Happy Anniversary!

It has been one year since I began writing this blog. It has been a slow process to get a solo practice up and running, with fits and starts. A lot like writing this blog. For the one year anniversary of this blog (which has been described by at least one person as a kind of soap opera), I thought I'd write a synopsis, of sorts.

Who am I?
I am a board-certified family physician, born and raised in Southern California, a UCLA alumnus with a double major in biology and English. That may explain why I'm writing a medical blog. I am also a husband (hi, honey!) and father of 3 daughters.

What is the purpose of this site?
To help other physicians who may feel unhappy with their current situation and wonder if there is a better way to practice medicine. A way to have enough time to provide quality medical care, to feel more connected with their patients, their family and their own lives, and not be just another cog in the machine. In other words, to help those who are tired of running find a way off the hamster wheel.

When did I start this?
I began thinking about starting my own practice after reading an article written by Dr. Gordon Moore in Family Practice Management in February 2002. In it, he described how he set up a completely solo practice (no nurse, no staff) and found greater satisfaction doing so. After 13 years working at Kaiser Permanente in Pasadena, CA, I felt like my practice style no longer fit in with Kaiser's system so I resigned my partnership and officially opened my own solo family practice office in February 2004, following the Gordon Moore model. Two years in the making.

Where am I?
South Pasadena, CA. It is a middle to upper-middle class suburb of Los Angeles, definitely NOT an underserved area, but for some curious reason, had no family physician practicing within city limits. This appeared to be a good business opportunity, I reasoned.

In the coming weeks, I plan to write about these topics:
How to get started with a solo practice
How does my practice run (nuts and bolts)
Sources of patients/income
Expenses/supplies
Status of my practice

Patient, Can You Spare a Dime?

I found this recent Washington Post story about doctors asking patients for voluntary donations to help offset rising malpractice insurance costs.

Kenneth M. Greene wasn't sure how his 1,500 patients would react when he asked them for a $10 contribution to help pay his $11,000 malpractice insurance bill.

"The medical malpractice insurance crisis has come full force to Maryland," the 47-year-old Towson internist declared in a letter he sent last December. A "small donation . . . is necessary if we are to continue to keep our doors open."

Nine hundred miles away in North Palm Beach, Fla., family physician Ira G. Warshaw launched a similar plan. Warshaw asked his 3,000 patients to send him a check for $125 ($25 if they were under 25) to help defray his $30,000 insurance bill, which has quadrupled since 2002. If patients didn't send him money, Warshaw warned in a letter earlier this year, he might be forced to stop participating with Medicare and some health plans.

"I felt like I was drowning, really," said Warshaw, a solo practitioner who said he felt "some guilt" about his request but was also grappling with a $100,000 debt from a failed venture in group practice. He felt compelled to act, he said, after his income dipped below the national average for his specialty, roughly $140,000.

I am fortunate to have an annual malpractice premium of about $5500, but then again, I'm in California (where malpractice rates have generally held steady) plus this is my first year of solo practice. Malpractice rates are designed to rise as your practice grows.

I think this is a reasonable request for doctors to make, basically to ask patients to help pay for the cost of doing business, especially if insurance reimbursements aren't enough to cover the costs. There is no free lunch, after all. High malpractice judgements = higher malpractice premiums = higher operating expenses which get paid by whom? Insurance reimbursement rates are relatively fixed by the Medicare fee schedule, so doctors can't charge patient more for services. But the money's got to come from somewhere.

Let the doctor pay for it out of their own income, some say. After all, he/she is still making enough money. The public may see an annual salary of $100,000+ and consider that adequate compensation. On the other hand, a doctor who has spent 7 to 12 years of their life in post-graduate training, with huge debts from school loans, who has spent countless sleepless nights of being on call, and who now has a young family with growing children whom he/she can barely spend time with because of long working hours and patient responsibilities would probably consider this inadequate compensation.

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As for my growing practice, I am fortunate to have more patients calling me in the past 2 weeks. I am nowhere near making a profit yet, but I am getting close to the number of patients I need to see to break even: 3 patients a day. Of course, it would help a lot once I start submitting medical bills regularly for reimbursement, won't it?

You can save a life, too

In one of my other lives, I am a Assistant Clinical Professor at the UCLA School of Medicine in the Department of Family Medicine. This is a fancy way of saying I donate my time to help teach first year medical students. I have been doing this for the past 10 years, and it has always been one of the most enjoyable activities that I do as a physician. Specifically, I help tutor a group of about 8 or 9 1st year medical students in the Doctoring course, which mainly teaches students how to conduct a medical interview by using actors who play the scripted role of a "standardized patient".

Last week, as each small group does every year, we visited the home of a family of a child with a chronic illness. This gives the students an opportunity to see firsthand the effects of a chronic condition on the physical, psychological, financial well-being of a family. In previous years, we've visited families of children with Tourette's, Type 1 diabetes, Down's syndrome, and cerebral palsy.

This year, we visited the home of John Paul, a 3 1/2 year old boy with Diamond Blackfan anemia, also known as DBA.

It is a very rare disorder, with about 350 people in the US having the disorder. His mother eloquently described the family's frustrations, hopes and determination in giving John Paul as normal a life as possible. Which is hard to do because John Paul has to get blood transfusions every 2-3 weeks to replace the red blood cells which his bone marrow fails to make. Because of the multiple transfusions, he has developed liver dysfunction due to iron overload and therefore must undergo daily chelation therapy with a portable infusion device attached to him that runs 12 hours a day. Because he is easily prone to infections, his family rarely takes him out and they've had to limit their own socializing for fear of bringing back a virus. On top of all this, his parents both work, and his mother is a tireless advocate for the cause of DBA and the recruitment of blood donors.

Because there are so few people with DBA, there are no government-sponsored funds for research. Instead the Diamond Blackfan Anemia Foundation was formed to help raise money to finance research for a cure.

John Paul's family is truly a brave and remarkable family. The medical students and my co-tutor and I were impressed and touched by their story. On their behalf and on behalf of the many people in need of blood, I encourage all of you to not only donate blood, but to become a regular blood donor. It is one of the easiest ways to save a life.

I'll be rolling up my sleeve this week for my donation.

From little acorns grow mighty oaks

Thanks to the links from MedRants and MedPundit, I've gotten more visitors in the past 3 days than I've gotten in 3 months. If only it were that easy to get patients into my solo practice.

My last entry talked about being interviewed for a newspaper article about my "Gordon Moore type" of solo practice. Here is the article that came out 4 days ago. The newspaper has a circulation of 35,000. The article was also published in a sister publication which has a circulation of 48,000. Since the article came out I've had 6 calls for appointments generated by the article, 2 calls from Kaiser patients who are unhappy with their care and want me to see them at Kaiser (I had to explain that I cannot do this), and 3 other general inquiries: what are my hours? do I accept HMO? (no); and one letter from a patient documenting how the last 10 doctors she saw couldn't help her but she was hoping that I could.

12 responses out of 83,000 potential readers. And that's not counting their websites. What this tells me is that there isn't as pressing a demand for a old-fashioned country doctor as I thought. Or maybe people just don't read the newspaper very carefully. Or maybe they didn't know how to contact me, since no contact information was included. The ones who found me said they just looked me up in the Yellow Pages.

But that's OK. I was plenty busy today. If I had 20 patients call for appointments, I don't think I could've accomodated them. I can't complain since it didn't cost me anything to be interviewed. I think that there is an abundance of primary care doctors in the suburban area where I live. Plus I think that as much as some people complain about the lack of accessibility to their doctors, it's probably good enough for most people. Of course, I may continue to get calls later on. Some people may have clipped that article and saved it for future reference. And the people I saw today will hopefully tell their friends and family about the doctor who answers his own phone and spent an hour with them. This is about planting seeds for a future harvest.

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Since starting this blog, I've found more and more medical blogs out there. In fact, if I read all the medical blogs from this site, I wouldn't have time to do any work.

The subject of blogs came up in a recent discussion about how to disseminate information about a new diabetes project being sponsored by the California Academy of Family Physicians. Well, consider this the first seed.

As part of the CAFP's effort to bring the Future of Family Medicine Project recommendations to fruit, it has decided to try and tackle the improvement of diabetes management. In our focus group last week, we decided that just about every family doctor knows what good diabetes care entails, we just need some help tracking and following up on our patients.

At Kaiser, they are ahead of most doctors. They actually give a printout every 3-6 months to each primary care doctor listing their diabetic patients and what percentage of them have had their retinal exams or microalbumin done, and what percentage of patients have their HbA1C in range. However, it is still up to the individual doctor to then contact any patients who may not have an optimal lab or may be missing labs completely.

We discussed the possibility of creating and distributing software to family doctors that would offer "one-stop shopping" in diabetes management. It would have a database which can track various parameters and allow you to see which patients are due for various labs or tests. The program would also be able to generate e-mails to patients reminding them when it is time to come in for a diabetes check-up. It would have links to up-to-date patient education material that can be e-mailed or given to patients to assist their self-management. In return for providing this software, the CAFP would get information. The database would be able to upload depersonalized aggregate data into a central database to help provide pooled statistics that can later be used to document (hopefully) superior diabetes care.

So hopefully this seed of an idea grows into something big.

Just as I hope this blog can plant some ideas into the minds of doctors who might want a practice that isn't too bureaucratic or just plain too busy to care for their patients. Now where's my trowel?

The Personal Touch

I was interviewed today by a reporter from one of the local newspapers to discuss my "unique" practice. My practice is following the "Gordon Moore model" emphasizing low overhead, minimal barriers, maximum accessibility via cellphone and e-mail. I described how I have no employees, in order to keep my overhead low, and how in return, I am able to spend more face-to-face time with patients. The reporter seemed impressed, so I'm hoping for a positive news story that might generate more patients.

Lately, I've been finding more news articles about physicians trying to "take back" medical care from the hassles imposed by 3rd party insurers and improve the overall physician-patient experience. Here's are two (1)(2) articles about Dr. Michael Stein in Hampstead, New Hampshire, who is starting a retainer fee practice with many of the same goals I have: more personalized care, flexibility in hours, house calls, unrushed doctor visits. His website is at http://www.realdoc.net/.

Dr. Vladmir Lorentz is highlighted in this article which talks about various businesses doing things the old-fashioned way.

This article talks about how rural medicine has a lot to offer, but seems to be dying out.

As a rural practitioner, Haynes said he loves what he does, especially the close relationship with patients.

''I have never had a burnout in medicine,'' he said. ''Every day I look forward to practicing medicine. I know all the families ... know the type of work the husbands do. I interact with the families as friends and as patients."

I think that this is what attracts many to the specialty of family medicine, getting to know people and their families in a personal, even intimate way that only a few ever get to experience. To be able to share in others' lives. I've always been amazed at some of the things people tell me that they would never tell their spouse or priest/pastor. I think this relationship is something that has been endangered for some time by the modern medical system, by appointment systems that prevent patients from seeing their own doctors, by 3rd party insurers that place restrictions on treatment options.

This opinion piece written by a general practitioner in the UK laments the "end of the patient-doctor relationship".

In an ideal system, the physician not only cares for the patient, but cares about them, too. Also, the patient cares about the physician, is respectful of his/her time, concerned for their lives. A couple of days ago, I got an e-mail from the mother of a boy I saw two months ago. She was reminding me that I hadn't billed her yet! How often does that happen???