be on topics that will help your aim assist in evaluating the types of complaints they're trained to handle. Have frequent meetings with your staff. Talk with them to see if they're having any problems you don't know about. You might get some good ideas on how to change algorithms or even the clinic structures so everyone can function better. Or make up a medical case on paper and see if everyone comes to the same endpoint on his algorithm. Or use a recorded interview to test their ability to pick up historical data from interviews. Or use periodic quizzes and tests to make sure your staff is still on the ball. It seems like a lot of checking and I can see that it's probably important. But I mean, don't aim assist get tired of it. I know I'd get pretty hacked off by somebody looking over my shoulder all the time. Especially if I were seeing the same cases day after day. I know it's a lot like working on an assembly line. Amisus is very restricted in what he can do. After a while it comes routine. He becomes overconfident and first treating patients without the algorithms. But that's dangerous and too expensive in time and tests. So what do you do? You counter the boardroom. The way they feel insulted with you checking up on them all the time. You counter the boardroom by giving them a sense of pride. You point out to them that they're treating more patients and maybe better too than most doctors could. But it will only work if they do it by the book. You can't get rid of the assembly line feeling altogether. But at least you can make them feel like you're working on an assembly line to make Ferraris. You know, a lot of your job is like that. Psychology, knowing how to handle people. Both those that work under you and over you. How do you mean? Well, first of all, Amisus system can't handle everyone. It's designed for just what it says. Acute minor illnesses. But what constitutes an acute minor illness and what's a more serious condition depends on what the triage manual and the algorithms say. That's already worked out, isn't it? Sure. When I took over, I adapted the manuals to work out the best system I could. But when I leave, when you take over, it's not my responsibility anymore. It's yours. You might not like the system I device. You might want to change it. Or you might wind up, Amisus MD, at a different installation someday. But the requirements are entirely different. There's no absolutely standard manual. You can't have a triage manual that refers a patient to OB-GYN if your installation doesn't have one. Okay, I see that. But I'm still not sure what you're getting at. What I'm getting at is this. The idea of an Amisus system is to handle as many patients as possible without sending them to the other clinics that are already understaffed and too crowded. But you can't handle them all even though sometimes the other clinics act like they think you should. You with me? Yeah, go on. Okay. Suppose someday the head of the allergy clinic comes to you and says, look, Dalloway, you're sending us too many patients. And the best thing to do is say, fine, how about you helping me figure a way to change the triage and Amisus MD so we can handle more of the cases we've been sending to you? You see, it's a lot like a PR job. You should stay in contact with the heads of all the clinics. Remind them how much you're helping them to make sure that they know your help depends on their cooperation. Don't make changes casually. A seemingly simple change in the triage manuals can affect clinics you never even thought of. If your allergy clinic suggests sending patients to ENT, check with ENT first. There has to be a formalized method of making any changes. Get everyone to agree to them in writing. What if you can't get them to agree? That's when you've got to remember that your clinic is one that benefits the entire hospital. If it doesn't run smoothly the way you think it should, the entire hospital will suffer. And that's a lot of clout you're carrying and make sure the hospital commander realizes that. Ambulatory care, especially walk-in care, generates a lot of higher command interest. Your commander will want a system that provides good care and few complaints. And he's the one that can get the various clinic chiefs to work together. Without your commander's support, the system can't work. That's it then. No, I wish it were. But even after you've got your staff trained and set up, after you've got the triage and algorithm manuals adapted to your satisfaction and got everyone else involved to agree to it, after you've got the support of your commander, the job's just beginning. I'm not sure I want to hear this, but go ahead. Okay. Take what we were discussing over coffee, the triage manual. It does no good to have even a perfect manual as if it isn't being followed. You've got to audit the screener's work every day. Seems like that could take up most of your time. Depends on how you do it. First of all, I have every screener make a record of what he does by writing on the triage slip the answers he gets to each triage question. Then I have the senior screener audit 25% of each screener's work using the carbon copies. That's what this is. Then I audit 10% of the triage slips the senior screener said were correct. I see if the senior screener's doing his job, which is to make sure all the other screeners are doing theirs. What do you do if you find mistakes? It depends on what kind of mistakes. If it's just that the triage note format is wrong, then that's easy to correct. If people are being sent to the wrong clinics, it may require more training. One thing you can be sure of is that you'll find some mistakes. No operation works perfectly. But you have to set some standard, say 2%. That's a realistic error rate in our clinic. You'll have to work it out yourself. The same thing applies to auditing the results of treatment by aimesses. You can't audit everything they do, but try to sit in on as many of their examinations and review as many of their checklist as possible. They ought to be doing the job right 90% of the time. When you find mistakes, try to find out where and the algorithms are occurring. Are they getting the history wrong, the physical? Is the algorithm not being followed? If you find everyone making the same mistake, then you need to have another training session. They didn't understand it the first time. Or else you're asking them to do something that can't be done. Can you audit the aimesses the same way you do the screeners? Sure. Train someone to help you in the auditing of the reports the aimesses turn in. Maybe you're a receptionist. One thing, though, every time you make a change in the system, make a new rule, take extra carefully to make sure it's being carried out until you're confident everyone understands it. You got any other tricks of the trade? Sure. I'll show you. Look around. What do you notice? Not much. You don't seem too busy. But we are. That's the point. We keep patients moving. There's a lot of planning that's gone into the layout here to minimize any bottlenecks. We've got separate waiting rooms for each stop along the way. We keep patients moving, and they're happier. It's psychology again. You know, the thing that patients hate most is waiting, you know? They'll all swear they've been here two hours when they've only been here 30 minutes. I wish there was some way we could prove otherwise. You think there isn't? I'll show you the handiest tool since the x-ray. It's the time clock. We've got them all over the place here. Every time a patient goes to a new station, his record is stamped. That way you can tell what really happened. And the time clock lets us locate our bottlenecks. Here at the screeners, for example, time clock should show that from his arrival in the clinic, it takes a patient 15 minutes or less to finish being screened. Any longer may jeopardize patients with serious illnesses. Of course, you might have to change your operation based on your time clock data. You might find, for example, that things get bogged down at a certain time of day. So you might want to change the schedules of your staff to have more people working some hours than at others. The point is that if you and your senior amethyst keep track of your time clock data, you'll be able to make your workloads more acceptable at the same time that you're making your patients happier. Something the matter? Well, I'm just thinking. The job's a lot better in some ways than I thought. There's more responsibility and more effectiveness. But it's also going to keep me a lot busier than I imagined. I'm just wondering if I'll be spending so much time administering that I'll lose touch with doctoring. Surprising as it may seem, we've already thought of that. It's not going to do you or this hospital any good if we change you from doctor into administrator. It's a requirement that you continue your medical education. You should attend lectures and conferences in the hospital. You might even arrange to rotate in areas in the hospital outside the Amy Clinic from time to time. I do, but I've trained other physicians and everything I've shown you today so they can cover for me while I'm away. The Amy Clinic needs a full-time physician in charge to make sure the system operates the way it was designed to. But that shouldn't mean you're a prisoner here. Just make sure you've got the commander's support for getting out once in a while. You've told me just about everything there is to do is there a list of don'ts. As a matter of fact, there is. Health Services Command has found these to be the most common problems in all Amy Clinics. I'll leave this with you. The most common problems are unsupervised aim assist, improper or no triage manual. Aim assist receiving patients he's not trained to handle. No permanent physician in charge. No audit of triage or aim assist procedures. Failure by aim assist MD to gain supportive commander. Lack of understanding by aim assist MD of the requirements and procedures of his job. Failure of aim assist to utilize and follow the algorithms. You can see most of these problems relate directly to what I've been telling you today. Use the tricks of the trade I've shown you and you shouldn't have any major problems. Remember the really important difference between a well and a poorly run Amy Clinic is the physician in charge. Well-designed system gives him the tools he needs to provide good medical care. If you don't use them, it's your fault. But use those tools and you'll be making a bigger contribution to health care at this post than any single doctor.