life Work

Word of the Year, Clinical Inbox Management, and Unreliable Weather Forecasts

December 14, 2022

Word of the Year

Gretchen and Elizabeth released their Words of the Year in today’s Happier episode, so I figured – why not decide on my own?

Annabel was pondering along with me and suggested CLEAN, which I do think has merit. It ultimately inspired the word I decided on which is:


product of my own google photos search for clear skies – taken in the keys!

C L E A R !

CLEAR. As in:

  • Clearing out clutter!
  • Clear boundaries
  • A less cluttered (more clear) schedule
  • Clear goals + intentions
  • Clear communication

Excited for a year of CLEAR. (And I didn’t even realize that rhymed until now . . .)

I do not set a yearly word every year. I did search the blog archives and noted that 2016 was PEACE (hmmm) and 2017 was BREATHE and 2021 was NOW.

We will see how CLEAR goes!

Speaking of CLEAR . . . (or, not CLEAR . . .)

This POF post fascinated me. This is part of POF’s Post-Fi Notes series, which is always thought-provoking and enjoyable to read, despite being nowhere near “FI” personally. In this particular installment, a surgical subspecialist in his 40s (with kids and a stay at home partner) has amassed ~10 million dollars in assets and zero debt through a combo of smart investing and relatively low yearly expenditures.

He has dialed down his work schedule to 4 days/week and is paying colleagues to take his weekend call (Side note: Good move and lucky! I’m not sure this would ever fly in my group, everyone dislikes call!).

But he is still working and spends HOURS every day beginning at 5 am dealing with his clinical inbox – filled eternally with patient questions, emails, and the like.

I have so many questions about all of this.

WHY hasn’t this been outsourced to an advanced practice provider (NP, PA, etc)?

WHY has he continued to be accessible in this way? Not every physician is or has to be! For example, I can’t just “Patient Message” my private practice OBGYN and expect a physician response, yet I still continue to go to her because she’s good and I like her.

WHY is he choosing to continue doing this when he has 10 million dollars and freely admits he hates this aspect of his career?

I am extremely interested in questions like these because inbox issues and the like impact my life significantly (Josh’s and mine).

Related tangent: I currently take one of my kids to a specialist that is cash only (100% recognize not every patient can do this) and private practice. Every so often, I pay a not-insignificant amount of money for 30 minutes of time spent with said specialist, and I do not mind doing so.

For other caregivers I use (or that I take my family to), I have literally never received a phone call directly from a physician when I have a question. It’s typically a nurse or other support staff, and the goal is to determine if an appointment is needed.

Seeing how I myself do not receive free care from other providers has led me to be less freely giving with my own time over the years. Because I DO think people serving as experts deserve to be compensated for time and attention given. There are absolutely exceptions (ie, a truly sick patient needs urgent advice) but for most questions, the answer is usually a) okay to be addressed by a non-physician or b) warrants an appointment, which sometimes can even be telehealth to make it convenient for everyone.

That applies to me (even though I’m a woman working in a lower-pay nonprocedural specialty and thus automatically expected to be giving and generous). It applies to my husband (though his burden is more about documentation than patient requests, from what I’ve observed — but could still be alleviated by more non-physician help, in my opinion). And it should definitely apply to the guy in the case study.


Thank you + Weather Update

Well. Apparently no one knows what the weather will be like in Montana in one week, because yesterday at one point it said the low was -31F and now it looks markedly less bad (though still cold), with low of 5 and high of 18 on day one, and low of 18 and high of 35 (!!) on day 2. So perhaps I should just . . . stop looking.

(The issue with not skiing on our first full day is that we already pre-purchased ski school, lessons, and lift tickets, because ski school/lessons apparently fill up. I’m not sure they are transferable to other days so . . . yeah. But if it’s hideously cold maybe they would be flexible, I guess we will see!)

((Thank you for humoring me and providing tips for what is clearly a very privileged problem to be having, concern about temps on a ski trip!!! At the same time, your suggestions have been truly helpful as I haven’t had to learn to really bundle up kids ever, and I feel less anxious! So thank you!))


  • Reply Jennifer Darnell December 14, 2022 at 2:42 pm

    I live in Crested Butte, CO (ski town) and here a few things that help with the cold. First, if the wind isn’t blowing and the sun is shining it will feel a lot warmer than you expect it to. Second, protecting little faces with buffs that can be pulled up or down (or balaclavas) is key. We also use the little disposable heat packs (the toe warmers go on top of the foot inside ski boots and hand warmers inside ski gloves on the backs of the hands works fine for skiing). My favorite ski gloves for kids are the ones with fingers inside of zippered mitts. Then the hand warmers can go inside the outer mitts.

    • Reply Melissa December 14, 2022 at 10:07 pm

      Take this advice re ski gear. It is exactly what we did with our kids. Balaclava is better for really cold temps. Heat packs are really good and mittens are warmer. Our kids either had seperate liners with mittens or the built in ones. You need the liners if you use the heat packs as they shouldn’t be on bare skin.

      • Reply Sarah Hart-Unger December 15, 2022 at 5:23 am

        I think the mittens I got from outdoor research have a built in pocket? But I will look into liners as well!

  • Reply Catherine December 14, 2022 at 3:27 pm

    I find that Apple weather isn’t really the most accurate, I instead use the NOAA weather site to check and keep tabs on local weather. It seems that the weather predictions change wildly from what they predicted 10-7 days ago, it’s not worth worrying about so far out. Maybe look again next Tuesday and then start to plan your attire. You are also, going somewhere that has stores, so if you get caught off guard with the weather, you can probably find what you need in Bozeman. Also, as a person who was born and raised in MT and who still lives there, the negative temps are bearable as long as you keep moving and cover your exposed skin. Hope you and your family have fun!

  • Reply Cara December 14, 2022 at 3:31 pm

    I am an OT (in pediatrics) and have come to the same realisation over time that you have (and I’m the same age as you so maybe it’s an age/stage of life/stage of career realisation). I don’t receive free consults from medical or allied health people I engage with, so why do I give them (see your comment re: women in lower paid health roles….grrr the patriarchy…). I’ve also realised that my clients don’t get this from their other service providers; they would never expect the pediatrician to call them for a “quick chat” about an issue they are having. I’ve tried this year to be more boundaried with this, if someone asks me to call and “quickly” answer their not quick question I schedule an appointment, if it can be answered in an email I’ll typically do that (I find once you get on the call for the quick question there is always a “while I’ve got you…..”). I’ve found telehealth and the pandemic to have helped immensely with this and made it a lost easier to schedule a zoom call, which is then clearly an appointment.

    • Reply Sarah Hart-Unger December 14, 2022 at 3:49 pm

      ” they would never expect the pediatrician to call them for a “quick chat” about an issue they are having.” — well, that has not been my experience as a peds subspecialist 🙂 Most probably don’t, but a significant portion do.

      otherwise YES to all of above!

      • Reply Cara December 14, 2022 at 3:59 pm

        I think it probably varies on speciality. My area is a lot of emotional/behavioural work and I know they don’t call the developmental pediatrician and ask what to do when their kid did xyz. I think if it’s more medical focused (like your speciality) they would call a lot more; and I do think when people tell me “I called the paediatrician…” it’s almost always a medication type issue, and they for sure should make an appointment.

      • Reply Irene December 14, 2022 at 4:05 pm

        I have children who see a variety of pediatric specialists and therapists and have found out pediatricians BY FAR the most willing to call and chat an issuing on short notice. I am more than happy to pay for anyone’s time, the issue for me is generally the time aspect of it. I have to schedule time weeks in advance for a parents session with my kids main therapist (all private pay, same rate for parents as kids) and it basically doesn’t happen with the speech therapist- if there’s an issue it is addressed during a session and kid just doesn’t get a full session that week. Which is also generally fine.

  • Reply Keren December 14, 2022 at 4:16 pm

    I live in a country with free medical care ( though I pay a lot for it indirectly in taxes) but phone calls to specialists aren’t really a common thing. Since COVID scheduled phone appointments are much more common, last time I wanted a blood test referal from my GP I scheduled a telephone consultation,which is just like any other appointment. But I could have asked for it without an appointment as well by submitting a request to the clinic, and I guess then my doctor would have done it in her not so free time. I also found out that my OBGYN has a scheduled hour a week in which she only does phone consultations,which seemed weird to me,because I usually go to her for a physical examination, and while there’s a long wait for in person appointments it’s much faster to get a telephone consultation, but is it really the best way to utilize her time when many patients need in person check up?
    I guess the real solution that will benefit all is more medical staff but in a none ideal world it’s hard to balance doctors needs and paitians needs.

    • Reply Sarah Hart-Unger December 14, 2022 at 4:28 pm

      Ordering labs –> that’s a quick request that totally doesn’t bother me, though often it’s best to have an appt first so I can understand exactly what needs to be ordered if it’s a complex issue.

      It’s more the long involved questions where patients call in or send a message requesting a “discussion” without an appointment. This is not uncommon in my specialty and can take a lot of time. I’d rather that take an appointment slot than have to call after a full day. If there aren’t enough appointment slots and all the physicians on a given team are highly productive then that (hopefully) is a signal to hire more doctors or support whether it’s nursing or advance practice providers (NP/PA).

      • Reply Gillian December 14, 2022 at 5:46 pm

        I hate ordering labs, not because of the order that is the easy part, but because the of review of the labs that the patient will want to do on the phone for free! My inbox today was full of requests to review labs another physician drew. These are appointments and need to be scheduled as such so I can be compensated for my expertise. The problem is my next available appointment is in March… It is a really challenging issue.

        • Reply Sarah Hart-Unger December 14, 2022 at 6:15 pm

          ugh. I totally get it. But reviewing outside labs is . . . often not quick! Maybe need to start blocking half a day per week or an hour/day for one-off telehealth? Or – if the volume of this need is high across the practice, perhaps the combined follow ups being billed for would support another provider!

  • Reply Amy December 14, 2022 at 4:27 pm

    As an attorney, I bill clients for my time responding to “quick” phone calls and emailed questions, so it is strange to me that doctors do not do the same thing. Our family doctor has finally started billing for some of the email exchanges (via MyChart) which I complete expect and accept – sometimes that’s a more convenient way to address non-emergency questions without the added hassle of coordinating a time to physically be present in office or via telehealth. I will also sometimes have my legal assistant respond if the answer is easy enough, or to gauge whether an appointment is necessary.

    Also in MT – you should be fine, the weather forecasts are notoriously unreliable that far out and as someone mentioned above, you’ll be near stores! And it is a dry cold which, to me, feels less cold.

    • Reply Gillian December 14, 2022 at 5:52 pm

      Until Covid we had NO mechanism to do this! There was no way to bill patients through insurance for their “quick questions.” Changes in how telemedicine is billed helped somewhat but in some states like mine (NY) it is still very difficult to bill for this time because you as the physician are supposed to be licensed in the state where the patient is physically during the virtual visit and the onus is on the billing physician to say the patient is in a state where they are licensed. I only have a license in NY. My patients live in NY, NJ, CT and beyond. If they are not in my office it is very hard for me to say they are in the state where I am licensed. Lawyers are not subject to those types of restrictions (my NY Bar admitted husband has been involved in deals all over the world!). VERY frustrating!

      • Reply Sarah Hart-Unger December 14, 2022 at 6:16 pm

        ohhh that is such a NY problem. 99% of my pts are Floridian (the other 1% are like Bahamas/Trinidad/etc). Didn’t think of how that would impact those near borders!! That’s really tough!

        • Reply Celeste December 21, 2022 at 11:03 pm

          On the other side of the “i just have a quick question” equation… I wish I understood how to get an appt with a nurse to NP or PA for things like expecting I have an ear infection that may or may not need antibiotics. Waiting days for an appt with a physician and then “wasting” their time with something so minimal really doesn’t work out well for anyone involved.

  • Reply Prefer Anon for this one December 14, 2022 at 4:43 pm

    omg yes! as a canadian doc the incessant requests for a “quick phone chat” are the bane of my existence. I probably get 20-30 patient emails/requests etc in any given day, in addition to routine labs/pharmacy requests/consult notes etc that come in. In our system we bill “fee for service” – which means the gov’t pays a set fee when you see a patient. The rest of it (above) is all expected as part of the standard of practice, but is ENTIRELY unpaid. I’ve started explaining to my patients in more frank terms – I won’t call you for a “quick update” or order labs you request over email because I don’t (won’t) work for free! Imagine someone calling their lawyer or accountant or anyone else and not getting a bill. Can’t imagine why the surgeon in question wants to keep it up. I suppose if practicing is important to them it might be something they feel they have to do as part of the job? Or if they’re super frugal/FI-focused don’t want to pay an NP/PA etc?

  • Reply Omdg December 14, 2022 at 5:15 pm

    As someone who recently left a gross, smelly hotel that was not refundable for a much nicer, cleaner one, and was out $600 because of it, I can assure you that it was WORTH EVERY PENNY to have the vacation experience I wanted. So, if you have to forfeit $600 on ski school because it’s negative 1,000,000 degrees and you avoid uncomfortable whiny children who hate every moment (and maybe avoid frostbite too!), just be happy you have that choice to make!

    • Reply Sarah Hart-Unger December 14, 2022 at 6:14 pm

      very very true!!!!!!!!

  • Reply Marie December 14, 2022 at 7:27 pm

    I grew up in Bozeman and skied much of my childhood, so a few thoughts from my experience. The sun makes it much better than you’d think, as long as the wind isn’t bad! Think layers — liner under ski helmet, long underwear under fleece/sweats under ski pants, etc. The hand warmer / foot warmer idea is a really good one. I’d also suggest having lip balm, Kleenex, and maybe hard candy in an easy accessible pocket that you can get to on the chairlift. I think you’ll have a great time! If the weather doesn’t cooperate, a drive to Yellowstone (assuming roads are open, the geysers contrasted with snow are really cool) or to Bozeman (Museum of the Rockies, etc.) might be in order!

  • Reply Lisa of Lisa’s Yarns December 14, 2022 at 7:40 pm

    I think I’ve mentioned before that when I submit a question to my rheumatologist, it can be charged as an e-visit if it’s not within 7 days of a visit. I am totally happy to pay for her to respond to a question. I am shocked at how fast she responds! I also had quick responses from my OB when I was pregnant, although I know my OB had an assigned nurse to respond to emails. Last year when Will had his awful reaction to amoxicillin, his doctor called me which was so surprising to me. She also called when I sent a pic of a rash that was textbook rosacea. I think she is the MPD of our local peds program and has 2 days in clinic/a lighter case load. But she is amazing. I am trying to decide if I would ask the same questions of male physicians. I think I would? I just happen to only have female physicians!!

    Mg word of the year last year was ‘connection’. I might repeat it this year. It was a good word to focus on after going off social media!!!

  • Reply Laura December 14, 2022 at 9:17 pm

    That Keys photo is lovely!

  • Reply Melissa December 14, 2022 at 10:10 pm

    I would never expect to ring or email a doctor to speak to them without an appointment. The only exception would be ringing for test results if they have told me to. I think you are right to value your time.

  • Reply Ali December 14, 2022 at 10:44 pm

    I find it so interesting…the large group my family goes to (for primary care as well as several specialties between all of us), the doctors are all far more willing than I would be to talk through things. I was sick last spring and called my doctor to set up an appointment—instead the nurse just said the doctor would call me. She did and talked me through what to watch for, when to get concerned, etc…all this at no charge. And we have had several things like this happen and never been charged.

    As a patient, it is AWESOME (so many $$ saved since we have a super high deductible AND so much time saved)…I would be more than happy to compensate our doctors for this service because it is a real service to us on their part. I won’t complain about not being charged, but I am just constantly floored by their willingness to do this.

  • Reply gem December 14, 2022 at 11:46 pm

    West coast Canadian who skis much of the winter — and I’m seconding all the winter clothes advice with a couple of additional thoughts: 1) mittens are definitely better than fingered gloves (even within mittens), 2) a change of socks at lunch time is heavenly (works well if you have access to a warm ski locker), 3) if there’s a cafe or bistro at the top of the ski lift, use it. I would get a couple more runs out of my daughter after a steaming hot chocolate and cookie at the cafe. And 4) dry your boots each night. Good ski resorts will often have boot warmers/dryers in the rooms or can provide them. If not, I have used a hair dryer before. To me there is nothing worse that wet cold ski boots on your second day.

  • Reply Meri Paterson December 15, 2022 at 12:39 am

    Sounds like that FI guy could use ‘Cal Newporting’ his life. Would be an ideal case study for a deep life section of his podcast!

  • Reply Erica December 15, 2022 at 11:24 am

    While you shouldn’t have to devote unbilled time to patient questions, I do think there is a gap in care in many systems, which has narrowed but not filled with the rise of telehealth. So many doctors are booked to the extent that it is impossible to see them without making an appointment weeks or months in advance, which means emergent issues – even if the patient’s schedule is completely clear – have to be handled some other way.

    We made the fortunate / foresightful choice to select as our pediatrician the pediatric practice of a hospital. They provide a 24-hour clinical call line, and whoever answers collects our info and puts us in the queue for callback by the on-call pediatrician. We have used this a couple times, and while I have no idea if / how it is billed, it has been wonderful to be able to speak to someone within a couple hours when e.g. a baby has a high fever. (I know being on call isn’t fun for doctors, but at least it’s a set-aside time and I’m not interrupting my own doctor at home or anything.)

  • Reply Anna December 16, 2022 at 9:40 am

    Before I share my opinion, I would like to make it very clear that I absolutely agree that no one should be expected to give away free time. However, here are the issues I see with the current system. I frankly do not understand how you can be billed 300-400 dollars for a 10-15 visit with a specialist, where in many cases they are rushing through the appointment and filling out the notes while talking to you. Even with the costs to operate a clinic or a hospital that amount seems astronomical to me. So it seems that some additional consultation either via an email or a phone call should be built into this amount and clinics should plan accordingly and give their doctors time to respond to these requests. Additionally, if you or your child have a chronic condition (or worse yet, multiple conditions), it’s simply not feasible to schedule appointments for every question, as you are already struggling to get time off work for each appointment and in many cases with the location of certain specialists it can be 3-4 hours of your day for something that could have been resolved in a 10 minute conversation over the phone (especially if the doctor doesn’t need to physically examine you). And as others have stated above, in many cases that appointment will be in several months. So the system is not set up for proper patient care. It’s set up to churn through as many patients as possible and squeeze as much as possible out of doctors, and I sympathize with that as well.

    • Reply Sarah Hart-Unger December 16, 2022 at 9:51 am

      Definitely valid points. From a number persoective, I just want to clarify that at least in our system, a self pay (no insurance) follow up costs $115 (sorry I initially wrote $92 but that is the rate for a PA or NP visit). $300-400 for a follow up seems quite high.

      • Reply Anna December 16, 2022 at 12:58 pm

        Oh, wow, that’s a huge difference! And I can see how the expectations would be different in this case.

        • Reply Sarah Hart-Unger December 16, 2022 at 1:37 pm

          It is more in the range you quoted for a new patient eval but I hope that in a new pt visit you get way more than 10
          Min of attention! Typically for a new patient i spend 10 min reviewing prior records and reading referral, 20-30 min in the room and giving them orders for studies etc, and just to be clear
          I do always follow up results of labs or studies I order for free, usually via a secure message. Totally makes sense to “bundle” that with the appt. It’s the longer one-off questions that I struggle with. Often they will say it’s a quick question and I end up on the phone 15+ minutes.

          • Anna December 16, 2022 at 4:04 pm

            It’s hard to believe that there is such a difference in price. Our established patient visit is billed at around 400 and our new patient visit is billed at 600+ and you do in fact get a little longer with the doctor during the first visit. The main point I am trying to make is that the doctor should not be expected to answer random questions “on their own time”, that is not fair. But I feel like if the clinic charges the patient 400+ dollars for 10-15 minutes, it’s fair to expect a little more outside of the visit and that should be built into the process.

          • Sarah Hart-Unger December 16, 2022 at 4:45 pm

            I literally just went on our insitition’s website and read the self pay rates. I just looked up CMS Medicare reimbursement rates for common return visit codes, and they are:
            99214 $90 and 99215 $148. 99215 visit should be 40+ min and have significant complexity.

          • Sarah Hart-Unger December 16, 2022 at 4:46 pm

            Totally agree with more value from a $400 visit being warranted! But where do you draw the line? Following up labs = reasonable. Extended conversation a month later = perhaps warrants a new appt.

          • Anna December 16, 2022 at 5:28 pm

            With the prices you are quoting I think it would be perfectly reasonable to schedule an additional appointment for a lengthy conversation. In our area, a regular general practitioner charges 150+ for a basic 10 minute wellness visit. I’ve always felt that these prices were not commensurate with the value provided. Granted, we never inquired about self-pay rates, and perhaps they are significantly cheaper. Something to think about for sure.

  • Reply maxine December 16, 2022 at 2:35 pm

    I agree that the reflection on inbox work in that post is strange! I definitely agree that LVNs/RNs +/- non-physician providers can review and triage messages. Or, share inbox coverage with colleagues (which is what my group does).

  • Reply Felicia December 16, 2022 at 3:30 pm

    PAs and NPs probably aren’t the right group to delegate these things to. Working to the top of our license means we are billable providers, and in many practices (at least here in CO) bill more visits than our MD/DO colleagues 2/2 lack of non clinical opportunities at a fraction of the labor cost (a whole other problem, obviously)
    a primary care PA

    • Reply Sarah Hart-Unger December 16, 2022 at 4:42 pm

      Interesting! But in the surgeon’s case… wouldn’t it be useful and less expensive to hire a PA or NP? Or are you suggesting an RN or LPN would be a more reasonable choice?

      • Reply Felicia December 16, 2022 at 5:36 pm

        Yes, I suppose it would depend on the specialty. For delegating labs, simple clinical questions, etc I would think an RN would be most appropriate.
        The APP role in surgery is quite different, but I assumed you meant in your mostly outpatient practice 🙂

        • Reply Sarah Hart-Unger December 17, 2022 at 6:41 am

          Totally makes sense!! Agree 100%. The guy who posted on physician on fire was a surgical subspecialist so maybe that’s where my line of thinking came from. I would be ssooo happy (and could see more patients) to work side by side with an RN. We do have medical assistants and they are helpful with many things, but not at the 1:1 level where they manage inbox stuff.

          We also have NPs (2) who work in our office primarily doing diabetes work but I 100% agree they are more like super-specialized providers alongside physicians not supporting us in that inbox management way.

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