What happens when there aren't enough generalists?

First, conscientious generalists get overworked, like this doctor:

Working 12-hour days and five-day weeks in her solo practice, she often double or triple books patients.

While most doctors in the area close their books to new patients when they get overloaded, the Aldinga Surgery GP refuses to. "I try to see people within a few days which is at my own detriment," Dr Mayne said. "We try to fit patients in at some stage, within a couple of days.

"Other people (GPs) just say `I am seeing this number', other GPs have a four week waiting time.

"But I have been here 18 years. I don't really want to knock back an 80-year-old woman who has been seeing me for many years."

Dr Mayne said demands on GPs had increased dramatically in recent years.

"The area has grown immensely and there is just no help," she said. "You can't get locums, you can't get people to do sessions, can't get partners in a practice.

"Waiting times for specialists have made people totally disillusioned by the public hospital system, this all puts more pressure on GPs.

"It has got to crisis point. I am sick of it, I don't want to do it for much longer."

A diary kept for The Advertiser by Dr Mayne showed she was seeing an average of 40 to 50 patients a day.

Secondly, frustrated generalists give up:

Christchurch doctors are walking away from their practices as the shortage of GPs spreads from rural areas to the cities.

Increasing paperwork, the growing threat of litigation and the lure of more lucrative positions in other health-related sectors are taking a toll on existing doctors and making the profession unattractive to debt-laden medical graduates.

A New Zealand Medical Association report shows the number of GPs nationally has dropped almost 10 per cent over two years, and with rural communities already in crisis, health professionals are now saying Canterbury's urban centres, once flush with doctors, are starting to suffer.

The West Coast has the lowest rate of active GPs per capita in the country, with some doctors reporting more than 6000 patients on their books.

In Rakaia, residents have been without a permanent GP for months, and the community has formed a trust to take administrative pressures off the doctor and keep the practice alive. The community is served by a locum and are close to securing a permanent replacement.

The Christchurch School of Medicine's public health and general practice department head, Les Toop, said compliance costs and uncertainty within the profession were putting people off taking on even the most sought-after practices.

"It's happened for some time in rural communities but now it's starting to be seen in the bigger centres. Some doctors aren't even bothering to advertise, they're just shutting up shop."

Thirdly, the remaining generalists are under more pressure because there aren't enough physicians. Overwork. Burnout. Rinse. Repeat.

OK, big deal. These news stories are from Australia and New Zealand. This couldn't happen here in the US, right? It already is.

As a retired schoolteacher with health insurance, Dot Goodwin never thought she would have a problem getting an appointment with her family physician.

She became ill and discovered that her doctor of 30 years had joined another practice.

The doctor who assumed his practice wasn't taking new Medicare patients.

"There I was, bad off, and had to go to the emergency room for treatment," she said.

An emergency room worker told Goodwin about a doctor with a new practice in Decatur. A Lawrence County resident, Goodwin got an appointment with the doctor and continues to see him.

She is one of the lucky few who are able to find a primary care physician in Alabama. Sixty-two of Alabama's 67 counties have doctor shortages so severe that the state has declared them Health Professional Shortage Areas.

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Barganier said some primary care doctors in Alabama treat as many as 8,000 patients.

"There is nothing like being the only physician in a town or being only one of two," Midgley said. "It's hard to take a vacation, it's hard to have family time because you're working all the time."

He called it a self-perpetuating cycle.

"It's hard to attract new doctors because they won't have any backup," Midgley said. "What we have said is that our medical schools need to do more to address the problem. They need to turn out more primary care physicians than they do."

I would argue that churning out more primary care physicians won't happen because let's face it: what medical student would want to walk into this kind of situation? One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

What happens when there aren't enough generalists? Patients and doctors suffer.

Good Press

Dr. Gordon Moore recently got mentioned in a news article that highlighted just one of the benefits of his solo practice model -- same day access. The open access model is certainly not unique to solo practice, and many different practice models utilize it, including some large medical groups such as Kaiser. In fact, the open access or "advanced access" model was first developed at Kaiser by Dr. Mark Murray in Northern California.

Here's another recent news article about a family physician in Kansas City, Missouri who is revamping his practice to better serve his patients: Trying to keep it all in the family:

Need to make an appointment? You can call Soper's office in Kansas City, Mo., in the morning and see him that day.

All your medical records will be computerized. Your prescriptions, printed by computer, will be perfectly legible.

"Patients really like it," Soper says of his approach. "And it makes it a little easier for us to survive."

Survival is on the minds of many family physicians, the better-trained version of the general practitioners of a generation ago.

They can rightly claim that they're already an economical source of quality care. But many say the future of their beleaguered field may depend on more doctors changing their practices, as Soper has done.

He sounds like he is doing much of the same things that I and many other doctors are trying, which is to foment a Revolution. I'm not trying to change the US healthcare system, at least not all of it at the same time. I'm just trying to change my little corner of the world, and maybe it'll work and work so well that others will look up and say, "Hey, that's a great idea. Let me try that."

Still, being a Revolutionary would be a lot easier if I could get some press about my practice, too. Coincidentally, I attended a local chamber of commerce meeting today which was also attended by advertising executives from a large local newspaper. I introduced myself and described my kind of "Gordon Moore" family practice: same day appointments, no waiting, 24 hour a day access via cellphone or e-mail, house calls. They said they would pass the word to someone in the editorial section, and maybe I could get a news story out of it.

The local cable TV advertising executive was there also, and he suggested that targeted TV commercials, especially to a female audience (since many women decide who the family doctor is going to be, so he said), could be very effective. Hmmm. I'm not so sure about that. I can't ever remember seeing a TV commercial for a family doctor before. Besides Marcus Welby, M.D., that is. I would be concerned that I'd come out looking like a cheesy infomercial doctor.

I arranged to meet with the cable TV advertising executive two days from now. Somewhat troubling is that when I gave him my office address, he recognized it immediately and said he had worked with another tenant in the building last year. The other tenant was a Chinese herbalist - whose office I took over. If this is a reflection of how well TV commercials helped his business, then it does not appear to be a very promising method of marketing a physician's practice.

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Best quote from Dr. Marcus Welby a.k.a. Robert Young:

According to an article in McCall's magazine, a doctor said to Young at a convention of family physicians, "You're getting us all into hot water. Our patients tell us we're not as nice to them as Doctor Welby is to his patients." Young didn't mince words. "Maybe you're not," he replied.

The Decline of the Family Doctor?

I came across an article that I had seen a while ago, but never finished (until now), troublingly titled, "The Decline of the Family Doctor". It offers a thoughtful and insightful analysis into why the United States health care system is in the trouble it is in, and how a large part of that is due to changes in how primary care has been valued as a society.

"In the early 1990s, managed care attempted to use primary physicians and nurse practitioners to improve access and quality while, at the same time, keeping costs down. There was talk of the primary physician as the coordinator of all medical care. It didn’t work, and the backlash resulted in a decline in prestige, job satisfaction, and income for primary physicians. Many of the young physicians who flocked to the field felt cheated and misled."

I remember that time in the early 90s when FPs were in demand, and were given the role of "gatekeeper". However, it was not a welcome role, as I and this author observed:

"Furthermore, naming the primary physician as a “gatekeeper” whose approval is required by HMOs before patients can see a specialist suggests more of an obstacle than a caregiver. Personally, I have never encountered rudeness like I saw from HMO patients who came to see me because they were required to do so rather than because they wanted to. This is especially true when they had no interest beyond obtaining a referral slip to see a specialist whom they had already chosen themselves. It is difficult to know how to feel toward such patients and to function properly as a physician for them."

I used to think that a single national healthcare system was the answer. But more and more, like this author, I'm thinking that a single-payer system isn't the answer.

"The first principle is pluralism. Imposed one-size-fits-all and one-fee-fits-all solutions are incompatible with the American tradition and will not work. Choice and diversity must be maintained if American medicine is to remain vibrant, creative, and attractive as a career."

Staying the Course

Last week was a pretty good week for my still fledgling practice: 9 office visits, 5 new patients who all had physicals. This week: 6 office visits, 5 more new patients. Six months into my solo practice, I've had 73 office visits with 60 unique patients, with an even 50-50 split between the sexes, 30 males, 30 females. The average age is 36, and I'm definitely seeing more children and teenagers than in my former practice at Kaiser. This means most of the patients tend to be healthy, which makes for easier and more enjoyable visits, too.

Compared to some of the other doctors who are trying the "low overhead" or "Gordon Moore" model of practice, I feel like an old tortoise racing against Olympic-caliber hares. Scott in Florida just opened a practice right out of residency and saw 45 patients in his first two weeks. Michelle in Colorado closed her practice to new patients after less than a year, capping her patient panel at 450 patients.

Getting approval for insurance participation should help my practice grow. I learned just last week that I have been approved as a participating provider in Blue Cross of California, which has been the most common insurance my patients have had: 36%. That makes two health plans I have joined, Blue Cross and Cigna. I called Blue Shield the other day to ask what the status of my application was and found out that somehow my application had "slipped through the cracks". My credentialing had been approved back in April, but my application was never sent to the appropriate department to finalize participation. Whoops.

Yesterday I received an approval letter from Medicare, which was very fast, compared to the others. Looking back, it took about 6 weeks from the time I mailed the application to the time I got the approval letter. The third party insurers took about 3 months (with some still counting.... )

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Even as my practice seems to slowly pick up steam, I recently got an offer to buy an existing practice in a neighboring city. It is a successful practice with about 1500-2000 active patients, and the doctor is able to make a good income despite having two part-time employees and seeing about 42 patients on the 4 days of the week he works. When I heard these numbers, my first reaction was, "How can he do that?" But in analyzing the numbers a little, it does seem credible. I think I'm still not used to seeing a lot of income because I have not been keeping up with the billing.

When I first considered going into private practice, it had occurred to me that buying an existing practice would be one way to become financially solvent faster. But at the time, no one was advertising a practice for sale, and I wasn't about to go from doctor to doctor asking them if any of them were thinking of retiring. But buying someone else's practice means you get a lot of things that you don't want, too. There would be his employees, who are probably very nice, but a new kind of responsibility to deal with. There would be all the paper charts, since he is not using electronic medical records. His patients might be used to a different style or philosophy of medicine. But I would probably be instantly busy, seeing 10-15 patients/day compared to the 3-9 patients/week that my practice currently enjoys.

It would also mean either:
1) moving my location to another city, which would force me to give up my goal of being my home town's one and only family doctor.
2) Or moving the other practice to my current location (and risk losing patients from that practice)
3) Or keeping both locations and shuttling between them.

I would not be able to keep as tight control over everything, since I'd be forced to delegate appointment scheduling, billing, keeping track of supplies, etc. Some of this would be desirable. It'd be nice to have someone else answer the phone when I'm busy with a patient, rather than a recorded message. And billing can be tedious, when you have a lot of bills to process or if you have to call the health plans to argue over a denied claim.

So today I thanked the other doctor for the generous offer, but I preferred to stay the course and continue building up my own practice. I hope I don't regret it.

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I recently read a newspaper article about another doctor in San Diego who has been practicing completely solo, but he seems to have come up with the idea independently of Gordon Moore. Great minds think alike, eh?

And what can I expect for the future? Hopefully a little of what Kelly is getting. Kelly in North Carolina opened her solo practice about a year ago, and recently provided an update to the members of the Practice Improvement listserv. She wrote:

"My practice is incredible...I knew how hard this would be, but there are so many things that come up which I could't have even imagined let alone plan for.  I finally had to hire someone to help with billing...actually allocating payments and keeping up with the insurance companies, as Alteer handles the actual billing beautifully.

I'm still getting many calls a day for new patients, I have started accepting two a week and am scheduling them into January.  It feels stupid, as I hold my open access system dearly (for my established patients only).  But my waiting list was daunting and I don't want the responsibility of that...so if the people aren't minding I guess I shouldn't.

Though the insurance companies were definately NOT worth the hastle from November until July, they definately ARE now.  The reimbursement has been excellent this month.  Now that I have my pattern established with the ten biggest companies here I'm not having to call much anymore.  What a relief, and I'm getting paid much better than if I charged cash.  I also like the variety of patient's that it allows.

Have to go pick up my kids, who are also very happy with the life this practice allows, and have dinner with my husband (also a doctor at a local clinic) who is getting very jealous of the time I get to spend with my patients."

This gives me hope for a financially viable practice. I already am enjoying the time I spend with my patients - a practically obscene 60-90 minutes with a new patient has been my norm. And it's certainly gratifying to get comments such as this from my patients: "Thank you for being someone who wants to bring the caring quality back into Doctoring!"

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On a final note, I passed my Family Practice Boards (like 90+ percent of the doctors who took it). Yay. Now I have an excuse to send off a press release to the local paper and try and drum up some more business. I may be slow, but I'm not dumb.

Patch vs. Crash vs. ... Switch

I originally sent my Cigna application on 5/13/04. I got a letter back last week informing me that I had been approved as a participating provider. About 3 months, which is what others had told me. I am no longer in the limbo world of out of network providers. I am now a Participating Physician!

Or not...

I looked on Cigna's website and I am not listed in the online Physician Directory yet. So more waiting. Hopefully, I'll be hearing from Blue Cross, Blue Shield and Aetna in the next few weeks as to whether I'm accepted into their plans as a participating provider.

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Stop me if you've heard this one before. Complex system and infrastructure integral to providing healthcare has numerous flaws and obstacles to providing excellent care. Patches and fixes are like applying bandaids to plug leaks in Hoover Dam. You can keep tinkering with the system even as more and more problems arise. Or keep up with the status quo and crash and burn. Or you can try a radical change in the way things work.

The Gordon Moore Model? No, this time I'm talking about computers.

Eventually, if you wait long enough, everything converges. I ran into an article on Slashdot.com which discusses two of my favorite topics: medicine and computers. Fed up hospitals defy patching rules.

Problem #1: WIndows-based PCs are vulnerable to new viruses and worms. This is bad for hospitals that use PCs, ie. ALL hospitals.
Solution #1: Apply system patches and updates to plug vulnerabilities.

Problem #2: System patches often render software programs inoperable, including medical devices and instruments.
Solution #2: Software vendor tests their program with system patches to make sure they are compatible first.

Problem #3: Testing takes several months.
Solution #3a: Software vendor finally produces a product compatible with patched operating system. Repeat Problem #1.

or

Solution #3b: Hospitals apply patches anyways, and roll the dice, hoping their medical software and devices will still work. This leads to...
Problem #4: Vendor voids warranty because they didn't promise it would work on a patched system.

"When Microsoft recommends we apply a critical patch, the vendors have come back and said 'We won't support you,'" says Dave McClain, information systems security manager at Community Health Network in Indianapolis.

So the hospital has gone ahead and applied critical Microsoft patches to vulnerable patient-care systems when vendors wouldn't, McClain says. The hospital views the failure to apply patches as a possible violation of the federal Health Insurance Portability and Accountability Act (HIPAA ). "We have HIPAA regulatory issues, and you can't hold us back from compliance," he says.

Sometimes, the software vendor itself is the source of the virus infection:

There have been several instances in which viruses originated from medical instruments straight from the vendors, says Bill Bailey, enterprise architect at ProHealth Care, a Milwaukee healthcare provider. Medical equipment arrived with computer viruses on it or service technicians introduced the viruses while maintaining the equipment, he says.

(Getting on my soapbox)

As medical systems become more and more dependent on computers and electronic medical records, the information confained within them is only as safe as the operating system they run on. Increasingly, the Windows-based operating system is being exposed for its poor design and lack of security. As a physician, I feel that we should not trust our vital data and patient care to a buggy system, especially when there are safer alternatives. Either a Mac or Linux-based computer is a more secure solution.

This is not going to be a viable solution for everyone. There are not as many medical EMR/software/practice management options for Macs as for PCs. But for a solo physician, this is certainly something that is affordable and feasible. I'm living proof that it can be done.

Computer: Powerbook G4 12 inch 867 mHz
Scanner: HP Officejet 6110 All-in-one
Printer: HP Laserjet 1150
EMR: SpringCharts
Billing: Medrium
Financial: Quickbooks
Web browser: Safari (no pop-ups!)
Other software: Microsoft Office, Mail
Backup: daily automatic backup to offsite storage site, once a month complete backup of entire hard drive to external Firewire drive.
No known viruses for Mac OS X as of this time.

For ideas on how to switch to a Mac, go here.

(Getting off soapbox now)