This Week on the Uncharted Podcast…
Could you imagine working in a practice that literally doesn't write more than the presenting problem and any treatments done during an exam in the medical chart? 😳 Gives me the cold sweats just thinking about it. This week on the podcast, Dr. Andy Roark and Stephanie Goss are tackling a letter from the mailbag from a CSR who has found herself in this situation. Our writer was previously a manager so she is well aware of the standards that are required legally for charts. The level of medicine seems quality and sound but the charts leave a lot to be desired. This CSR and the rest of their team feel like they are left holding the bag when clinics/insurance companies as for more info and they have to say “that is all we have.” Let’s get into this…
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Episode Transcript
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.
Stephanie Goss:
Hey, everybody. I am Stephanie Goss and this is another episode of The Uncharted podcast. This week on the podcast, Andy and I are tackling a letter that came in through the mail bag that, I have to be honest, completely caught me by surprise. They sent me an email and said, “Hey, I joined this practice and I am shocked that there's not soap notes for our charts.” And at first I read this and I thought, “Oh, well, what format are they using? Are they using chronological format? Are they just not using SOAP?”
Stephanie Goss:
Maybe the doctor went to a school where they learned something besides SOAP. I don't know. I thought, that's a little different, but. So, I sent an email back and I got a clarifying email back, who said, “No, no. It's not only that we're not using the SOAP format. We are using the soap format, but really, the charts aren't just getting written up. Patients come in and it says, “Here for an exam,” and then there's not a whole lot of notes or they come in for a surgery and there is more details, but it's not in the SOAP format. It might be written up on an anesthesia sheet or something like that. And it sounds like this practice is doing awesome, Medicine and yet the charts are a hotness.
Stephanie Goss:
And I have to tell you, there's not a lot of messages that I've gotten in the mail bag that have caught me off guard, but this one definitely did. And I couldn't wait to dive into this conversation with Andy. This is going to be a fun one. Let's get into it. Shall we?
Stephanie Goss:
And now, The Uncharted podcast.
Dr. Andy Roark:
And we are back. It's me, Dr. Andy Roark and Stephanie, write this down, Goss. Can I get stuff out of that? Yeah, and I don't want you to go write this down. Some Alan Jackson from the '90s.
Stephanie Goss:
I love it. It makes me so happy.
Dr. Andy Roark:
My wife is very cosmopolitan. She is a college professor. She loves some Alan Jackson. I mean, it just-
Stephanie Goss:
Hell, yeah.
Dr. Andy Roark:
It just comes out of her. And if I put on some…
Stephanie Goss:
Who doesn't?
Dr. Andy Roark:
… Alan Jackson-
Stephanie Goss:
Who doesn't like some Alan Jackson?
Dr. Andy Roark:
Oh, yeah. She dances around the kitchen to Alan Jackson. It's so silly and God, I love it so much.
Stephanie Goss:
I love that. That makes me like Allie even more.
Dr. Andy Roark:
Oh, yeah. It's funny. Anyway, it's those little things, you know what I mean, in life?
Stephanie Goss:
Yeah.
Dr. Andy Roark:
Where you know about people and you just, I swear. I think about that sometimes and I'm like when I die and people come together as for a funeral, I want people to talk about the quirky things that I do like dance to Alan Jackson, because I think that's how you really know people. You know what I mean?
Stephanie Goss:
Sure.
Dr. Andy Roark:
I think that's who people really are. And I think we talk a lot about these formalities. But I think a story that captures a little piece of who somebody is, I think that's just magic and I love those stories. But anyway, but yeah, I think about that sometimes of what stories or what little quirks really…
Stephanie Goss:
What is, yeah.
Dr. Andy Roark:
… encapsulate my wife or my kids. And anyway, it's just, it's fun stuff.
Stephanie Goss:
Alan Jackson, I love it.
Dr. Andy Roark:
It's so funny.
Stephanie Goss:
I love it.
Dr. Andy Roark:
It's because we listened to that when we were dating. And so, it's one of those things that always sticks around. It's so funny.
Stephanie Goss:
Oh, that's fantastic. How's it going?
Dr. Andy Roark:
It's crazy today. It's half day at school, so I've been running around. I took kids to school and then I turned around and I went back and got the kids again. And I was like, “Why do owe do this?” It's because legally, they have to be at school for three hours to get credit for a day. And so, they're like, the school board is phoning it in. They're like they got three hours and eight minutes they were at school killing it. I spent three hours and 12 minutes in the car line in dropping off and picking up, but whatever, anyway.
Stephanie Goss:
Oh, man. Yeah, that was me last week. I am glad school is done. Report cards have been had. Lockers have been cleaned out. It feels good to be on summer break.
Dr. Andy Roark:
Oh, man. Time marches on, it's just. And we are into the summer and the kids are like, “The swimming pool is open.” And it's just, there's funny things like that in life that are signs of the season. Just, we were cutting up watermelon for Memorial Day and eating it and I was like, “I guess it's summertime,” you know?
Stephanie Goss:
Yes, yes, yeah, no, I love it. I love it. Well, I love this topic that we're going to talk about today. I'm super pumped about this.
Dr. Andy Roark:
It's a good one.
Stephanie Goss:
Oh, we got a mailbag question. And this is funny because I actually had to go back to the Mailbag writer multiple times and ask clarifying questions. Because I was like, “I want to make sure that I actually have the whole story.”
Dr. Andy Roark:
Yep. Yeah. This one's hard to believe. This one's hard. Yeah, this one's hard to believe in its entirety. Okay.
Stephanie Goss:
I was shocked and I was just like, “I'm sorry, what?” So, we got a Mailbag question from somebody who's been in the field for a really, really long time. They had been a manager and wanted to cut back and so, they have been working reception. And so, they've been at the front desk and they joined a new practice. And since joining that practice, they found themselves very shocked because apparently the practice actually doesn't really write SOAP notes. And I thought, “Oh, well maybe, it's just learning a new practice management software.” Maybe they're putting it in a different place.
Stephanie Goss:
Because the comments were like, “Sometimes there's communication notes and sometimes there's info attached to the surgery.” But overall, a lot of the times it's missing information and we get calls from other vets in the area, the ER specialists, et cetera. And we get calls from insurance companies who are like, “Hey, we need more info.” And this manager was, or this writer said, “I find myself having to say, ‘I'm sorry, like that's all we have on this record.'” And so they were saying, “I feel like I know legally what's required, but I'm not sure do I even bring this up? Am I just not knowing where things live?”
Stephanie Goss:
And so, we went back and forth and I was asking some questions and I was like, “Well, every practice management software does it differently and has their SOAP format set up differently.” And so I said, “Is this really that? It's just maybe it's hidden?” But as it turned out, no. They actually just really aren't writing up charts. And really, the focus is on capturing some surgical notes, but the standards, or what we would assume to be standards, seem to be missing.
Stephanie Goss:
And so, they were like, “I don't want to step on anybody's toes because I'm just a part of the front desk team here. I'm not the manager, but I feel like this is really wrong. And it really bothers me.” And they said, “I feel like we're practicing a good level of Medicine and a quality level of Medicine, and at the same time it really concerns me that nothing is getting written down.” So, there were like, “How do I even approach this?”
Dr. Andy Roark:
Yeah. When I first saw this and they were like, “Oh, they don't write down SOAP notes.” And I was like, “What format do they use then?” No, no, no. It's not that they don't write down SOAP notes, it's that they don't write down notes.
Stephanie Goss:
That was the first response I had to them. I was like, “Are they using Problem-Oriented Medical Records?” Are they-
Dr. Andy Roark:
Yeah. I'm like interesting. Yeah, and yeah. Are they just writing paragraphs? No. Nope. And then also, examples of the type of records that are there. There are things like SPADE and the date.
Stephanie Goss:
Right. And that's it.
Dr. Andy Roark:
And that's the record, SPADE. And so, that's what we're talking about here, guys. So, anyway, there's-
Stephanie Goss:
So, let's just say for the record, both, Andy and I, were mind boggled.
Dr. Andy Roark:
That was, yeah. I had to sit with this for a little while.
Stephanie Goss:
And per day and age.
Dr. Andy Roark:
Yeah. It's like an ugly truth that you knew, but you didn't really want to believe was there. You know what I mean?
Stephanie Goss:
Yes.
Dr. Andy Roark:
It's, yeah. I don't know of a good analogy to give other than like [inaudible 00:08:20]. When I really think about it, am I surprised that their practice is out there? No. But I don't want to believe that there are, you know?
Stephanie Goss:
Right. Yeah, no, not at all. I think about it and I think about when I started in Veterinary Medicine. I haven't been in Veterinary Medicine as long as our Mailbag writer and so, it didn't surprise me because I think back to my first clinic and like that, we had paper charts and you were writing everything by hand, right?
Dr. Andy Roark:
Yeah.
Stephanie Goss:
And so, there was a lot of shorthand and a lot of shortcuts and it was like, “Here's the date? They're here to be SPADE. Our records have more info about anesthesia and suture and stuff like that. But compared to what technology makes happen easily now with hybrid records or with completely paperless records, it is amazing to me how little we did back then.
Stephanie Goss:
And so, when I read this, like you, I was like it feels like an ugly truth, but then my thought was, “Well, I could totally see some old practices where there's an older generation of veterinarians who when they went to school and learned like that was what they were doing. And I could totally see where… in veterinary medicine there, how many things do we do in our practices every day that we're doing them, because that's the way we've always done it. Right?
Dr. Andy Roark:
Mm-hmm.
Stephanie Goss:
So, I see this being one of those things where if we have an older generation veterinarian where that's how they've always done it. I could see that being the case and yet at the same time, I was really shocked because I was like, “They're not right.” Nothing? Not suture. Were there any problems? Not anesthesia note. Really nothing? Just the date and that they're here to be SPADE, like “Oops, that's what you get.” So, yeah, it was surprising.
Dr. Andy Roark:
Well, so I want to talk about this and then I want to add a little bit of nuance to it. And talk a little bit about the practice that writes up most things. But not all of the thing. There's way more unwritten charts than you would like, because I feel like this is an extreme case and it's going to let us really tee up in a couple of ways. But I don't think that most practices are at a, “Help me. We don't have medical records.” I think most are at, “I have a doctor that doesn't do medical records and all the other doctors do,” or you know?
Stephanie Goss:
Yes, yes.
Dr. Andy Roark:
Or “We were pretty lax about it and we miss a lot of charts that don't get written up.” And that bothers me. So, I'd like to address this problem, but also lean a little bit more towards those shades of gray, less extreme cases because I think that's where most of our listeners, who wrestle with these problems are going to live.
Stephanie Goss:
Okay, that sounds good.
Dr. Andy Roark:
All right.
Stephanie Goss:
So, where do we start?
Dr. Andy Roark:
I think we could start with Head space. I think we could start with Head space and you have to get your head around it. And so, let's just say when you're working at a practice where this is happening, to some degree. Whether it's every record or some records. I think the first thing is that you need to figure out how you feel about this because it is going to affect what you do from here.
Stephanie Goss:
Yes, yes.
Dr. Andy Roark:
So, when we talk about Head space and I would talk to this person, now this person is reaching out and they are a paraprofessional. They've been a manager and they are working as a paraprofessional. Not a credentialed vet tech, but another professional in the practice. I had some concern when we started out. It was like, “Oh, man.” I'm always a little weary that we make a podcast and people are like, “Oh, my gosh, that person is talking about our practice.” And they'll be right.
Dr. Andy Roark:
And then I thought about it. “These people don't listen to our podcast.” The people who write up zero records, they're not listening to this podcast. I'm pretty certain. But anyway-
Stephanie Goss:
For the five practices who are listening, just went, “Wait, are they talking about my practice?”
Dr. Andy Roark:
Yeah, I know, I know. So, anyway, let's get our heads straight about how do we feel about this. Now, it's an important differentiator because if you are a doctor at this practice, that's your license, my friend. Again, I'm not telling you what to do, but I'm saying you need to have eyes wide open and if there's no medical record and you get taken before the state board, your bum is grass, as my dad used to say. And that's it you're toast and that's not good. And honestly, I've talked to a number of people. I talked to them. Generally, I'm very interested in talking to people who sit on the state boards.
Dr. Andy Roark:
Just for the Cone of the Shame podcast. And I'm always just interested in what the experience is like of going to state board and what's really going on there because I think it's really important. And the number one piece of advice that I have gotten from a half dozen of these people at different states is, “For God's sakes, Andy, just write down what you do. You're doing good medicine. Just write everything down and you're going to be fine.” And that is the saving grace. And they say, “The people who get nailed are the people who don't write anything down. And then they got nothing. They got nothing to fall back on and they're torched.
Stephanie Goss:
Yes, yes.
Dr. Andy Roark:
And so I just go, “This is dumb.” It's just, it's dumb for you as a doctor. It's your license. And even if you're working in a practice and this is where we're going in the shades of gray a little bit. Let's say that you write up your records by other doctors in your practice, who don't write up your records. If there is a case that you are involved in and then it gets transferred over to them and then it comes back to you later on and the whole thing goes sideways and crashes and burns. And you end up in the state board, this is going to make your life significantly harder because there's big holes in the story.
Dr. Andy Roark:
And you might have written everything down, but other people did not. That's a stress that I don't want. And so, eyes wide open. And again, if you're a credential vet tech, you're going to feel some of this because you have a license to protect.
Stephanie Goss:
Right. Exactly.
Dr. Andy Roark:
And so, you need to be thinking about that. If you're a non-licensed professional, so like this person working up at the front, it really becomes a bit more of you don't have a license on the line or anything like that, but you need to think about how you feel about the work that you're doing. I have a problem working in a place where I'm really embarrassed about something that happens. And I just, that's a weird life thing for me is that I can't tell a lie. I'm a terrible liar. I am. Just, I'm not a secretive person. I just, I have a big mouth and I talk a lot.
Dr. Andy Roark:
And so, my life is just better if I work at a place where I'm proud of what we do and I don't have anything to hide or anything that I'm embarrassed by. And so, I just learn that along the way and I just go, “Yeah, I really like to work in a place where…” Every practice has got its flaws, but they're not flaws that bother me deeply. And that just makes my life a lot better. And so, start to have those thoughts about, “What are the repercussions here and do I feel good participating in a hospital where this is happening?”
Dr. Andy Roark:
And it would bother the heck out of me to send records to another practice and have them say things like, “Is that it? Is this all you have?” And you're like, “Yeah, that's all we have.” That would bother me every time I did it or even if they didn't call and I faxed it, I would still send the fax being like, “I'm feeling embarrassed about what I'm sending to you.” It would just nag at me.
Stephanie Goss:
Well, and I think that's why our writer wrote in. They are the ones answering the phone and talking to clients and talking to the insurance company when they call in the other vets clinics who are like, “What? That's it?” We can't do anything with this. We need more information. And they feel like they are the ones answering the phone, so they are the gatekeeper. And coming from the front desk, I want to do my job. And whenever I felt like I wanted to support my team and so for me, I would do everything possible to try and find the information myself before I had to ask somebody else on the team.
Stephanie Goss:
And it would have driven me absolutely bananas if I constantly had to go ask somebody else, “Hey, what'd you do on this case? Hey, what'd you do with this patient?” The fact that I can just look it up. Even if it was a paper chart, the fact that I couldn't look it up and say, “Oh yes, Mrs. Smith, I see that this was the medication that we gave Fluffy.” The fact that I couldn't answer simple questions like that would drive me absolutely nuts. There's no way that I would want to work in a practice like that.
Dr. Andy Roark:
Yeah, I agree. So, that's the big part of my head space is, “What is the risk to you and what are you willing to tolerate?” And then the step beyond that is to start to say, “Okay, what level of action am I deciding to take here?” And to me, there's a couple of different things you could do. You could say nothing. If you say, “Hey, I'm not a doctor and I'm part-time here. And they haven't asked me what my opinion is and I'm just going to do my job and go on.” I think that that's a choice that you can make and a lot of people would make that choice and just say, “Hey, I'm going to believe that they know something that I don't.” And they're the ones, “You have licenses on the line and so I'm going to go on.”
Dr. Andy Roark:
I think you could do that and I think a lot of people would do that. I think more people or probably most people would fall into the next two categories, which is, “I'm going to say something and then I'm going to sleep soundly because I said it.” And they may totally ignore me, but I am going to go on record saying, “I am bothered by this. I have concerns about this. And I just want to bring it to your attention.” Or making it some conversational point with the manager, with the owner. “But I am going to bring this up, so that I have the peace of mind and said that I saw this and I said something about it.”
Dr. Andy Roark:
And I think that for me is the easiest position as far as balancing what I feel is personal responsibility and feeling like I'm doing the good thing. And also, accepting that I'm not the boss here and I have very little power and no one asks me for input. But still, I'm going to bring this up. And I can't make them do anything with it, but I will at least have a clear conscience.
Dr. Andy Roark:
And then I will continue to say, “Am I comfortable here?” You know what I mean? If I bring it up and they don't do anything, maybe I go, “I don't like this. It still bothers me.” And if it continues to bother me or there was another instance and usually, what will happen is there's some instance, there's something that happens that really shines the spotlight right on it, you know what I mean?
Dr. Andy Roark:
And then you go, “I not doing this anymore.” And then the last level is to say, “I'm not messing around with this. That thing has already happened. And I'm really bothered and I'm going to go, and I'm going to tell them, I'm planning to leave because of this. And if you convince me that things are going to change in the next 30 days, I'll consider staying around. But unless there's a significant change coming, I'm going, and I want you to know why I'm going.”
Dr. Andy Roark:
And you can do that and that's not wrong either. So, all of those things and this all fits into the degrees. If you're working at the practice and one of the doctors occasionally forgets to write up their notes, I'm probably not going to go and give an ultimatum that I'm going to leave. You know what I mean? I will pick one of the top two, you know?
Stephanie Goss:
Right.
Dr. Andy Roark:
If you're at a place where it happens all the time you did that, that's going to influence us. So, there's degrees in nuance in which of these paths you take, but I really think that those are your three options.
Stephanie Goss:
I agree. I agree with that. I think the other thing from head space perspective for me, too, probably before I even start figuring out for myself where does my head land on it, is you got to assume good intent. Because if you're coming at this from the space of they're doing this intentionally for a bad reason, you're probably going to approach it more towards the latter, which is, “I don't like this and I'm just going to quit.”
Stephanie Goss:
And I've had people leave the practice because they felt strongly about something that they didn't ever ask any of the questions. And when I found that out after the fact, like I wish they would have asked the questions. But I think it, when we get into that head space of like, I assume that they're doing this for a reason and it's really easy to spiral yourself in a negative way, I think, if you don't assume good intent.,
Stephanie Goss:
And so, the second part for me is get curious and ask those questions. And so, before I started tackling it, I would want to make sure, and again, this is just me, but I would want to make sure. Could I be missing something here? Are we recording stuff? Are they doing a surgery sheet and maybe they're writing all their notes on there? And it's supposed to go in the chart, but it's not part of the chart. You know what I mean? I would start to ask those questions of like, “Am I missing anything? What are we doing and why are we doing it?”
Stephanie Goss:
And I would use being new to your advantage. This is where you say, “I just want to make sure that I really understand. Help me understand this. Can you tell me how this is supposed to look because I feel like based on my previous experience and other practices, this feels very different. I wouldn't say like I feel like there's lots of things missing. I would probably lean into the middle and I'll just like, I feel like it feels pretty different and I want to understand what we're doing and why we're doing it. And asking those questions to make sure that you have all of the answers.
Stephanie Goss:
When I went back to our Mailbag writer and I was like, “Is it possible that they just haven't shown you where this stuff lives? Is it really?” Because it really can't be that the charts are empty. And so, I think that's, for me. It's about assuming that good intent and getting curious and asking a lot of questions, because I think you're going to need to ask those questions and maybe not, maybe your mind is already made up and you could figure out which level of Andys you sort into. But it totally makes sense to me, Andy, that's your next step is what are you willing to tolerate? What are you willing to live with? And then, what level are you falling into?
Stephanie Goss:
Are you just going to put your head down and do your job because you decided you don't care about it or do you care and you're either going to say something, so you can sleep at night? Or you're going to say something and say this, “I feel really strongly about this. And if this doesn't change, here is how I need to move forward for my own personal satisfaction.”
Dr. Andy Roark:
To me, there's two things in what you said and I think you're spot on with both of them, but I separated these out. So, the first thing, the head space thing for me is in your mind, consider the idea that you are missing something. That there's something that, not you're making yourself leave, but genuinely, “This seems weird to me.” And rather than just assuming it's not getting done. Let me just assume that it's possible that something else is happening that I'm not aware of, especially being a new person.
Dr. Andy Roark:
And so, doing that and just going, “I could be wrong on this,” that is going to affect how you think about it and how you talk about it and you approach it. And that type of curiosity on yourself tends to make your conversations with other people go better. You know what I mean?
Stephanie Goss:
Mm-hmm.
Dr. Andy Roark:
Because you're genuinely just saying, “I just want to make sure I'm not missing anything here.” And it takes the danger or the fear or the stress out of it for you and go, “I don't know. I don't know. I could be missing something here.” So, in your own mind saying, “Maybe I've been set up to fail” Maybe I am just not aware of this.” I think that's a great healthy head space to be in. The why I say it's two things is one, is you do that to yourself in your own mind. And then, the first action step for me is asking the question.
Stephanie Goss:
Yeah. Got it.
Dr. Andy Roark:
And so when you go to engage, I would start with that curiosity and that's how I would engage.
Stephanie Goss:
Got it. Okay. I like it.
Dr. Andy Roark:
Well, that's what I got for head space.
Stephanie Goss:
Those are your notes for head space?
Dr. Andy Roark:
Yeah.
Stephanie Goss:
Should we take a break? And then come back and talk about how do we actually ask questions about this without knowing what the heck are you doing?
Dr. Andy Roark:
Yeah. Let's do it. And yeah, we'll start with the question and we'll wind up from there.
Stephanie Goss:
Okay. I love it.
Stephanie Goss:
Hey, everybody. This is Stephanie. And I'm going to jump in here for one quick second and make sure that you know about a few things that are coming up that I'm pretty sure you're not going to want to miss. But before I do that, I just have to say a thank you.
Stephanie Goss:
Thanks to a generous gift from our friends at Banfield Pet Hospital. We are now able to provide transcripts for all of our podcast episodes. And we have just to say thank you, thank you, thank you so much. Andy, and I have wanted to make the podcast more accessible. And when we're pondering the idea of how do we make transcripts a thing, our friends at Banfield stepped up in a big way and said, “Hey, we are striving to increase accessibility and inclusivity across the profession. This fits with that mission for us and we would love to sponsor it.” So, the 2022 podcast episodes are all now being transcribed and brought to you by our friends at Banfield Pet Hospital.
Stephanie Goss:
To check out the transcript and find out more about what Banfield is doing to increase accessibility and inclusivity across the vet profession, head over to unchartedvet.com/blog and you can find each one of the podcast episodes and a link to find out more about equity, inclusion, and diversity at Banfield.
Stephanie Goss:
And now, hey, party people. I am going to jump in here for one quick second and make sure that you know about a workshop that is coming up. It is called Navigating Neurodiversity: Your clients, coworkers, and self. And it is with the amazing Dr. Amanda Doran. Amanda is an Uncharted member. She is a wonderfully kind and funny person and she is going to be leading us through a conversation about learning how to navigate interactions with different individuals and creating a culture within our practices that is both supportive of and inclusive of neurodiversity. It is a really, really important topic.
Stephanie Goss:
It is one that I think needs to have a lot more discussion in Veterinary Medicine and we are really excited to be bringing this one to you. It is happening on July 27th. It is a 7:00 PM Eastern session, so it is two hours. It will be over at 9:00 PM Eastern, which means 4:00 PM Pacific, 4:00 to 6:00 PM Pacific Time. And it is $99 for members of the public. And it is free as always for our Uncharted members and this workshop is awesome.
Stephanie Goss:
We also have more coming up throughout the summer and the calendar at unchartedvet.com/events is constantly being updated. I encourage you, if you are not currently an uncharted member, to head on over to the website, check out what's coming up. And remember that all of our workshops like this are free for our Uncharted members. And now, back to the podcast.
Dr. Andy Roark:
So, let's go ahead and talk about taking action on this.
Stephanie Goss:
Okay.
Dr. Andy Roark:
All right. So, as I said before, the break, I think the first action step is to ask the question. It's to be curious. I think this is a really low stakes way and I'm all about lowering the stakes. It's having low stakes conversations that don't feel scary to people. But still introduce important ideas into their mind, hopefully, in a way that they will realize what is going on and parse through the possible implications and decide to make an idea and a plan and take action on it.
Dr. Andy Roark:
And so, going in and genuinely going with curiosity and going to the manager and saying, “Hey, I may be totally missing something. And I just want to understand and just make sure I'm not missing anything.” And I love that opening phrasing, “I just want to make sure I'm not missing anything. I just want to make sure I understand. That is a very disarming phrase.”
Dr. Andy Roark:
And so, then I would show the manager, one of the medical records and say, “I just got a call about this person's records. And when I look at them, these are the only things that I'm seeing. And I have sent some of these to practices before and they call and ask if there's more. And I tell them that there's not. But I just want to confirm is this really all that we have on these cases? Is there somewhere else I should look?”
Dr. Andy Roark:
And honestly, anyone with half a brain is going to read between the lines. What I'm saying is I've been doing this a long time. And is this really what we're doing here? And honestly, their reaction will tell you a lot. If they get really defensive really fast, you just learned a lot. And if they say, “Yeah, what else would be there?” Then I go, “Okay, this person needs some education on what good medical records look like. But what am I dealing with here? Am I dealing with somebody who's given up? Am I dealing with someone who just doesn't know any better?”
Dr. Andy Roark:
If I had to bet and again this is 100% just instinct, I was completely wrong on this. But if I had to bet, I wouldn't be surprised if they closed the office door and said to you, “Let me tell you a story about how we got here.” And then they tell you about the battles that they fought and lost spectacularly trying to get people to do what they're supposed to do. I would not be surprised by that.
Stephanie Goss:
Yeah, yeah. No, I think that is a good call. And I think part of it, too, is it's a little bit head space, but also for me a little bit action, which is like, “Look, we recognize that,” like you said, “not everybody loves to write records.” And there's always going to be people that write more and less. But at the end of the day, the written records, they are patients. They are patients in paper form. So, Fluffy can't get on the stand in front of a medical board or Fluffy can't get on the phone and talk to Mrs. Smith about why something was or wasn't done for her. Only our records can do that and our team accessing those records.
Stephanie Goss:
And so, from the head space perspective, I think thinking about it from very much for any member of your team, you should be able to pull the lever here about pet care and patient care and wanting to take care of our patients and make sure that we're doing right by them because this writer was like, “Look, they're practicing a level of Medicine that I agree with and I believe in.” And I just don't understand why there's no record of that. And so, I think this for me, when addressing it, like you said, whether you're asking the questions openly with that.
Stephanie Goss:
And they're answering them openly or whether you're having that closed door conversation, learning the background, the ability to be able to say, “I want to take care of Fluffy.” And I love your example of being able to say, “I just got a call about this record. Here's what I'm seeing. And this isn't the first time. And this is how I've answered it in the past, but I could be missing something. I really want to make sure that I'm not.” Because then if they tell you, “No, there's nothing else.” That is what it is. Like you said, you have now learned a whole lot. And I think it makes your moving in the head space about how you make decisions a whole heck of a lot easier.
Stephanie Goss:
And if you do get more information and more background, and maybe it's like we have fought these battles and this is the background on it. It's still thinking about it from the patient perspective, I would still be willing to go to and do that battle over again from the perspective of, “I want to help us really good care of our patients.” And being at the front desk like I really believe that this is our ability to speak for Fluffy. This is my way of being able to help her and so, I want to help us get in a better frame of mind or be in a better place to be able to answer questions that people are asking us, “How can I help with that?”
Stephanie Goss:
It helps bridge that gap between asking the questions and asking for change and coming at it from that place of patient care. And I can't imagine, even if you have a super old school veterinarian who didn't have to write massive records when they went back to school. And it's like, “It's my practice. This is the way we're doing it.” And I won't care what anybody else thinks.
Stephanie Goss:
I still think that I would feel good about having a conversation with that veterinarian and saying, “I know you care about your patients. And I care about our patients, too. And this is why I'm struggling because I view this as us taking care of the patients. And when it's missing, it makes it really hard for me to help support you.” And I don't think that you could say that to anyone even that veterinarian that I'm picturing in my head and not have them go, “Hmm, maybe that's something I should think about.”
Dr. Andy Roark:
Yeah. I agree with that. So, I 100% agree with where you're coming from. But I would counsel here a little bit of a little slide of hand and I agree with where you're coming from and your motivations. And I promise that we're going to get there, but it's not going to look like that's where we're going for a minute. So, just bear with me and say, trust me when I say that's where we're going.
Stephanie Goss:
Okay.
Dr. Andy Roark:
All right. And so, we go into the practice manager and I would start with the practice manager because it's their job to manage the practice. And so, especially if this seems routine, then I would say, “This is the way our practice functions.” If it's not routine, even then I would still go to the practice manager because if it's the practice manager's job, I assume the practice manager's job is to oversee medical record quality and medical record systems and unless, you've got some weird job descriptions that tends to fall into their purview. So, even if it's one doctor and I had concerns or questions, I would still probably go talk to the manager.
Dr. Andy Roark:
And here's the thing, okay? So, file this away, my friends. Doctors can take critiques of their medical records very personally in my experience. And the reason is they feel like a criticism of their records is a criticism of their medical competence. And again, it depends on the individual and that's not everybody. And I would not have a problem with someone critiquing my medical records and I'm happy to talk about it and listen. And I always try to get better. And I can also defend my position and why. I write what I write and things like that.
Dr. Andy Roark:
But I'm happy to have that conversation because I'm not super insecure about that stuff. But other people are not that way and there are some people, and we all know doctors, who can't take being criticized before it really hits them and they get real defensive real fast. What I want to avoid ending up in an old West style shootout with a doctor in the street. You know what I mean? Where they're standing at one end with their hands on the pistols and I'm standing out and they're like, “Draw.” I don't want that. I don't want to shoot out with them over this thing.
Dr. Andy Roark:
I want to be smart in how I introduce this. And I want to get heard and I want to understand what's going on. And so, I go to the practice manager and I ask the questions and say, “Help me understand, is this going on?” And guess what happens? They might close the door and say, “I cannot get these doctors on board.” And then they'll just tell you what the problem is or what the holdup is. They might just act like, “No, this is what we do and it's totally fine.”
Dr. Andy Roark:
If they don't tell me what the holdup is, I want to find out what the holdup is. This is called root cause analysis. Before I make any statement or a stand, I really need to know where this is coming from and why it's coming from, so I can know what I'm up against before I take a stand. I just need to know where is the pressure going to come from? And what's it going to look like?
Dr. Andy Roark:
And so, if they tell me, “Hey, this is has come down from the doctor, so I can't do anything about it.” I'm going to say, “Why? Why is this coming down? Why did they feel that way? What did they say when you talked to them about it? What is their concern? What seems to be the push back?” And I'm pumping the manager for information, because I want to understand, like, “Why is this happening? Help me understand.”
Dr. Andy Roark:
If I don't get that volunteered information from the manager and they start to say, “Well, this is just what we do or that's who the doctor is,” or it's just they indicate to me that they don't think it's worth the effort to try to correct this, I want them to understand my why in asking. And so, one way this conversation ends is I go and say, “Hey, is this right?” And they're like, “Yeah, that's what we do. Not a big deal. That's just how we handle it.” And then, the conversation stops. And so, I don't want that, so I needed to keep going.
Dr. Andy Roark:
Remember when we start to talk about things like medical records, honestly, a lot of these things, there are some people who will be motivated by data. And you can talk to them about aha standards and you can talk to them about state regulations, and you can pull that stuff out if it's important to you and say, “Well, I didn't know the State of South Carolina says this.” Or “I know that aha has these things in their guidelines. I suspect this is not an aha practice given the fact that they don't write any medical records.” And so, that's not super motivating.
Stephanie Goss:
I know that this is not an aha practice.
Dr. Andy Roark:
Yeah. That's not super motivating. I think I would probably go in and they said, “Well, that's just what we do.” And I'll say, “You know I worked at a practice one time and two doctors got called into the State Board.” And I remember the pet owner was really adamant that they had done something wrong and they had not done anything wrong. But I remember, there was a man and a woman and I remember the man lost 20 pounds in the four to six weeks before he got cleared. And they looked awful every day because they went through this stress. And they had good records, and I've heard that is the number one thing that saved them and saved other people.
Dr. Andy Roark:
And so, I would really reconsider this. I'm just, I'm really worried about what would happen to the doctors, given what I've seen before. And so, that's me trying to get them to engage in a conversation. If they still blow it off, then I'm going to say, “This person does not want to. They don't want to engage with me.” But ultimately, I'm trying to explain to the person I'm talking to, “Hey, this scares me.” Not bothers me, not makes me angry, not in a judgmental way. I'm not saying, “This is shotty medicine. This is inappropriate.”
Dr. Andy Roark:
Now it might be and we can come around to that. But at least in getting the conversation open, I want to use nonjudgmental language, which is, “I'm not saying these guys are bad. I'm not saying they're not doing good medicine. I am saying that I've had friends who went through this and they were saved because of their records. And I don't think it would have gone well at all for the doctors here because of this stuff. And it's really just about trying to keep the conversation as productive as possible and not trigger that defensiveness. And again, I'm using that to try to get this person engaged, so I can understand what is the hangout here? Is it that it takes too much time? Is it that the doctors don't like the medical record system or was there a plan that we were going to have scribes and we never got them? I don't know what's going on.
Stephanie Goss:
Right. Yeah, yeah. That makes total sense to me and I think trying to get on their side and being able to have that conversation about knowing what can happen as a result is a super impactful tool and a good one to pull out of your toolbox, because you do care about them. You're enjoying your job. You want to work here. You believe they're practicing a good quality of medicine. You just need to understand what is happening here, because you don't want them to not be able to defend themselves. Whether it's to an owner or to an insurance company or to the board, it doesn't matter. You don't want to feel powerless.
Stephanie Goss:
And so, for me, working at the front desk, every time I had to have a conversation with the doctor about their medical records, I usually approach it from the place that I want to help. I don't want you to have to get on the phone and have this conversation. I want to just have it for you and be able to give Mrs. Smith the answers that she needs. And so, I just want to make sure I understand where I get this information from. Because in your head, I'm thinking, “I'm not a mind reader. I can't go into Dr. Roark's head and know what he talked about in the exam room with Mrs. Jones because I wasn't in the exam room.”
Stephanie Goss:
But if I look at a chart and I could read back to her what you recommended, I can certainly have that conversation and save you that half hour on the phone, right? And so, I think your point about not everybody is that way, there definitely are people who will take any question of the medical records as a critique against their medicine is a super valid point. And I think it's definitely something that you have to frame really, really well.
Stephanie Goss:
And so, it's funny that you brought up the aha standards, because that's a feeling that was a part of it for me. And I would suspect, our writer as a previous manager would know what some of the resources are, but for any of our listeners out there who are just getting started or learning. The reality of how do we actually address this, is that everybody. I think everybody needs to know that every state is different. So, every state is going to have actual specific requirements.
Stephanie Goss:
And so, if you're getting curious and you're asking like you can look it up for yourself and find out what does your state practice act or medical act actually say about what your records have to include. And some of the states are super vague. There's not a whole lot there. They've got some basic stuff. And then you have other states, California was one of them, that really lays out. Tells you that you got to cross all these Ts and dot all of Is.
Stephanie Goss:
And so, I think for your own knowledge, like learning what is your state requiring? And then looking at what are the aha recommendations are wonderful because they do give a great outline. And also, respect the fact that there is going to be shades of gray because every state is very different. And so, when I think about learning or coming at it from a gentle perspective, when I think about what do we do here in our practice, because every practice is different. And every practice within every state is still going to be different.
Stephanie Goss:
And so, I would take being a new member of the team and use that as a tool and be able to say, “I want to know, where do we record? What medications of pet is on in our records? Where does that go?” Asking about something like, “Where do we put what diets a pet is on or medications or their vaccine history?” Coming at it from that place of curiosity and asking, “I want to understand how we are doing things here.” It goes back to what you were talking about earlier, asking the question in a very gentle way. Because I'm not accusing them of not putting it in there. I want to make sure I'm not missing something. And I want to make sure I know where this goes here in our records within this practice.”
Stephanie Goss:
Which feels very different than saying, “I know that our state requires that we record this information. I'm not seeing it in the record. What am I missing?” Those are two very, very different conversations. They're both, they're saying the exact same thing, but it feels very different to the person who is receiving…
Dr. Andy Roark:
Yeah. I agree.
Stephanie Goss:
… that question.
Dr. Andy Roark:
There's two types of presentations that we want to do. And so, the first one is the gentle presentation that's meant to not put them on the defensive. And the second presentation, which we'll have going on, especially this is a great conversation that if we're going to talk to that specific doctor is I might have strong feelings about patient care when I look at medical records and those are very, very valid. And I might mention those feelings, but to me, the most effective way to have conversations like this, we're talking about changing behavior is to talk about what the person who's doing the behavior cares about.
Dr. Andy Roark:
And so, for example, when we talk about medical records, things that motivate doctors would be, in some cases, patient care and not the patient care of the doctor. But I would make the case, “Hey, when we transfer patients, other doctors don't know what your plan was and they're not carrying out your plan.” And so, you can see that that's still, it's not a very critical approach. It is a benefits approach of, “Hey, we want other doctors to be able to follow suit with what you had planned.
Dr. Andy Roark:
Your reputation. “Hey, I want to make sure the client,” because the clients get copies of the records and they call for them and I want them to see that they're getting treated. And I want them to see the care that's being offered and what their patients or what their pets are getting when they come in here and I want to make sure that's clear to them. It's the standing in the vet community is, “Hey, the other vet practices see these.” And often ask us if there's more information.
Dr. Andy Roark:
And I don't want us to be perceived in negative light with the other clinics in the area. There's a simplicity in the life-balance argument, which is, “Hey, I want you to be able to go and be off and not have people calling you and asking you about what your plan was.” I want you just to be able to lay it down and then to leave and to know that the next person is going to know what the plan is. And also, when somebody else doesn't write up the chart or with somebody else as the case, I want you to be able to pick up their chart and have the information that you need to make this job easy and not have you going back and starting over again.
Dr. Andy Roark:
And then the client experience in the exam room. It's like, “Hey, I want our doctors to be on the same page,” so that when a client comes in and sees the vet, they haven't seen before that person stays up fumbling around. The client has confidence and that person that they know what's going on. And so, all of those are very soft ways to set this up. But it's all different ways to try to get at what that doctor cares about or what's going to motivate them. But those are the things that I bring up. And I'm very selective about what sorts of leverage I try to use to move the person in that direction.
Stephanie Goss:
Yeah. I think that makes total sense because who isn't going to want to hear that somebody else on their team cares enough about them, that they don't want them to get called on their day off. I just feel like there's no defense to that. Even if I'm a doctor and even if I'm the doctor who does have insecurity and feels worried about my medicine being questioned. If you came to me and you said, “I just want to make sure that you can take a day off and that we don't have to call you and ask questions.” I can't imagine that you could be bothered by that. It's just, it's feels very disarming in a good way.
Dr. Andy Roark:
Yeah. I really don't want to go the state board at all. And if I do, I really want to have great medical records, like I really want that. And so, I am highly motivated by that. And also, by not getting called on my days off. And again, I don't blame doctors who are like, “Hey, I'm looking at your case. I have no idea what you were thinking or where you were going. What do you have going on?” I don't blame them for that and I'm not getting mad.
Dr. Andy Roark:
I kick myself for not being like, “Hey, this is where I am. And this is what the idea is. And if you feel like this idea is not good or you want to try something else out, God speed. Go for it.” But at least you know what I was thinking and where I was going and that was two weeks ago. And so, you're looking at something totally different now. You have the benefit of hindsight that I didn't have. “Here's where I was going, but take it. Make the call and go on, but you don't need to call me. And I don't need to get involved back into this because I laid everything down and gave all the information that I had.”
Stephanie Goss:
Yeah, yeah, no, I like that. I think this is one where ultimately I think the final answer is you have to pick your poison, so I think this is one where if you're working in a practice, this goes back to your head space. You have to decide where you live. Are you okay with this? Are you not okay with it? Are you going to be able to say something and then sleep at night or do you need to say something and ask for a change. And what is that change going to be?
Stephanie Goss:
And so, I think ultimately, we talked about different ways that you can approach and the different levers that we can pull. But ultimately at the end of the day, I think this is once you go on your fact finding mission and you ask good questions and you're coming from that place of curiosity, and you're here asking, “Tell me more.” At the end of the day, you have to decide if the practice is willing to change or are they not, and if they are, great. What do you need the change to look like for you to feel good and sleep at night? And if they are not, what are you going to do about that?
Stephanie Goss:
What is going to make you be able to sleep at night because the answer may be that you can put your head down and go on from there. And the answer may be that you cannot. And you need to know that and be able to have a plan to move forward because ultimately, I think you're going to have to pick your poison here at the end.
Dr. Andy Roark:
Yeah. I think that's the advice for everybody, regardless of where they are on that spectrum from nothing is written up to once in a blue moon, a chart gets missed. The steps are still the same of you going through collecting information, figuring out why this is happening, figuring out what the pain points or resistance points are. Making a presentation about why you think this is important or what your concerns are. And then assessing what the response is and deciding how severe a problem this is or how strongly you feel.
Dr. Andy Roark:
I would say to the person writing, if you were a doctor or a licensed vet tech, I would tell you I'd cut and run, just because I would say this is too risky. This is too risky to my license, my license. I worked too hard for this license to worry about it getting tanked like this. And that stress would bother me enough then I would be like, “Hey, look, there's plenty of opportunities for me out there. I'll go somewhere else.” Those are generally my thoughts on that.
Dr. Andy Roark:
And again, as a paraprofessional, you have a little bit more leeway because no one's expecting you to make those medical calls you. But I still think you just want to think about what you need to feel good about the work that you're doing. And then there's nothing worse than going in and not feeling good about what you're doing with your time in interview.
Stephanie Goss:
Yeah. And I think that it's also not wrong that every member of the team contributes to the level of medicine that you practice collectively as a group within the practice. And there, I find nothing wrong with the front desk team wanting to be active, engaged part of that process. And so, I want to interview, especially when I interview people with experience, I want them to tell me what do they want to be a part of, medicine wise. Just because they don't have a license, just because they haven't gone to school doesn't mean that they don't have information to share that is important and valid.
Stephanie Goss:
And so, I think it's good and healthy for the front desk team to think about what level of Medicine do they want to be a part of. And that's when I interview as a CSR or looked for new clinics as I grew in my career, that absolutely was a piece of the interview process for me is, “Tell me about your Medicine. Tell me about what you're doing. What about your standards of care. I wanted to see, are they using paper charts? Are they using hybrid? Are they using completely paperless? What are they doing and how are they doing it?
Stephanie Goss:
Because at the end of the day, there were things that were important to me that I wanted to have in place to feel like I could go to sleep at night and feel good about what I was doing. And that, what that is for everybody is going to be very individual, but there's nothing wrong with asking those questions. And I would say you should be asking those questions.
Dr. Andy Roark:
Nope. I agree. I'm on board. All right. Yeah. I think that's good. I think that's the advice that I have.
Stephanie Goss:
I love it.
Dr. Andy Roark:
I think this is, to some degree, is a common pain point for a lot of people. Not to this degree, but to some degree, it definitely is. I hope that that's been helpful.
Stephanie Goss:
Listen, I think this is going to be one of those episodes where we're not going to have very many people who are like, “Are they talking about my practice?” But I do think that this is going to be one of those episodes where you step back and say, “Today, I'm going to be happy about the dumpster fire that is my practice.” Because there are practices out there that have bigger problems than I do. And sometimes that reminder is just as important, so you're welcome. You're welcome everybody.
Dr. Andy Roark:
Awesome. See you, everybody.
Stephanie Goss:
Well, gang, that's wrap on another episode of the podcast. And as always, this was so fun to dive into the Mailbag and answer this question. And I would really love to see more things like this come through the bag. If there is something that you would love to have us talk about on the podcast or a question that you are hoping that we might be able to help with, feel free to reach out and send us a message. You can always find the Mailbag at the website. The address is unchartedvet.com/mailbag or you can email us at podcast@unchartedvet.com. Take care of everybody and have a great week. We'll see you again next time.
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