Monday, November 22, 2004

SpringCharts on a Mac

While researching whether I should upgrade to version 7.0 of SpringCharts, I found this article about another family doctor who also uses SpringCharts with a Mac. (Besides me, that is.) I keep thinking that as smart as doctors are supposed to be, why don't more choose the intuitive, hassle-free Mac platform, rather than the buggy, insecure Windows platform?
"I hear it all the time from other doctors," says Michael Marlow. "They'd like to move to an EMR system, but their partners aren't ready." To convince his own partners that SpringCharts on Macintosh was a sound business solution, Marlow used a number of very logical - and ultimately, persuasive - arguments:

Affordability. "It's far less expensive, in the long run, to own and run anything on Macintosh. Because it lasts longer. The software technology doesn't outpace the hardware technology - or vice versa - within sixteen or eighteen months, like it often does in the Windows environment. And the cost of technical support is minimal."

Ease. "It's easy enough for someone with average skills to install the network, the hardware and software. You don't need an IT support person to come in and do it for you. You may choose to, because you're pressed for time. But if you have the interest; you can do it yourself."

Security. "When you're dealing with confidential patient information, Mac is a far safer choice. It's extremely difficult for someone to get into my network from the outside. But for them to get into my Power Book is almost impossible. And viruses? With Mac OS X, they simply don't exist on the Mac."

While the other two physicians in Marlow's practice have yet to make the leap themselves - "they're still scribbling notes on paper," he smiles - they are impressed with "the oohs and aahs they hear from patients when they see what I can do with my PowerBook."

Come to think of it, I'm still scribbling my notes, too, then retyping everything in later. Maybe I should skip a step and just type everything in at once. I'm proficient enough of a typist where I can type and maintain eye contact at the same time. I'll try it on my next few patients and see if anyone oohs or aahs.

Wednesday, November 10, 2004

The Ideal Doctor

Found this great NY Times article by way of Medrants.

In my idealistic zeal (okay, what little I have left), my first thought after reading this tale of two interns was that I would rather be like the caring but overworked intern than the efficient but emotionally detached one. In fact, that has been my practice style for the past few years, with the typical results: my self-respect intact but my life an eternal Sisyphean struggle.

As I thought about this more, I realized that these are not the only two choices. Couldn't it be possible to take the best from both practice styles and meld them into one? An efficient, unoverworked, caring and careful doctor who still has time for family, friends, patients, self and sleep? Who not only feels valued and respected, but is also able to generate a reasonable income that is sufficient to pay off school loans, raise a family and live comfortably too? A good doctor who is also a happy doctor? Am I dreaming?

And then I got to thinking, what would be an ideal doctor anyways? It depends on who you ask.

Patients want a doctor who listens, is compassionate, and treats them with respect. Some people have specific criteria or a checklists of things they want to see in an ideal doctor. But many of these things, such as having a courteous staff, or not being rushed because of an overbooked, may be out of a doctor's control. So when people say they want an ideal doctor, they really mean an ideal health care system.

And even though people want a patient and caring doctor, they also expect a doctor to be knowledgeable and clinically competent. Makes sense. Various medical organizations expect an ideal doctor to meet certain endpoints as a surrogate for knowledge and competency.

Many people's ideal doctor is someone like Marcus Welby, M.D. But you know what? Robert Young, the actor who identified closely with the role he played, suffered from depression and had an alcohol problem. If that is what happens to a fictional ideal doctor, imagine how hard it must be to be a real one.

Other television shows have inspired others as to what an ideal doctor should be like. When the British Medical Journal was conducting a survey of the best doctors of all time, real or not, Medpundit wrote:
My vote would be for Dr. McCoy. Despite living in a high-tech world where diagnoses could be made with the pass of a scanner, he never lost sight of the essential requirement for a good doctor: keeping the humanity of his patients at the forefront. He treated enemies and crew members with the same dignity and respect and competence. He was a hands-on doctor, and compassionate. Unlike later Star Trek doctors who spent more time beside their computers than at the sides of their patients, he was always at the bedside, keeping an eye on his critically ill patients. In many an episode he pulled all-nighters to come up with a cure for the latest alien malady to strike the crew. He never hestitated to stand up to his captain if his orders were contrary to his medical ethics. And, I suspect, he was the inspiration of many a child from my generation to go into medicine. (Although you won't find it admitted on any medical school application essays.)

And what about doctors themselves? Most doctors and doctors-to-be recognize the importance of emotional and financial self-preservation.

Patch Adams, MD had this to say about what he values as a physician:
My God, its friendship. Remember, I make my patients my friends. I can't distinguish between them. I don't want a patient that isn't my friend. I want to be intimate with every person that dares be intimate with me. I'm very confused about my boundaries. I literally want to fall in love with every person I'm with. I want that kind of relationship because I love friendship. It's just such a magnificent creation.

And I am curious about people. It doesn't matter where people come from for me. I just want to be with people and enjoy it. The magic of being a physician is that they will let you into their lives. If they perceive you care, they will let you into their lives in ways you cannot dream. People spend their lifetime with a friend trying to get what I can get on the first encounter with a patient. It's pretty breathtaking.

Okay, I'm not going to be best friends with all of my patients, but he's got a point. It's not about being an ideal doctor, isolated in a vacuum. Doctors can only be doctors if there are patients. So it's the relationship that we want to be ideal. All doctors have patients who love them and others who hate them. It's about the right personality match.

It's not about being a perfect doctor, because no one can be perfect. Personally, I think malpractice lawyers (intentionally or unintentionally) continue to foster the myth of a perfect doctor so that they can continue to blame doctors when they prove to be only human.

Patch Adams again:
Also, malpractice is wrong. Malpractice insurance set up an adversarial relationship with your patients. You get afraid if the patient is your adversary. The doctor says, "God, I made house calls, but then my hunch said don't get an X-ray, so I didn't get an X-ray, and they sued me to the wall". We do not carry malpractice insurance. We will not practice in fear and mistrust. In addition, the whole malpractice thing inadvertently reinforces the doctor-as-God concept. If we can't make mistakes, we must be perfect. It also implies that the doctor is responsible for the cure and the patient is the passive recipient of it.

Perfect is the enemy of good. As long as we expect perfection, nothing will ever be good enough. As long as people continue to die or have imperfect outcomes or are unhappy because they feel disrespected, there will be malpractice lawsuits. Which result in higher judgements because of injury inflation. Which means higher malpractice insurance costs. Which means doctors have to see more patients to pay for their premiums, and have to order more tests to protect themselves. Which means higher health care costs for everyone. Which means people expect even more for their hard earned money. Like perfection. Which keeps the cycle going.

For me, I think being an ideal doctor is about being trying to be a decent human being, treating trying to treat others as you would like to be treated, and balancing these with accepting that I can't do everything for everybody and that it's okay to say, "No". All while sharing an experience called life together. Let's see if it works.

Friday, November 05, 2004

Making Contacts

I haven't posted in a while but I'm still here, still in business, still slowly growing, still behind on medical billing, still finding it hard to find time for blogging.

I've gotten a number of calls from doctors who read the article about me and my solo practice in American Medical News, some to ask me questions about how I'm doing things (and how I'm doing, financially). A few have called to say that they've already been there, done that, and offered encouragement to hang in there. It makes me wonder how many other doctors are out there already doing what I'm doing, but who haven't been publicized. Quite a few, I think.

One particular local general internist has gone out of his way to help me. He went solo 7 years ago and now has a booming practice. He has been closed to new patients for the last few years. He read about me in AMN, then called me to see if I wanted to meet for lunch. I visited his office, and he gave me a copy of his original business plan (which was better than mine but similar in many ways), and gave me pointers on how he started his practice.

After residency, he had been working for a group of older internists and he was very busy, and getting busier. The older partners weren't that interested in working as hard, so the younger doctors saw a lot of patients. Since they were thinking of retiring, they offered to sell the practice to him and the younger doctors for more than he was willing to pay. They ended up lowering his pay, so he decided to quit and set up his own solo practice. However, he decided not to sign up with any HMO contracts, which at the time was considered very radical. He was called crazy by his colleagues and written up in newspaper articles and interviewed on national news networks.

(Arizona Republic; 03/21/99)
Now is the winter of doctors' discontent. Across the United States, doctors are complaining that the era of managed health care has robbed them of autonomy, income, time, prestige - even self- respect.

"This is life in hell," says Rex Greene, a Pasadena, Calif., oncologist and president of the Los Angeles County Medical Association - and he says he's an optimist.

A growing minority is rebelling - dropping health-maintenance- organization contracts, seeking clout in professional alliances or unions, filing lawsuits, retiring early, going out on disability or moving out of markets colonized by managed care.

Consider the San Diego gastroenterologist who slapped his physician group with a lawsuit after he was fired for spending too much time or money on patients. Or the cardiothoracic surgeon from the same city who moved to South Dakota, where managed care is nearly non-existent. Or the Pasadena internist whose frustration forced him to cut all ties to HMOs.

"I have been unneutered, restored to my vigorous self," said internist Andre Ettinger. "I can take care of patients rather than having to punt the ball all the time."


Times have changed. Managed care is no longer the main game in town. I have personally chosen not to sign up with any HMO or capitated plans, and this is no longer fodder for national news.

Hopefully, like this doctor, I will succeed without any HMO contracts. The key to his success, he feels, was in introducing himself to other doctors on the hospital staff. In other words, networking. He would have lunch in the doctor's dining room, and chat with the doctors who were there, and later that afternoon get a call from a patient who was referred by one of the doctors he had lunch with. Eventually, he had more than enough patients and he was on the road to a successful practice. Perhaps too successful as he now finds himself staying late, squeezing in extra patients, etc.

He said he is grateful to the many doctors who helped him get started, with no gain for themselves, simply because they wanted to help him out. Now he wants to "repay" their kindness by helping new doctors like myself out, and I'm very grateful for his help.

I hadn't really considered other doctors as a major source of patients. I figured other primary care doctors might see me as a competitor. And I thought specialists only received referrals FROM other doctors, not made referrals TO other doctors. But there appears to be a collegiality among all the doctors I've met so far. Since this doctor's practice is closed to new patients, he said he is actually glad to know of another doctor he can refer new patients to. And apparently, lots of specialists see patients who are looking for a primary care doctor and hope for a recommendation from their trusted doctor.

So this week, he introduced me to a dermatologist. Next week we're meeting an Ob-Gyn and an orthopedic group.

Apart from his contacts, I'm finding out how important networking is. I just mailed a practice brochure and business cards to another Ob-Gyn who contacted me after reading about me in AMN and, feeling a kinship because of our mutual solo status, requested some business cards. And a gastroenterologist I referred a patient to also asked for some business cards. At this rate, I'm going to need to order more business cards. I hope this translates into new patients, but it certainly can't do any worse than my ad in the local church bulletin: $400 annually for a weekly ad = 2 patients (so far).