Yes to No Free Lunch

I haven't come across their booth yet here at the AAFP meeting, but I applaud AAFP's decision to allow No Free Lunch to host an booth here in the exhibit hall.

I have come to the conclusion many years ago that the pharmaceutical companies do not have America's health as their number one goal, that free drug samples end up costing the public more, that doctors can indeed be bribed with as little as free luggage tags.

That is why I do not stock drug samples in my office, nor do I have drug reps come visit me in my office. I confess that I did accept a couple of computer mice (my daughters thought they were cute, and of course they each had to have their own), assorted pens and pads and a laser pointer (which I will offer my wife, as she often gives presentations).

Freebies cost money, and that money comes from all of us. And for some of us, we pay that extra tax called "guilt". Truly there is "no free lunch" (except when I treat my medical students).

We Meet at Last

Tonight 19 of us got together for dinner. For most of us, it was the first time we had ever met face to face, even though we had been communicating for over a year. We are physicians who participate in the Practice Improvement listserve, an e-mail group started by Dr. Gordon Moore, father of the low overhead, high tech practice model. We also happened to be in San Francisco attending the Annual Scientific Assembly of the AAFP.

It was very nice for us to meet Gordon Moore, the pioneer who started it all, along with each other. Some have booming practices in Albuquerque, NM, Lexington, KY or Bellevue, WA. Others are getting ready to make the leap, or at least try to muster up the courage to do so. We shared experiences and stories, and encouraged each other. We all agreed that open access rocks, that we love surprising patients by answering our own phones and telling them we can see them today, instead of making them wait 3 weeks (or more). We shared tips about billing, electronic medical records and computers. We talked about how much we enjoyed being able to go home at a decent hour and spend time with our families. We loved being able to do the right thing for patients, and in a way that made medicine fun again.

As one person said, "This is probably the largest concentration of happy family doctors in town tonight." I think he is not far from the truth.

Stumbling over the truth

My solo practice has been busy lately, despite "closing" to new patients about a month ago. More of a filter than a barrier, I am still agreeing to see relatives of pre-existing patients. This has resulted in 16 new patient this past month, or about half of the number of new patients I was getting before.

This week has been especially busy. On Monday (2 days ago), I saw 9 patients in the office, the most I've seen in my practice in one day. In addition, I had 2 in-patients to see, too. I'm thinking it's a good thing I closed to new patients when I did otherwise I don't think I could have handled it.

Plus, it was an abbreviated work week for me. I am currently in San Francisco attending the American Academy of Family Physician's Annual Scientific Assembly. It will be the longest time I've spent away from the office since going to Canada last summer. Fortunately, a couple of local family physicians agreed to cover for me while I am away. Nevertheless, I am still checking my answering machine every few hours and getting back to people. Since I carry my EMR with me in my PowerBook, I can look up anyone's chart just about anywhere.

Today I attended a lecture, "Cardiovascular Disease Treatment with Evidence-Based Nutritional and Lifestyle Changes". The lecturer, a family physician and certified nutritionist, went through the current thinking about CAD (coronary artery disease) and plaque formation. A couple of telling statistics:

• 500,000 new cases of CAD diagnosed annually in the US
  
• In 2000, we spent about $200 billion of CAD therapy but only 6% on medical treatment and prevention.
  

*Gets on soapbox*
This seems to be the American way of thinking with a lot of issues. We'd rather spend money jailing criminals and drug abusers than on dealing with the social causes of crime and drug abuse. We'd rather spend billions of dollars and the lives of our soldiers fighting terrorists than try to figure out political solutions to stop terrorism in the first place. We'd rather spend billions of dollars rebuilding New Orleans than on developing an adequate flood control infrastructure.
*Gets off soapbox*

Anyways, the lecturer goes on to describe how to fight CAD. As he's going along explaining the lifestyle changes, I'm thinking, even I don't follow most of the dietary recommendations he's talking about. I've always figured that as long as I exercise regularly (1 hr of basketball twice a week), keep my weight normal and have a normal cholesterol level (total <200 with an HDL > 60), I figured I'm okay and can continue to eat junk food. But as a doctor, I know that people can have coronary artery disease even with no risk factors. It's tough to think that I have to go on a "diet" when I'm not having any health problems. It's also an admission that I might be getting old.

Anyways, the lecturer talked about fish oil supplements, folic acid, Co-enzyme Q-10, flaxseed, garlic, hawthorn, magnesium as having some benefits for heart disease prevention. Some had better evidence than others. He talked about the recent studies which showed that vitamin E could be HARMFUL to those with low HDL levels who are also taking a statin and niacin.

He gave a quote by Winston Churchill: "Everyone stumbles over the truth from time to time, but most people pick themselves up and hurry off as though nothing ever happened."

My take is that with science and medicine, there have been many truths presented through the years that upon closer scrutiny have turned out to be something less. The formerly widely held belief that vitamin E could help reduce the risk of CAD is just one example.

So I hope that if I stumble over something, I'll check it carefully for some truth before I hurry off to see my next patient. Before I go recommending supplements to all my patients, I'm going to have to do some more reading and examine the evidence myself. I may even find something that convinces me to take fish oil supplements. At any rate, I will try harder to discuss with patients the many ways they can prevent heart disease through nutrition and lifestyle changes.

Intellectually, I know that I should eat healthier. Besides, I know if I don't then I am practicing what I just preached against: waiting to deal with the problem after it happens instead of doing something beforehand to prevent it from happening. I guess I'm as American as the next guy. *sheepish grin*

A Resident's View

One of the mantras we learn during medical training is "See one, do one, teach one." To that end, over the summer I had 2 medical students and one family medicine resident visit me to learn what a minimalist solo practice is like. I figure even if they never set up their own solo practices, they might at least tell others about this crazy/unique (depending on your point of view) practice model. After they've seen what my practice is about, I ask them to write their thoughts so that others may learn from a different perspective.

About a month ago, David Liu, a 3rd year resident from the Kaiser Orange County Medical Center Family Medicine Residency Program, visited my office for 2 weeks. Here is what he wrote:

I first heard of Dr. S through my med school classmate, Beth. She told me that she had chosen a new family physician who was just excellent. He spent a lot of time with her during their initial consultation and answered all her questions and concerns. I was in the middle of my second year of residency in family medicine at a Kaiser program. I had already begun thinking of what I wanted to do with my career after graduating. I had grown accustomed to the Kaiser way of doing things. It was daunting thinking of my future with 15 minutes per patient and the constant feeling that I had to rush with my patients to get done on time. I knew part of this was due to my lack of experience and knowledge. With time it would get better, right? I wasn't so sure.

Thus, I decided to use some of my elective time early in my third year to shadow different private physicians, to see if there was another way of doing things that fit me better. I had already done a rotation with a "holistic" physician and with a small group practice. Dr. S's practice was next. My friend told me that he had been a former physician in Kaiser and just started private practice after many years with the organization. I thought it would be perfect to see how a former Kaiser physician was doing in private practice.

My experience with Dr. S over the course of 2 weeks was illuminating. On my first day with him, Dr. S explained that he was utilizing a low volume/low overhead model of practice. He explained how he did everything, including answering the phone, taking the vital signs, administering vaccines, etc. He did not have any staff. Patients needed binding arbitration agreements and insurance forms filled out. He used an Electronic Health Record and scanned all documents for the patients into his Apple notebook computer.

Every time he saw a patient, he would bring his notebook computer with him and interview them. With patients he could take an hour or more if needed. He never seemed rushed. I could tell that patients he saw appreciated how much time he had available to investigate all their problems. In addition, it was easy for them to make same day appointments with Dr. S. He was also easily accessible because he gave each of his patients e-mail, cell phone, office number.

He was very open about showing me how his practice worked--including costs, earnings, number of patients, building location, and marketing. In his fledgling practice, Dr. S has had to take a big pay cut from his former Kaiser salary. However, this was in exchange for practicing in a manner that suited him better.

There was also the potential for growth. He typically saw about 8 patients per day. [Actually it's anywhere from 0-8 patients per day.] This was a lot compared to when he started where often he would have no patients. He said that if he wanted more patients, it would be easy to accept HMO insurance, do more admissions at the hospital, etc. But, he felt that for him, it was preferable to take it slow and not take on too much too fast. He thought about how he saw the practice growing and that if he wanted to recruit more patients, there may be a need to hire an assistant. In the foreseeable future, he could be taking over the entire suite of the building he occupied. Then expansion would be possible.

There were inefficiencies. Often, Dr. S would have to leave the exam room to see if a new patient had arrived so they can begin filling out paperwork. Without staff, if a patient needed a lot done, it could take some time to do everything that a patient needed--UA, EKG, vaccines, etc. I could see how it might be easy to fall behind if there ever were any sick patients that needed close attention. Taking care of all the insurance paperwork, organizing his finances, and all the business aspects took time. Dr. S said there are days that he is forced to take work home with him. There was also the logistics of how to best keep track of patient labs and preventative measures. However, given his small volume of patients, I never saw any compromise in patient care during my time with him.

Dr. S was quick to point out to me that his model was still a work in progress and had its pluses and minuses. For a young physician like myself, who still needed seasoning in the practice of medicine, he thought Kaiser or a group practice might be better ways to go--more stability, more patients to see and to learn from, and in Kaiser, less worries outside of the practice of medicine.

I can see how it would be difficult for a brand new graduating resident, in terms of money and experience, to start a practice such as Dr. S's. Conversely, I also feel that perhaps starting young and learning from my mistakes now may be the way to go. From following Dr. S, it has definitely given me insight into a special type of private practice. He also exhibited excellent bedside manner with his patients--always calm and organized, which instilled confidence in his patients. There are definitely aspects of his practice and dealings with patients that I hope to be able to incorporate.

It's hard for me to predict what I will be doing in 5 to 10 years. I do know that I hope to practice medicine in a manner where I will be able to give my patients optimal care to the best of my abilities while being able to maintain a balanced life outside of work. Is Dr. S's way of practice the best way for me? It is hard to say. However, I do hope to follow his lead in striving to practice medicine in the way that best suits my patients and me.

David

Thanks, David, and best of luck in finding out where you want to be.

(This part is for David and Phil Nivatpumin, one of my former students.) I do think that for a new physician coming out of residency that working at Kaiser is an attractive environment to work in. There is minimal administrative paperwork. You have set hours. Once you are off duty, you are off. No worries about being called by a page operator. You can go on vacation and know that someone is covering for you. Call coverage varies for primary care physicians. Depending on which Kaiser facility you work at, call can range from staying in the hospital overnight to working a 4 hour shift in Urgent Care to nothing. At the clinic I used to work at, we didn't work any extra duty for several years.

As a Kaiser physician, there is relative autonomy. You can order almost any medication or test you want without having to have it pre-approved. Of course, that has been changing over the past few years I was there to place more restrictions on the more expensive drugs/tests. I often had to re-educate patients who assumed that physicians were under orders to practice medicine the "Kaiser way".

The salary and benefits were very good. My annual salary was higher than I ever thought it would be as a family physician. Once you become a partner (after 3 years), it's almost impossible to lose your job. Plus I learned a lot, just because of the variety and volume of patients that I saw. For myself, working at Kaiser was a good place for me to be just out of residency.

So why am I no longer at Kaiser? You can read my older entries for a longer explanation. I guess you could say I grew in a different direction. I saw, I did, I taught. Now I want to see, do and teach something new.

Published Pith

The always pithy and often poignant Dr. Charles has published a book of his fictitious (but based on real-life) patient stories, titled "Legends of the Examining Room". I have found his stories to be sometimes humorous, sometimes sad, always reflective of the relationship between patients and healers. We all wish we could write as well, but at least we have Dr. Charles to represent the physician-writer.

Tweaking

I was visited by Dr. Linda Lee and her husband, Ben, yesterday morning. She is another family physician practicing in the solo-solo Gordon Moore mode, and she also happens to be Gordon Moore's next door office neighbor in Rochester, NY. She was in town visiting relatives (and getting some surfing in!).

It was fun to share experiences and compare notes. She has a practice that seems very similar to mine. She has about 500 patients, and works about 3-4 days/week while her 3 kids are in school. She is very flexible with her scheduling. She has a working spouse so they are not solely dependent on her income. She has closed her practice (sort of) to new patients, accepting only relatives of already enrolled patients. She has no employees and does everything herself, although Alteer makes it very easy for her to bill electronically, while I have to use a separate program that doesn't share info with my EMR. On the other hand, I didn't pay $20,000+ for my EMR, so I'm not so worried if my EMR company goes bankrupt and takes my data with it.

We first "met" online though the e-mail listserve started by Gordon Moore as a resource for physicians wanting to go solo like him. The online community that has gathered around this listserve has been invaluable to me and many other physicians who have gone solo or are contemplating it. It has been a wonder to see discussions by physicians from all four corners of country (Washington, Florida, Maine, California) as well as many states inbetween. We even have a member who is serving in Afghanistan!

We are like a start-up lab for solo doctors. It is very gratifying whenever another doctor posts an announcement saying that they are going live, like this doctor in Canandaigua, NY did just today:

Here we go! In another five hours, my malpractice insurance engages, my new provider numbers and tax ID kick in, and I have my first two patients scheduled tomorrow morning and about 22 other new patient visits scheduled for the month. My 150 square foot office is stocked (mostly)and the rent is paid. I can't thank the group enough for the outstanding support and advice.

I remember the excitement and dread of starting up. My practice has come a long way since then, yet I feel that I still have a long way to go. The destination is not as important to me as the journey itself. I continue to fine tune my practice to try to become more efficient and provide optimal care, as well as more financially stable.

On August 23rd, I saw my 400th patient. Just last week I changed the announcement on my answering machine to say that I am not currently accepting new patients. This is a temporary closure to give myself time to catch up on my billing, which I still do myself. Actually, it's more of a filter than a closure since I still accept family members. I've added 7 new patients since I "closed" to new patients.

After the article about physician blogs came out, I added a paragraph in my Notice of Privacy Practices:

F. Weblog Notice:
The doctor maintains an online weblog that sometimes describes information about his practice and interactions with patients. At no time is any protected health information (PHI) given out. No patient identifiable information is ever given out and details are changed to protect patient privacy. The weblog is located on the internet at: http://akifox.blogspot.com.

So far no one has said anything about it, but that's probably because, instead of giving everyone a separate copy like I used to do, I laminated the Notice of Privacy Practices and put it on the clipboard with all the other registration forms. Probably no one has even read it. I know I wouldn't. Plus it saves on paper. I'm still working on trying to shorten my registration and intake forms to save even more paper.

About two month ago, I started asking/requiring all new patients to sign a Binding Arbitration agreement that was provided by my malpractice carrier. I think they suggest it to all their policyholders, as I have not been sued. Arbitration bypasses malpractice court in the event of any medical dispute, which I think most people would agree is a good thing. Instead (and this is how I explain it to patients), "You get a lawyer, I get a lawyer, we agree on a 3rd neutral party and then we arbitrate." Faster, quicker, easier, fairer. I hope I never have to use it.

I reason that if I ever did get sued, I would have to shut down my practice temporarily since there is no one else available to keep it running. I feel secure enough now with the number of patients I have that I wouldn't mind if I lost a patient or two because they refused to agree to arbitration. Plus I think it may be more common in California for medical practices to require arbitration. I know Kaiser requires all of its members to accept arbitration.

So far, only one person has refused to sign it (the first person I ever gave it to), and I went ahead and saw her anyways. But now, I would tell them that I would not be willing to accept them into my practice without it. As my established patients come back for repeat visits, I am asking them to sign the arbitration agreements, too, and everyone has agreed so far. In fact, most people have been very supportive and express sympathy for the plight of doctors having to deal with malpractice.

I am also very happy with my new high-speed Fujitsu Scansnap fi-5110EOX scanner and wish I had gotten it sooner. The only drawback has been that they haven't officially released a Mac driver for the US Market, so I had to download one from the company's Japanese website. It works perfectly, but it does look a little strange to see a Japanese dialog box pop up every time I scan something.

More tweaking to come...

Dodged a bullet

If someone calls you on the phone from out of the blue saying they are calling from the NRCC and Congressman Tom Reynolds' office and they ask you if you would like to be part of the Physician's Advisory Board, do not pass Go, do not give them your credit card number, and hang up immediately.

Someone did that to me last week, and I was, like, who are you? and why are you calling me?

He only got as far as explaining that the NRCC was the National Republican Congressional Committee. I said thanks anyways, but I'm a Democrat.

After hanging up, I was curious. Who were these guys? How did they get my name? A quick Google search confirmed my suspicions. I should have been paying more attention to the medical blogosphere back in April.

From ABC News:

The good news reached the Jamestown, N.Y., office of Dr. Rudolph Mueller in a fax from a congressman in Washington. Mueller had been named 2004 Physician of the Year.

"My secretary came running in and said, 'Dr. Rudy, look at what you've won, you're Physician of the Year,' " said Mueller, an internist.

But to receive the award in person at a special two-day workshop in Washington last month, Mueller found out that he would have to make a $1,250 contribution to the National Republican Congressional Committee. It was a disturbing discovery, he said.

"To actually buy your award and it's not from your peers or from your patients or from the community that you serve, it's really deceptive," said Mueller, author of "As Sick As It Gets: The Shocking Reality of America's Healthcare, A Diagnosis and Treatment Plan." "It's not being honest, it's just not right."
-----
Mueller soon found he was not the only winner. There were hundreds of Physicians of the Year present, many of whom found the criteria for being selected equally as opaque.

"You know, nobody knows, so don't feel bad about it," Mueller said one attendee told him.
-----
It's like the old diploma mills," said Fred Wertheimer, president of Democracy 21, a government watchdog group. "It's the kind of scam that we've seen congressional investigations look at when they take place in the private sector. But here, since members of Congress are doing it, we're not going to see any investigation."
-----
Wertheimer warned that the award was misleading and that they should add the award was given "because I paid for this certificate, not for anything else that happened."

A Republican spokesman said there were thousands of doctors around the country content with their Physicians of the Year awards, and that there was nothing about the program to apologize for.

Unfortunately, there are some physicians who seem to agree. Someone's even keeping track.

Paid More and Punished Less

There is a doctor shortage in Arizona. Is this a harbinger of things to come for the rest of the United States as more doctors retire (from aging) or quit (from burnout), and the Baby Boomers of yesterday gradually becomes the Greying Boomers of today?

When Barbara Straining learned it would be more than a month to see a doctor for another bout of bronchitis, she called her physician "back home" in New Jersey to ask him to phone in two prescriptions to a Valley pharmacy.

The quick-fix strategy worked, and the 54-year-old Straining quickly recovered.

But Straining, who moved to Paradise Valley in September with her husband, remains frustrated by the long waits to see a physician and the number of doctors who aren't taking new patients.

-----

Arizona has a large number of health maintenance organizations, or managed-care plans. In fact, about 60 percent of the state's residents who are insured commercially are in managed-care plans, according to the Jim Hertel, publisher of the Arizona Managed Care Newsletter.

Many doctors complain that low reimbursement rates from these plans hurt physicians' income, forcing them to pack in more patients per day and increasing burnout and early retirements.

------

Still, Dr. Sebastian Lopez, a Phoenix surgeon, said his malpractice premium of $80,000 is hard to swallow in light of low reimbursement rates.

"The answer to the doctor shortage? The answer is we need to get paid more, and we need to get punished less. You can't have somebody who is overworked, underpaid and abused," he said.

Those complaints are being heard in medical schools, where doctors-in-training are choosing non-traditional fields to avoid areas like family practice or delivering babies.

I remember hearing the predictions back in the 80s that there would be a glut of doctors. I never understood why they said that, and now I guess it was just plain wrong.

Unfortunately, medicine is a tough field to go into these days. You have to study hard, get high grades, go to school for at least 11 years (usually while racking up a lot of debt). Then when you get out, you are expected to see a lot of patients, work long hours, manage complex problems, struggle to convince people to change their habits, stay on top of medical advances, deal with mounds of paperwork, have your medical decisions second-guessed by insurance administrators, all while making sure you don't screwup and get sued.

Most of the primary care doctors that I've talked to lately are dissatisfied. One family doctor I met said he works from 7AM and doesn't get home until 11PM, and only sees his family awake every few days. Another family doctor I know came home from work one day to find that his wife of many years had packed up the kids and left him because he was spending so much time working. Medicine is still a noble profession, but altruism can only go so far in attracting new doctors in this kind of environment.

I agree with the suggestion in the article above, that in order to attract more people into the medical profession, doctors need to get paid more and punished less. American society is going to have to give people more reasons to go into (and stay in) medicine and less reasons to avoid it as a profession. Otherwise, what's happening in Arizona will eventually be coming to your town, too.

Making Time to Write

Who has time to write? I don't.

This article, by way of the Annals of Family Medicine, looks at the plight of the physician-writer and the lack of time available for writing:

People do not, of course, make time. Time exists, for practical purposes, as a linear flow, and people are swept along in it. Like a fast-moving river, time propels us forward, but sometimes we can swim hard to stay at the edges where the flow is a bit slower. So how do busy people find a way to write as they are swept along? I mean, how do people who are practicing clinicians—doctors, nurses, therapists—people with clinical commitments and sometimes life-and-death interruptions—how do they write?

It goes on to describe 3 strategies one can use to find time to write:
1) Deck clearers (aka procrastinators). They can only write when everything else has been done (which means nothing gets written), or when there is a deadline. This has been my modus operandi for years.
2) Wedgers write whenever they find a little free time. Blogging has moved me to this kind of writing - a little bit here, a little bit there and it starts to add up to something substantial.
3) Schedulers force themselves to write by blocking time off specifically for writing. This is the strategy of those who consider writing to be their profession.

I will strive to become a Scheduler, just as soon as I can clear my deck of the all the things I've been meaning to finish.

Who has time to write? I don't. And yet, I do anyways.

Doctor, can you write me an prescription for a robot?

This article (by way of Slashdot) gives a preview of the latest greatest thing for elderly assistance since the electric scooter: robots that you wear like body armor.

Yoshiyuki Sankai is among those who see robots as the future of elderly health care.

A researcher at Japan’s University of Tsukuba, Sankai has developed a robotic suit designed to make it easier for elderly people with weak muscles to move around or for care-givers to lift them.

Although very cool-looking and probably fun to operate, at $30,000-plus a pop, this would only put Medicare into bankruptcy that much faster. Which brings up the question: how long before we see infomercials advertising robots to Medicare patients?

Me and My Shadow

These days my solo practice has actually been getting, well, busy, which has not been the case for the preceding 16 months. Busy for me is seeing as many as 8 patients in a day, although I am averaging 17 patients/week. It may not sound like much but since I usually spend an hour with new patients (sometimes longer), it is a full schedule for me. Plus I have to do all the scheduling, intake, scanning, charting, collecting copays.

As a result of seeing more patients, I have decided that I am busy enough to precept medical students again, as I used to do at Kaiser. At Kaiser, there was never a shortage of patients for medical students to see. In my solo practice however, I would discourage 3rd year students who called asking if they could do a rotation with me because up until lately I didn't think there would be enough cases for them.

Recently a second year medical student from Albany Medical College, Gladys Ng, spent 2 weeks shadowing me in my office as part of a summer family medicine preceptorship. Apart from spending time in her father's Ob/Gyn practice, it was her first experience rotating in a doctor's office with real patients. For those unfamiliar with the concept, shadowing means that the student usually stands quietly in the room observing the patient-physician encounter, i.e. being a shadow. Usually I invite the student to take part in some aspects of the physical examination, such as listening to the heart and lungs. When they get proficient enough, I ask him/her to take the patient's vital signs. If the patient and schedule permits, I may ask the student to interview a patient on their own, getting a chance to "practice" their interviewing skills on a real person. Gladys got a chance to do all those things while she was with me.

At the end of her rotation, I asked her to write a short summary of her experience with me and this solo-solo practice model. She has allowed me to post it here:

I was very excited when Dr. S agreed to let me shadow him, but had mixed feelings when he proceeded to describe his current solo practice. I thought, how could he do all of that by himself (be the receptionist, nurse, doctor, biller all at one time)? This is when I thought that this experience will be interesting, I could either be stuck with the phones and office work, or get a chance to do/see everything that the doctor does. Fortunately, it was the latter.

As Dr. S is still in the growth phase of his practice, the most patients we saw a day was five and this left me ample time to ask questions and have informative discussions on the ever changing or hopefully, evolving practice of medicine. These discussions and accounts of real life experiences really brought home some of the issues that were discussed in some of our classes at school. It was good to hear Dr. S’s reflections on his previous experience at Kaiser.

What really impressed me upon our first patient encounter was the length of time that was spent with each patient. In a typical patient encounter, especially new patients, Dr. S would spend 20-30 minutes speaking with the patient to get a complete understanding of the person. He would start off the whole session with the broad question of “what can I help you with today?” and then gently direct the conversation to draw out pertinent points of information. There were many encounters in which I was amazed by the willingness and the many aspects of the patient’s life discussed and their indirect relevance to the patient’s chief complaint. I learned to let the patient do most of the talking, to employ useful moments of silence, and to listen while maintaining eye contact.

Important to any “one-man show” is the concept of efficiency. Armed with a cell phone on the belt, a sleek Powerbook, and a speedy scanner on his desk Dr. S has paperless set-up, a practice without any patient charts. All necessary paperwork, such as those requiring signatures, are signed and then immediately scanned into his computer while the paper is left for the recycling bin. Also, instead of taking notes on paper while seeing the patient, Dr. S directly types the information into his computer. The benefits to this system were clear to me- save space and time, information is kept in one organized central location, and the chance to be environmentally friendly.

As I have just finished my first year of med school with my head still in the books and the science of medicine, it was a great experience to shadow Dr. S as well as to partake in the practical aspects of clinical medicine. Patience and compassion are two imperative qualities to being a caring physician and it might be hard to convey that to patients in today’s practice of medicine that focuses on the number of patients seen. I am ultimately inspired by Dr. S’s courage and drive to recreate a conducive environment in which his genuine intentions to help and get to know his patients are conveyed in actions as well as words.

I hope that experiences like this can inspire someone to someday become a family doctor, or at least spread the word that there can be a kind of medical practice that isn't driven by productivity and time limits. Also, I strongly encourage other physicians to volunteer to precept a medical student. Not only is it fun, it is educational since my "shadows" always teach me a thing or two. Thanks, Gladys!

My small part to change things

Christopher Brown, M.D. is another family physician who opened a solo practice after being inspired by Dr. Gordon Moore's model. An article in his local Salina, Kansas newspaper last year described what led him to open his practice, Providence Family Health Care, in September 2004 :

Chris Brown went into the medical field to mend patients. He was prepared for that.

It didn't take long, though, for him to realize the profession he had chosen could use some mending of its own.

In medical school and during his residency, Brown, 30, a Kansas City native, saw many patients spending longer waiting than they spent with a doctor. Then, they were rushed into exam rooms and hurriedly pushed out.

"Something was wrong with medicine," he concluded.

The clues were everywhere.

He met children of doctors who were adamant that they didn't want to follow in their parents' footsteps, because their parents were never home.

He saw a documentary where a "dog-tired-looking" medical resident told the filmmaker, "This career is for people who hate their children and never want to have time with their spouses."

Brown found himself apologizing for being late to appointments and cringing when he'd ask patients if there was anything else bothering them, because he knew there was someone else waiting for him.

He wasn't alone. Doctors everywhere are feeling the pressure, he said.

Too many Americans are getting what Brown calls "the fast-food version" of health care.

He easily could have turned his back on the profession. His calling, though, was to practice medicine, and he wasn't going to ignore it just because he didn't like what he saw.

"I started on this career path to be in the healing profession," Brown said. "I believe in this and was very idealistic about what I could do."

And realistic about what he couldn't do.

"It would burn me up inside not to be able to do my small part to change things," he said.

You can read about how he changed things by opening his own solo practice here.

I can't fix the U.S. health care system. I don't know the best way to provide medical care to the uninsured. I don't understand why the we spend more on health care than any other country in the world but still ranked only 37th among 191 countries for overall health care according to the World Health Organization.

But I can blog. And I like to think that in doing so I, too, am doing my own small part to change things by sharing stories like Dr. Christopher Brown's. Good luck, Chris!

The Village Doctor

John Brady, MD, is a family physician who opened his own solo practice in May, 2003 in Newport News, Virginia. He is one of many doctors around the United States who is using the "Gordon Moore" low-overhead practice model.

From a Hampton Roads Daily Press article written by Alison Freehling in Feb 2004 (and no longer accessible online):

Last year, Brady opened a solo practice called "The Village Doctor". His only employee is a nurse who also answers the phones. Instead of a modern building, he rents an old home along Warwick Boulevard.

By slashing his overhead costs, Brady said, he can see fewer patients a day, go out on house calls and still survive financially.

"For me, it has allowed the joy to come back into medicine," he said.
------
Before opening his Newport News practice, Brady spent four years at a large local practice. He said he was lucky to get five or 10 minutes per appointment and got to know just a small number of the practice's 25,000 patients.

In Hilton, Brady has 680 patients and plans for no more than 1,500. He schedules hour long visits with all new patients and blocks out 20 to 30 minutes for others, unless there's a simple complaint such as an ear infection. People get in to see him the same day they call.

The advantage isn't so much catching more problems, he said, but having time to talk about how to stay healthy down the road.

"I don't just deal with the immediate health concern that brought them in," Brady said. "When I'm not in quick mode, I get to counsel them about not smoking, about dieting and exercising."

Brady has made as many as three house calls a day, although it's usually no more than one. He tries to limit trips to people who live in or around Hilton Village.

Maria Brooks, mother of 7 year old Michael and 2 1/2 year old Ben, has taken full advantage of the service. Michael has chronic ear infections and getting to the doctor's office with two young kids isn't easy.

"To be able to call him at 7 a.m. or 4 p.m. and you know he'll be there, that's amazing," Brooks said. "He's looked in their ears and listened to their chests, and you don't have to sit in a roomful of sick people to wait for it."
----
Stories like Brady's are already becoming more common, said Dr. Gordon Moore, a New York-based physician who started a similar practice in 2001 and helps other doctors do the same. More than 100 doctors are part of his online discussion group.

"We help each other as we navigate these uncharted waters," he said. "The number grows each month."

In the Practice Improvement e-mail listserve, John Brady recently shared this update on his 2 year old practice for the benefit of other physicians:

As was stated on my business plan (posted months ago), I ended up about $120,000 in debt at my nadir in 3/04. Since then, the practice has been doing relatively well and I currently sit about $86,000 in the hole. (Much of the indebtedness was my salary which I kept at $100,000/year so I would not go personally bankrupt). My accountant states that this is wonderful growth for a business, but I still hate being in debt. I am currently seeing 12-15 patients a day (4.5 days/week) and strive to see 15-18/day.

Lessons learned:
1) Moonlight to cover salary for the first few months the practice is open.
2) Market everywhere you go (church, children's activities, luncheons, restaurants) and always keep business cards handy.
3) Tell people "if you like it here, tell a friend."
4) Be careful which insurance contracts you sign

Biggest headaches:
1) Insurances-I have come to loathe them. They serve no real purpose except to make money and they do this by creating loop after loop to jump through until we get tired of jumping, and then they blame us.
2) Isolation-I was always in big practices before making the leap and I do not do hospital, so my interaction with other doctors is minimal. This leads to some professional isolation. I fill the void with local medical society meetings, etc, but it's still not the same.
3) Juggling financial responsibilities at home and at work (hopefully will get much better as the loans get paid off and my salary increases).
4) Trying to determine when to cut off to new patients-we are currently seeing 1 new patient a day which I hope will fill the void of those leaving the practice through moves or death (not my fault), but the balancing act between being too busy and not being busy enough is more difficult than I thought it would be.

Biggest benefits:
1) Freedom to practice medicine like I want. No bean counters (except my wife), no administrators.
2) Unfaltering patient satisfaction/loyalty
3) Being a small business owner. I know it sounds goofy, but starting something from scratch, nurturing it, and watching it grow is quite satisfying and a sense of great pride.
4) Scheduling freedom-If I need time off, I take it. Since opening the practice, I have only missed one of my kids' performances/meetings/parties/etc and that was because I was in Richmond lecturing to doctors about the benefits of EMRs. I have also found time to train for and run a marathon, which would have been impossible in the previous office.
5) Being on the cutting edge of the future of medicine-computers, database research, evidence-based information at my fingertips. How cool is that?

Would I do it again? Without question.

John

How cool is that, indeed.

Jumping off the hamster wheel

I am a solo-solo physician, without any employees. I answer my own phones, schedule my own patients, take vital signs and give shots myself, do my own medical billing, order my own supplies, mop my own floor, scan and shred all documents myself (except when I pay my daughter 5 bucks to do it).

No, I am not crazy. Yes, I have way more control over my professional and personal life. No, I don't make anywhere near the money I did at my previous job. Not yet, anyways. Yes, I am happier.

I am emulating Dr. Gordon Moore, who helped pioneer a low-overhead practice model. The basic idea: if you keep your overhead low, you don't need to see as many patients to have a financially sustainable practice. And if you don't have to see as many patients, you can spend more time with them. And if you can spend more time with them, you and your patients will be healthier and happier.

Dr. Moore started a Practice Improvement website to bring together those who are interested in improving their medical practices. As part of this website, there is an e-mail listserve, where others (mostly primary care physicians) trade notes and experiences, or just learn about the possibilities of a practice free of corporate constraints. Some physicians on the listserve are completely solo, like me. Others, including Dr. Moore, have at least one nurse or receptionist/assistant. Some charge a retainer fee. There are many variations of this practice model.

Lately, some have written updates on their practices so far, which I hope to be able to share on this blog. Here is one physician couple's story:

My wife and I are practicing together in a small town of 10,000. Draw area is reportedly about 50,000. We have managed to bill about $144,000 over the first year with about 1200-1300 visits between the two of us. Collections were $84,000 with about $40,000 left in accounts receivable. Collection percentage has remained stable at 79.8% of billed charges. THAT WILL DROP WHEN MEDICAID STARTS PAYING AGAIN.

Startup costs were $60,000 which included $34,000 for EMR, IT, and 5 computer network, Fujitsu high speed scanner, $14,000 for equipment supplies including two exam tables - one motorized for disability access. The remainder of overhead runs $60-70,000 per year for phones, malpractice insurance, etc. I have a spread sheet that I may share when I have time to update it.

Our largest expense was salaries of $120,000 with $60,000 for myself, $30,000 for my wife 1/2 time, and $20,000 for my individual 401k at Fidelity and $10,000 for my wife. Total first year expenses including salaries = $240,000. Operating loss of $150,00-160,000. Fortunately, the local hospital supported us throught the first year. We are targeting the same overhead and salaries for the second year without support.

Breakeven for this next year will likely be 2000 visits and $185,000 net practice revenue or $232,000 gross charges. We averaged 5.41 visits/day over 48 weeks, 5 days per week. We believe 7 patients per day will be enough to sustain our practice and keep the mortgage paid. Obviously not the salaries of 1.5 FTE internists. The key is similar take home pay minus income needed for student loans as these have been forgiven.

In our former employment, at a large multi-specialty group, we were each seeing between 18-24 patients per day with management looking for 28-30 patients per day and annual gross charges of around $400,000. Overhead was high at 55-65%. Salary was ok for 2 years, but production-based compensation was poor. My wife wanted to go part-time and income would have dropped to $130,000-140,000 and resulted in revoked shareholder status and profit sharing, added overhead expense of malpractice and health insurance. Key is we would have been working much harder and longer for slightly more pay ($20,000) than we receive now. But student loans were eating $20,000 per year. Taxes would have been higher and real income lower.

What a blessing to jump off the hamster wheel of the corporate practice of medicine. The problem was there was an inflection point because of 50% medicare and PPO, 50% HMO. When everyone increased productivity from 18/day to 28/day, the only real increase in pay was 5 visits because the other 5 were already prepaid hmo care. Overhead increased 30-40% and actual incomes continue to drop for the physicians there.

We both like the time we now spend with patients. I loathe dealings with insurance companies. Patients pay 30-40% of actual receipts with insurance paying the remainder. Net receipts per visit is about $75-95 including accounts receivable at current collection percentage. Otherwise, $64 per visit and only 60% of gross charges collected to date. (Insurance companies and deadbeats laughing in the background.)

Patients are starting to talk about our clinic. They tell their friends that "The doctor answers the phone!" Others note that we take time to figure out their problems. One patient, after a bout of cellulitis and 4 day hospitalization, suggested that the hospital staff and I restored his trust in humanity by the kindness and concern we showed to him. He had become jaded working as a HVAC contractor and receiving healthcare in the city and suburbs. I have had the time to spend with dying patients and their families. I have returned a patient to health after an attempted suicide by caustic ingestion. A twenty-year-benzo user has stopped after successful treatment of her depression. She almost died of C. diff colitis after routine antibiotic therapy for a dental abscess. Her care was free until public aid approved her disability from my detailed notes. She just turned 65 and lived through the ordeal of being uninsured with multiple serious medical problems at age 64. The list goes on. I am very happy with my practice and medicine today.

Our challenges this year remain improved patient care that can be documented to insurance companies for higher reimbursement. I plan to add laboratory services in addition to my Cholestech cholesterol machine because I can use the revenue, but also because self pay and high deductible patients do not need $300-500 lab bills from a hospital lab. I don't want to bite the hand that fed me, but this borders on extortion. We hope to use Quest, but there may be an interface fee of up to $5000. If so, faxing lab results into e-MDs, our electronic medical record, should work just fine.

Brent and John, I am happy your practices have taught you so much and bring you satisfaction after multiple challenges. I am proud to be a member of this group which reflects and embodies so many of the things I have gone through myself in the last two years, First, when I was contemplating a practice and now, after living it the last year. Our collective knowledge is priceless as we move forward in our own practices and for those who follow the thread of starting their own practices from scratch.

Sincerely and Thank you all !!!

It isn't easy to get off the hamster wheel, but it can be very worthwhile to actually get somewhere for a change. Thanks, K. for letting me post your story and I wish you continued success for you and your wife in your new practice!

Those who wish to check out the Practice Improvement listserve can do so by sending a blank e-mail to
"Practiceimprovement1-subscribe@yahoogroups.com".

To unsubscribe, send a blank e-mail to
"Practiceimprovement1-unsubscribe@yahoogroups.com".

The Good Doctor is Out Not Out

A local family doctor retired last month. While I have never met Dr. Riley, he epitomizes what many think of when a family doctor comes to mind:

"I was 6 years old when he stitched up my chin and he's been my doctor ever since," said Mart Brower, Jr., who is now 54. "He's been there for me all these years."

"He's a very generous man. If you don't got it, you get it anyway, you know what I mean," said Thomas Herod, a patient for 27 years. "He's more like a friend than a doctor. You can talk to him about anything."

Herod's wife, Gloria, agreed. "He's like the old family doctors they used to have years ago," she said. "He's not just business. He's very friendly."

"You did not sit in his waiting room a half an hour waiting to be seen," said Mildred Hawkins, a longtime patient and former employee. "He put you in there and got you out."

Riley said he always made an effort to be available to patients.

"I tried to be not only a doctor and treat everybody well, but to become a friend," he said. "Many people say they can't reach their doctor and he never returns their calls. I've never done that."

--------

Riley said he liked the variety of family medicine. "If I were in a specialty where I had to look at people's feet all day, or mouths all day, I'd go crazy," he said. "Every patient is new and every patient is different."

Riley also kept his days varied by writing. While maintaining his practice, he also published a novel, a book of poetry ("all mushy love poems," he said), a collection of short horror stories, and two collections of funny anecdotes he encountered in his practice.

I bet if Dr. Riley were still practicing, he'd have a blog.

His patients said they will miss his combination of patience, warmth and long experience.

He is "the opposite of how today's doctors are," said Frankii Elliot, who came in for a checkup on Riley's last day as a doctor. "He'd take his time with you. He'd sit there until you were done. It's a huge loss."

Read the rest here.

Fortunately, Dr. Riley is not the last of his kind. A new breed of physicians is slowly appearing that aims to revive the old-fashioned notion that a good relationship between a physician and a patient is essential to good medical care.

Dr. Doug Roberts spent years working for the mega-health care corporations, the ones that force doctors to treat patients like a fork-lift driver treats cartons in a warehouse. As he cared for those who came to him for help, he gradually developed a better idea. Now he has put it into practice, and he expects that other physicians will follow.

Roberts and a couple of other doctors have, as he puts it, "hung up a shingle" in Sacramento. By careful management and cutting overhead dramatically, he and his colleagues are able to dispense good medical care out of small offices. Their guiding principle, Roberts says, is that the doctor takes responsibility for and develops a long-term relationship with his patient.
---
There is one exam room. The doctors use a computer for medical records, which eliminates filing and "saves the need for another room to store charts."

"The technology has allowed me to go back" to the days when doctors focused on patients and not paperwork and bureaucracy. "I take an hour with each new patient, half an hour with everyone else." Roberts estimates that he has reduced overhead by as much as 70 percent.
---
He stresses that a happy doctor is good for the system. "I get a lot of enjoyment," he says. That includes working three long days and taking off the other two, so he can spend more time with his children, who are 3, 5, and 9. "I can't tell you how nice it is to stay at home two days." The doctors cover for one another when the situation calls for it.

"Job satisfaction," Roberts says, "is better for everybody."

The rest of Dr. Roberts' story is here

Duck Hunting

A group of doctors went duck hunting one morning. As they sat waiting in their boat, a flock of ducks flew by.

The psychiatrist pointed his gun at the birds, took aim, but didn't fire. "It looked like a duck, but it didn't feel like a duck," he explained.

The next time some ducks flew by, a general internist took aim, fired and a duck fell from the sky. "I got a duck, rule out pheasant, rule out quail," he said to the others.

Next, a surgeon pointed his gun at some ducks flying overhead and shot and another duck fell from the sky. He fished the carcass from the water, picked it up and showed it to the pathologist, asking, "Is this a duck?"

Finally, when more ducks flew overhead, the family physician whipped out an Uzi and started spraying bullets in the general direction of the birds. After dozens of ducks landed in the lake around them, the family doctor said, "I don't know what I got, but I got it."

This joke was first told to me by my preceptor, Dr. Robert Millman, when I was a 3rd year medical student shadowing him in his family practice office. Unfortunately, he passed away several years ago from pancreatic cancer. I will forever be grateful for his warm demeanor, his sense of humor, his trademark handlebar mustache, and for the lessons he taught me that I pass on every year to new students.

One of the most important lessons I learned from him was "You can't help someone if they don't want to be helped." This has saved me many times as I found myself frustrated by patients who wouldn't stop smoking/drinking/snorting/shooting up or generally abusing their bodies in some way.

A few years before his passing, we ran into each other at an AAFP National Meeting. We were both attending a lecture on community preceptors. I was happy to point out to everyone there that I was living proof that being a preceptor made a difference, because through the inspiration of my former preceptor (pointing to him, making him stand), I became a family physician and a community preceptor, too. I remember how proudly he smiled as the room erupted in applause, never expecting anything more than the joy of teaching and sharing some pearls of wisdom, and a joke or two.

God bless you, Bob, and thanks.

I'll have to remember to tell my medical student that joke before she leaves.

Big Doctoring, Little Doctoring

Psst! Is everybody gone yet? I am appreciative of the recent publicity about this blog, but at the same time, I found the extra attention a little uncomfortable. Anyways, back to normal low volume hits.

I recently read a book review on "Big Doctoring in America: Profiles in Primary Care". The author, a physician, interviewed 74 primary care physicians and put 15 of the best profiles together.

From www.bigdoctoring.com:

Once upon a time, the general practitioner was America's doctor. The GP delivered babies, treated colic, extracted gall bladders and sat by the bedside of the sick elderly. As the 20th century progressed, though, and as scientific medicine advanced and differentiated, specialty medicine was born and the pattern of medical care in the United States changed dramatically. By 1960, the GP was almost extinct.

The last forty years, however, have seen the concept of general practice rebound with a new name - "primary care" - and with new practitioners. The general practitioner has been reborn as the family physician and has been joined by the general internist and the general pediatrician as providers of big doctoring - comprehensive care over time. Additionally, new clinicians - nurse practitioners and physician assistants - play important roles in the "general practice" of the 21st century.

Primary care is a way of medical life, an approach to health care and healing, a skill set and a mind set that is big doctoring. It is about care that is humanist, comprehensive, efficient, and flexible, doctoring that builds on the legacy of the past and the rich tradition of care that has characterized much of the history of medicine and nursing.

"Big doctoring" is a term coined by the author used to describe primary care, meant to convey a sense of the broad scope of problems/issues/organ systems that FPs/GPs/GIMs/GPeds tackle everyday. For me, however, it sounds presumptuous, even patronizing, aimed at boosting the egos of physicians who get too little respect, except perhaps from their own patients.

"Big doctoring" also sounds too similar to "Big Brother", "Big Government" or "Big Pharma". Shades of black monolithic towers, shadowy nameless figures in trenchcoats and institutional red tape up the wazoo.

"Little doctoring" is a more fitting description of what I do.

My exam room is small, my office is tinier still. I see 2-7 patients a day. I listen to the latest chapter in the stories of their lives. I reassure a mother whose child has a cold. I do a physical exam on a healthy young man who hasn't had a physical in 3 years. I freeze a wart. I give a shot. I talk with the slightly overweight woman about the best way to get in shape. I try to convince a diabetic to take his medicine without making him feel guilty. I share a woman's grief at the loss of her mother to pancreatic cancer 3 years ago. I wonder if a patient is late for his appointment or if he will be a no-show. I write a prescription for Cialis to an embarrassed senior. I do a rectal exam. I treat a cough. It's all mostly mundane, not the stuff of heroic 12 hour surgeries or emergency life-saving code blue action.

And yet, sometimes what I do makes a big difference. I recently referred an about-to-retire podiatrist for a colonoscopy because of heme positive stools on a routine rectal exam. 5 polyps. 1 turned out to have cancer. But because all his colon polyps were completely removed, he is cured. Not as dramatic a cure as cutting out a grapefruit-sized tumor, but when it's your own body and health on the line, drama is bad, boring is good.

This is the frontier and we primary care physicians are the scouts. We see, hear, feel and smell many things, and every once in a while, we hear distant hoofbeats and we think: horse or zebra? And often, we never come close enough to even catch a glimpse of what just went by. We're just glad it went away without trampling something we'd rather not have trampled.

Tomorrow is the first day a second year medical student will be visiting me and my solo practice. I remember what it was like for me in medical school, being the 4th or 5th person to ask a patient their symptoms and getting a diagnosis handed to you like a cold steak on a platter. The exception was when I got to visit my preceptor's family practice clinic. There I was sometimes the very first person to hear about a patient's chest pain or headache. It was like exploring uncharted territory.

To paraphrase Forrest Gump, a patient's visit is like a box of chocolates, you never know what you're gonna get. In the next two weeks, I hope to convey to my student the same sense of wonder that "little doctoring" can bring.

Confidentiality and Blogging

An article came out today on the LA Times website (and tomorrow in print) about doctor blogs, and this site was one of those mentioned. Perhaps that's why you're reading this now. During the interview with the reporter, she asked me if any of my patient knew about my blog. I said that I didn't know. Then she asked me if I would want to tell them about my blog. I didn't know what to say. It never occurred to me that any of my patients would want to read it.

My original intent when I started writing this was to tell other physicians and physicians-to-be what it was like to start a solo practice. I hoped that it might encourage some physicians who might be considering it, but felt apprehensive because of all the unknowns. That is how I felt when I made the decision to "leap" into solo private practice. Along the way, I happened to write about some of my experiences with patients (since it's hard to write about being a doctor without mentioning patients at least once).

From the beginning, I made sure never to put down anybody's name or any other "Protected Health Information", as stipulated by HIPAA. I am very careful to keep things vague enough so people cannot be identified. However, I realized, if any patient reads some of my entries, they might be able to recognize themselves. How would they feel about that? How would I feel if my doctor/lawyer/auto mechanic wrote about me and posted it on the internet? I think many of us enjoy reading stories about other people, but not about ourselves.

Other physician blogs, such as Shrinkette and The Examining Room of Dr. Charles have grappled with the issue of patient confidentiality, too. Some medical blog authors remain anonymous, probably for the same reason: to maintain as much confidentiality as possible.

In reading back over my past entries, I notice that I didn't start writing about patients until a few months ago. Prior to this, I mostly found articles pertaining to being a solo physician and commenting on them. I think this is because initially I didn't have that many patients, while lately I've had more people come to see me and consequently, more topics to write about.

I think it is unreasonable for a doctor to NEVER be able to write about their experiences. If that were so, then stories such as "The Use of Force" by William Carlos Williams could never have been written. But a physician's writings needs to be balanced with respect for patients' privacy. I guess I feel it is acceptable to share experiences about others as long as they cannot be identified. I believe that knowing what happens in a doctor's office can be educational for both doctors and patients. There is precedence for this in the medical literature in the case report, which presents an anonymous patient's usually enigmatic ailment and details the winding path that ultimately leads to the actual diagnosis. They can be thought of as a medical detective story with clues littered all over the place, and it is a test of one's diagnostic skills.

So after thinking about this for a while, I have come up with these thoughts:
1) In my professional life, the health and privacy of my patients come first.
2) I intend to continue writing my blog, but I will go even further to anonymize and remove any identifiable patient information.
3) If any of my patients recognize themselves in an entry and want any mention of them removed, then I will remove it.
4) I will amend my privacy notice to inform patients that I have a weblog and may write about them, but only anonymously with all identifying information removed. I think this is the fair thing to do, and what I would want my physician to do.

I hope that this blog inspires other physicians, residents and medical students to consider a solo career in primary care. It is not for everybody, but I believe it can be very rewarding for those who want a more personal interaction with their patients, and have the desire to control their own destiny. It can be wildly wonderful or extremely frustrating to be a solo family doctor. Most of the time, it's somewhere in between.

I also hope that non-physicians find this blog an enlightening view behind the scenes of a small town doctor's practice, and see that doctors are human, too.

And if any of my patients do happen to read this, I hope that you enjoy whatever you find here. And if not, I hope that you'll accept my apology if you feel that your privacy has not been honored. This is, after all, the work of a human and prone to (hopefully) infrequent errors and occasional truths.

Referring Back to Kaiser

I suppose my solo practice would grow faster if I didn't keep turning people away.

Several weeks ago, a mother called me to request an appointment for her daughter who injured a toe a few days before. Although she had Kaiser medical insurance (which won't reimburse for non-emergency out of network visits), she was willing to pay me cash in order to have her daughter be seen today and avoid having to go the the Urgent Care in Hollywood. I told her that I would be glad to see her daughter, but that I wanted to try to help her get an appointment at Kaiser first, since it seems, well, stupid, when people have health insurance but feel they can't use it.

So I called the Kaiser clinic I used to work at, spoke to one of the nurses who remembered me and I explained the situation. Even though there were no available appointments, she said that she would make sure this patient could be worked in as long as the patient came in right away. I promptly called the mother back and told her what the nurse told me. About a week later I ran into the mother at some school function and she thanked me for helping get her daughter seen. I figured I saved the patient at least $125, if you count my $50 office visit plus $75 for an x-ray of her toe.

This has happened two more times since then. Once for a family friend's son with a toe problem. And another time for one of my patient's mother who was having what sounded like cervical radiculopathy. She said she was told her regular doctor was on vacation, so she had to go to Urgent Care. I tried to explain to her that there are at least 15 other doctors at the Kaiser clinic, but she didn't understand. Anyways, both times I called the triage nurse, and somehow she worked them in.

So although I missed out on some income, I feel like I was able to help someone by NOT seeing them. Plus I hope that these patients will be so grateful to me that they tell others how helpful I was, and maybe I'll get a few patients that way.

But I think this will have to stop. I don't want to be known as a back door way of getting an appointment at Kaiser. Plus I don't want to abuse any goodwill I may have left with the Kaiser triage nurses, all of whom work EXTREMELY hard (thanks, Leni, Pat and Wanda!). Plus, I should commend the doctors who stayed late and squeezed in an extra patient so these people could get seen.

That used to be me. I'm happier where I am at now.

Hopefully Kaiser will improve its appointment system so it can see all of its patients at their regular clinic without having to send people miles away to Urgent Care. Until then, I'll be available to anyone who needs to be seen today.

Ordinary Care vs. Extra-ordinary Care

How often does real life intersect with the blogosphere? Outside of Bloggercon, not often, I'd bet.

A few months ago, I dipped my feet back into the world of 15-minutes-per-patient medicine at two locations, my old Kaiser office, and a multiphysician group in Pasadena. I know one of the doctors in the private practice group from when we used to play basketball together. When we ran into each other again, he mentioned that his group was looking to hire a new primary care physician since one of their partners was moving out of state, having had a hard time trying to find affordable housing here in Southern California. I told him I wasn't really interested in giving up my solo practice just yet (it hadn't even been a year!), but that I was interested in moonlighting and helping him out as a part-time doctor.

I was surprised to find out that the doctor who left was none other than the author of Galen's Log. I was hoping for a chance to meet him, just to put a face on a fellow medical blogger, but his office had already been cleared out by the time I showed up to work. Fortunately, it looks like he is finally able to afford a house. Congratulations, Galen! Maybe we'll meet in the real world some day.

One afternoon while I was moonlighting there, I saw a woman who came in for a cold. I asked her for her symptoms, examined her and told her there was no evidence for anything more serious than a viral URI (upper respiratory infection). Advised rest, fluids and OTC cold medications. Took about 5 minutes. This is what I would consider ordinary care.

As I was finishing up, she asked me if I could prescribe something for her back pain. I could've just given her a prescription for some anti-inflammatory pain medicine and gone on to my next patient. But I don't like to do things halfway. So I asked her about her back pain, how long had she had it, was she injured, what has she tried for it, if she had any renal symptoms, etc. I examined her back, doing straight leg raises, range of motion, a brief neurologic exam, checking for costovertebral angle tenderness. Some tender muscles but otherwise nothing abnormal. Call it lumbar muscle strain. I advised she try yoga or Pilates to strengthen her core spinal muscles, some massage and heat. She had already tried Motrin, so I could have suggested she try Naproxen instead, use heat, rest her back and come back if she's not any better. This took another 10 minutes. This is what I would consider better care.

When I asked her what made her back pain worse, she said when she was stressed. It turned out she had been very stressed at her job for the past year due to downsizing. Too much to do and not enough time to do it. Her pain got worse when she was at work and eased up on the weekends. She had trouble sleeping, often woke up in the middle of the night, unable to fall back asleep. She had trouble concentrating. She felt "on edge" a lot. She had been getting irritable and easily angered. She often cried for no apparent reason. She admitted feeling depressed but denied any suicidal thoughts. This was the source of her back pain. If she tried every pain medicine known to man, she would have continued to have back pain. We talked about stress and how it can cause physical symptoms. She wasn't doing much on her own to reduce stress. No time.

I pointed out (like I do for everyone who is stressed out) that when you are stressed, you can do one of two things:
1) get rid of or away from what is stressing you, or
2) change how you respond to stress. I brought up the usual natural forms of stress reduction (eg. meditation, exercise, prayer, yoga, tai chi, listening to music, reading a book, taking a walk). Plus the medicinal forms of modifying one's stress response (eg. St. John's wort, anxiolytics and antidepressant medications). I pointed out how every choice has its potential benefits as well as downsides. Exercise and you can sprain an ankle. Take an antidepressant and you can lose your sex drive. Do nothing and continue to feel miserable.

In the end, she chose a nonhabit-forming SSRI medication, which would help her feel less anxious and stressed. She understood that it would take up to two weeks to have any effect. She thanked me for listening and for the time I spent with her. I advised her to follow up with her regular doctor, whom I wondered if he would spend as much time as I had. This had taken another 15 minutes, for a total of about 30 minutes. I was now 15 minutes behind for my next patient. But this is what I would consider extra-ordinary care. This is the kind of care I strive to deliver every time I see a patient. It is hard to do when you are expected to see a patient every 15 minutes. It is easier to do in my solo practice.

I think most people would agree that this is the kind of whole-person care they would like to have, but don't get very often. For that encounter, I got paid $18.75, based on $75/hr divided by 4. Even though it took 30 minutes, I still had to see 4 patients an hour. In my own solo practice, I find that I am spending an hour talking with a new patient, getting to know them, trying to deliver the best care I can. And then finding out I can only bill their insurance company $100-150, for which the insurance company will cut down to $62-100. So, in the end, I still am making about the same as what I would make if I worked for someone else. Hmm, frustrating.

I know lots of patients who are frustrated by how much they have to pay in healthcare premiums yet how little they get in benefits. And I know firsthand what insurers pay physicians for their hard work, and I don't think it's enough. Where does all the money spent on insurance go anyways? And while it sounds bad for a doctor to gripe about how much money he makes, I know that if my practice cannot survive financially, then my goal of providing extra-ordinary care cannot survive either.

Therapeutic Use of a Harley

The other day, I was doing a general check-up on an 84 year old gentleman who shared with me a interesting treatment for his kidney stones when he was a young man in Germany. He described how much pain he was in, and how the doctor at the time (60+ years ago) told him if the stone didn't pass then they would have to operate.

That's when he decided to take matters into his own hands. He went home and proceeded to drink 10 glasses of water, followed by a couple of beers. Then he borrowed a friend's motorcycle and rode on it for an hour. After his bumpy ride, he went to relieve himself and out came several small stones in his urine. He never experienced any more pain from his kidney stones again.

Still Having a Life

I took today (Friday the 13th) off to drive north to San Francisco with my family because my middle daughter is taking part in a "bridging" ceremony for Girl Scouts. She and her troop, along with 4000 other girls, will be walking across the Golden Gate Bridge tomorrow to mark their transition from Juniors to Cadets. It was a chance to take a short vacation in a wonderful city.



I hoped there wouldn't be as much demand today for my services as there was yesterday, when I saw 6 patients in the office. Being a solo physician, I have basically been on call 24 hours a day since I started my practice about a year ago. Except for a one week vacation to Canada last summer, I haven't been away for longer than a weekend. If anyone needs to see a doctor when I am not available, I have an arrangement with a fellow solo family physician who has agreed to see my patients if I go out of town. But so far, no one ever has had to yet. And fortunately, either because my patients are healthier or I just don't have that many patients, I rarely get called in the evenings or on weekends.

This morning while stopping for breakfast along Interstate 5, I received a call from a mother who was hoping I could check her son, who has had a URI for the past 5 days, to see if he had strep throat. I explained that I was out of town but reassured her that strep throat was unlikely since he was coughing and to continue using Robitussin DM. She was satisfied with this and even admitted that she figured that I would just diagnose a cold anyways if I had been able to see her son today.

An hour later, while filling up the gas tank near Panoche Junction, I reassured a patient who was worried because she continued to have dizziness and headache from her sinus infection despite starting antibiotics yesterday. I reassured her that it would probably take a few days for the antibiotics to "kick in". She was grateful when I suggested she could take Tylenol or Advil in the meantime for relief.

Upon arriving into San Francisco, I checked my answering machine and listened to a message from a mother who said her toddler-aged son suddenly broke out in a red itchy rash after swimming today. I left a message advising that she give him some Benadryl. Hours later she called me back to tell me that she figured out that he was on the tail end of a course of Amoxicillin and that his sister had had the exact same kind of reaction to Amoxicillin, too. His rash cleared up instantly with Benadryl, and she was appreciative that I had called to find out how he was doing.

While I was leaving the Borders bookstore in Union Square, a patient called to let me know that she had spoken to her psychiatrist because her antidepressants wasn't working very well so far and that he adjusted her dose. I thanked her for keeping me informed and for being conscientious in taking her medicines daily, since up until now, she had never been willing to be compliant with her medications.

The one person I wasn't able to help was someone who would've been a new patient. In his staticky phone message, he said he had a bad sore throat, which may have explained why I wasn't able to hear his callback phone number clearly. After several attempts at a few different number combinations, I had to give up. Finally, I cleverly called the person who he said had referred me to him and managed to reach his father who told me that his son had gone to the local urgent care to get treatment, which was probably the best thing he could've done.

In between all this, I managed to drive a lot, enjoy 3 meals with my family, check into our hotel room, get a new Hello Kitty necktie and buy a lot of books.

Coincidentally, today another solo physican wrote about her current vacation on the Practice Improvement Listserve, so I thought I'd share another perspective on vacationing while living "la vida solo":

Greetings to all you hardworking Family Docs from the sunny waves of Key West:

I am just finishing up my first week of vacation in a little over a year, and I want to:
A) Thank all of you (especially Gordon for pointing out this path) for all the advice and suggestions that have added up to making this trip possible; and
B) Confirm that it *is* possible to practice solo and still have a life.

I am by no means making anywhere near the income that I expected when I went into medicine, but taking this week off is not going to break me, especially because I am not paying for staff to run an office that I am not in. By using the technology that I have been putting in place over the past 2 1/2 years, I am able to be here, enjoying myself 23 hours of the day, and have been able to respond to patient needs that can't wait the other hour each day (right before Happy Hour!)

I have been able to record a message on the office phone that says 'I'm away but if you need me I'll call you back'; it also gives the name of another solo doc in town who will see them if it really can't wait-but no one has used that option; I check the messages, and also the faxes, and return all the calls; I schedule appointments for after I get back, and I phone or fax short term refills for the folks who already ran out of their meds, or will before I get back.

I have prevented three ER visits by reassuring anxious people that the symptoms they describe do not sound life threatening (like the guy who had a radical prostatectomy last week, then got readmitted for pneumonia, but called me because he can't sleep and thought Levaquin was causing insomnia--he thought maybe he needed to go the ER to get the levaquin changed to something else. After talking a few minutes about the stess of a life threatening cancer diagnosis, a major surgery, a complication of hospital acquired pnuemonia...no wonder he's feeling scared and having trouble sleeping! He's going to try a few behavioral modifications and a little Tylenol pm and call me again if things worsen.)

I have fielded about 6 calls and 8 faxes each day, and have had to spend $8/hr for highspeed access. Of course the services I am providing will not generate any income, but that's the trade off. If I were home, I would require an office visit for refills or acute problems. Patients can't very well just run down here to see me, so I have provided "telecare" that I would not ordinarily do. Everyone has been extremely pleased that I called them from my vacation, and all have limited the length of calls and number of issues they wanted to address. It seems like a reasonable compromise for now, but someday I hope to make those services pay a little.

Anyway, I am here and grateful for the chance to relax. I wish the same for all of you! Thanks again.

Lexington, KY (but Key West at the moment)
Solo 2 1/2 years, Nurseless 18 months
emr = Healthmatics from A4

I, too, wish for a chance to relax for all physicians, both solo and non-solo. And Happy U.N. International Day of Families to everyone!

Diary From A Week in Solo Practice

American Family Physician journal has a regular feature called "Diary From a Week in Practice" written by a family physician. I always enjoy reading this, so I thought I'd try doing one of my own.

Sunday
On Sunday mornings I regularly play basketball with a group that was started by resident physicians from the Kaiser Los Angeles Sunset program over 17 years ago. There are still 2 original members left. Although I am not one of them, I have been playing with them for the past 14 years. A good workout is emotionally satisfying to the competitive spirit, as well as a necessary part of keeping fit -- no small task for a middle aged physician. Later that day, I listen to a message on my answering machine from a father who thinks his 12 year old son has pink eye. He was hoping to get his son antibiotic eyedrops so that he won't have to miss school tomorrow. After a bit of phone tag, I arrange to see him at 8PM. His mother brings him in, and like many cases of conjunctivitis, his eyes aren't particularly red now, but he describes waking up with his eyelids glued shut by a crusty discharge so he gets his antibiotic eyedrops. Meanwhile, his mother tells me about her "pulsatile tinnitus" and how the ENT specialist advised to consult with a cardiologist for a carotid duplex scan. I don't hear any neck bruits or see any ear abnormalities, so I give her the name of a local cardiology group. After they leave, I read up on "pulsatile tinnitus" and its association with glomus tumors. So I phone the patient to find out if she has ever gotten an MRI scan. It turns out that she has had both an MRI and CT scan of her head and they were reportedly normal. I don't know if the cause of her tinnitus will be found, but at least I feel reassured that it is not anything immediately life-threatening.

Monday
Only one patient is scheduled today: a physical which I perform with 65 minutes of "face time". This is typical in my practice. Since I have no staff, basically all the time patients spend with me is "face time". She has already scheduled an appointment with a gynecologist for a pap smear, so I don't have to worry about getting a chaperone. With most of my day free, I do some much-needed catching up on my medical billing. A combination of checks from patients and insurance companies totals $1,300 which I happily deposit in the bank. In the afternoon a patient I've seen before calls to say that he started having dizzy spells again for one day, and thinks it might be his sinuses acting up again. He is hoping to get a prescription for antibiotics called in over the phone. When I was at Kaiser, I would occasionally call in antibiotics if I knew the patient had a history of recurrent sinus infections because it would mean one less patient in my already busy Kaiser schedule. But now that I have my own practice, I politely tell him that my policy is not to prescribe antibiotics over the phone because of the need to do a proper evaluation first. I offer to see him today, but he prefers to see me tomorrow. He has told me in the past that he prefers to have the first appointment of the day, so as to avoid being exposed to whatever germs an earlier patient may have been reeking of. I arrange for him to see me the next morning as the first patient of the day.

Tuesday
The patient with dizziness left a message cancelling his appointment because he is feeling better, as I hoped he would. I also avoid the awkward situation of trying to talk a patient out of antibiotics. In the afternoon, I drive to UCLA to help teach the Doctoring course to a small group of 1st year medical students. I and my co-tutor, an insightful medical anthropologist, try to guide the medical students through the process of the patient interview which they perform firsthand by interviewing actors playing the role of a standardized patient. It's a valuable tool and one that I wish we had when I was in medical school. Today's patient is "Roberta Baron", a 50 year old woman who presents for a follow up of an emergency room visit for a fractured ulna which she says was caused by a hit and run car accident. She has had multiple visits for other injuries, such as broken ribs from a fall. The actress is very convincing, and an obvious contusion under her eye and an arm sling add to the realism. The students have already surmised that there may be domestic violence involved. But despite his empathetic demeanor the interviewing student seems to be making the patient more defensive with his questions about the particular details of her accident. With gentle prodding, the students recall what I've told them about the importance of building rapport to gain a patient's trust and confidence. The student switches tack and asks the patient about her work and background, which makes the patient feel more at ease. Eventually when he gets to asking her about her family situation, she becomes tearful and gradually reveals that she has indeed been injured by her police officer husband in a drunken fit. The students marvel at the power of rapport-building and empathy, and I am impressed with how advanced the students have gotten in their interviewing skills over the past 9 months.

Wednesday
Today I see 3 patients, with the last patient being a physician who was recently diagnosed with type 2 DM. Like many physicians, she is extremely busy and hasn't had time to exercise. She is fortunate enough to be in demand as a speaker on her area of expertise, and consequently gets taken out for dinner frequently by pharmaceutical reps, which hasn't been very good for her weight. There is a stereotype that doctors and nurses are among the most difficult patients to treat, and in general I have found this to be true. I think this is because health care providers know too much, and often have already decided what course of action is best for them. In addition I often cut corners when treating other physicians, because I assume that they already know what I know. Plus I don't want to offend them by talking down to them. Today I make an extra effort to treat her like any other patient and present all the pertinent information, without leaving anything out. I encourage her to start a regular exercise program, and limit her caloric intake, and try to avoid any hint of paternalism. I advise starting with Precose, 81 mg aspirin for cardioprotection and an ACE inhibitor for her HTN. She declines the pneumovax injection because she doesn't think she is likely to get a pneumococcal infection, plus she is worried about possible adverse reactions even though she recognizes they are highly unlikely to occur. She has not contacted a nutritionist yet, but intends to soon. In the case of diabetes, patients are often their own worst enemies. Or I should say, their habits are their worst enemies. As everyone knows, it can be very difficult to change habits. I hope to be able to coax and encourage this physician to adopt a healthier lifestyle in the coming months, but I realize it will be a struggle for her and me both.

Thursday
Today I see a patient for a follow up of his recently diagnosed HTN. Despite gradually increasing his atenolol and adding HCTZ over the past 6 weeks, his systolic BP remains about 146 even though it has improved from the 162 he initially came in with. There are a number of possible confounding factors: his self-run business is very hectic and demands his constant attention (he hasn't taken a vacation in over 2 years); he rushed over in his truck from a job site to make his appointment; he smoked a few cigarettes while driving here; he is worrying about how to pay for his 3 children's college educations. Despite his ongoing stressors, he maintains a positive outlook on life. A few years ago, I would have considered this drop in BP acceptable, but I am trying to go by the newest JNC-7 guidelines. We agree to not make any changes in his medication for now, and he will come back in 4 weeks. I told him I will remind him not to smoke on the day of that return appointment. Hopefully, his next BP reading will be in the optimal range. As we are finishing up, he asks me to look at a growth on his arm which turns out to be a wart. This is quickly treated with my Verruca-Freeze kit. He reminds me that I haven't sent him a bill yet, even though he's seen me 5 times already. I thank him for reminding me, and reassured him that I will bill him eventually. He is concerned about getting a huge shocking bill all at once. I tell him that everything is negotiable. I have already bartered my services in exchange for the printing of business cards with another patient. And although I would accept it, no one has offered to pay me in chickens yet.

Friday
Since opening my solo practice, I have been averaging about 2-3 patients a day. Today I see 7 patients in the office, which is the most I've seen in a single day since opening my practice. When I was at Kaiser, I routinely saw 24 patients a day, and sometimes as many as 30. Today's patients come in for 3 routine physicals, 1 case of bacterial vaginosis, a woman with sleep apnea and a strange recurring rash, a teenager needing antimalarials for a trip to Costa Rica, and lastly a case of a recurrent cough, which I diagnose as post-viral reactive airway disease, AKA bronchitis. Most of these visits were scheduled that same day which patients find to be a pleasant surprise. Even the physicals were scheduled only one day in advance. I am trying to use "open access scheduling" to allow patients the greatest flexibility in terms of scheduling. Benefits of "open access" include less no shows, reduced waiting times, greater patient satisfaction, higher quality visits, higher reimbursements. Although I've had more than my share of days with zero appointments, they are happening less and less. I know that there will be days when I may have to turn away people, but hopefully the odds will work in my favor and demand will always match my availability. I finish in time for me and my family to go see the Middle School production of "How to Succeed in Business Without Really Trying".

Saturday
Today is South Pasadena's 3rd Annual Relay for Life fundraiser for the American Cancer Society. With my daughters to help me, we get to the high school track at about 8AM to help setup. It is a large community event with many volunteers from our small city taking part. I am in charge of Mission Delivery, which encompasses patient education and raising awareness. Through my participation on the organizing committee I've met many community leaders and helpful volunteers. The same faces keep popping up over and over again at the various community functions. The interconnectedness helps me appreciate the closeness and caring of living in our small city. The whole event lasts 24 hours. I do my part by walking the 1-2AM shift, and spend the time reflecting on the loss of loved ones and how my life has changed since deciding to go solo. When I finally go to bed at 2:30AM, I make sure I set my alarm clock so I can play basketball in the morning.

How much is perfection worth? $60/hr

Last month I called a plumber to come fix a garbage disposal unit that had been broken for the past few months. The first thing he did was flick a switch on the bottom (the reset button) and it worked. 15 seconds. Done. Since he was already there, I had him fix a leaky faucet and a slow running drain. His bill for an hour of work: $80.

When I work at Kaiser, as a per diem family physician, I get paid $60 an hour. Which brings me to something I've come to realize: that somehow, people don't seem to place a high value on the services of primary care physicians anymore. I see it when I get the reimbursement checks from the insurance companies, and they knock off $50 from the $150 charge I billed for spending 1 hour doing a complete physical. I see it in myself when I feel guilty because I ask a patient to pay me for my services. When I first started my solo practice, I would spend an hour with a patient. Then because I felt sorry that they had no insurance, I would only charge them for 30 minutes. And even then I would give them a 20% discount for paying me at the time of service, so a $200 visit dropped to $100 down to $80. I was doing to myself what the insurance companies are doing to me.

This article describes how primary care is often undervalued:

Most experts agree that something should be done to get more sensible pay for primary care doctors.

''Just think about it,'' said Penny Tenzer, head of the family medicine residence program at the University of Miami. ``They want to pay very little to a doctor treating a diabetic so he doesn't lose his foot from gangrene, but then they'll pay a lot to the surgeon who would cut it off.''

The American healthcare system traditionally puts little value on primary care. About a third of America's doctors focus on this basic treatment, compared to about two-thirds of doctors in Europe.

''Other places pay primary care much better than we do in the United States,'' said Gerard Anderson, a Johns Hopkins professor who compares healthcare systems.

Dartmouth researchers have found that healthcare costs are extremely high in South Florida because patients get bounced between many specialists, which often results in ''uncoordinated care'' with repeated tests and other duplications that could have been more economically handled by primary care doctors.

''The importance of the primary care doctor doesn't have societal backing,'' said Robert Forster, a primary care physician who works for Blue Cross Blue Shield of Florida. ``The problem is that it's hard to measure the value of talking to a patient.''

Experts at the American Academy of Family Physicians and elsewhere have developed proposals that would pay for telephone and e-mail consultations, which are frequently not covered now.

Others point to pay-for-performance concepts, so that primary care doctors would receive more if they did well in controlling patients' diabetes and blood pressure, and if they kept them out of emergency rooms and hospitals.

Ultimately, primary care doctors would like insurers simply to recognize the value of time spent with a patient, but that may not be easy.

''Since the 1950s, American medicine has emphasized specialties and procedures over primary care,'' Forster said. ``It's going to take some major changes in our society and our thinking to turn that around.''

So I guess I should be proud of myself the other day. I spent 30 minutes with a returning patient and charged her for 30 minutes. Except for some reason she thought I charged $100/hr. I politely stated that my usual fee was $50 for 15 minutes with a 20% discount for payment at the time of service. And she paid me. I think with more practice, I will get better at this.

So public devaluation of physician services is one major problem I see in our broken healthcare system. To be more specific, poor compensation for cognitive physician services is a major problem, specifically for primary care. As has been stated elsewhere, there is an unbalanced emphasis towards procedures. If I spend 30 minutes talking to a patient, I'll get paid $40 by insurance companies. If I take 3 minutes to freeze a skin tag, I'll get paid $77. It's a messed up system.

Because of poor reimbursement, primary care physicians can't raise their prices to offset their rising expenses. The only other options are to start charging an extra retainer fee like a concierge practice or see more patients (and spend less time with each patient). But this places a lot of pressure on primary care physicians (registration required), some of whom burn out:

When Audrey Martinez's former patients in South Miami-Dade run into someone who knows her, they ask when she's coming back to practice. They loved her because she devoted so much time to them.

In fact, that was Martinez's problem. She insisted on spending at least 15 minutes with each patient, when her payment levels afforded her only nine or 10 minutes. That didn't make economic sense. ''We are in a crisis, but no one seems to understand,'' she said.

Crushed financially, she became part of a growing trend of primary care doctors in South Florida who are abandoning their private practices.

They closed their doors because they couldn't overcome the squeeze between low fees from insurers and soaring costs. Or they refused to survive by cutting their time with patients.

I used to feel this pressure to be productive, too, when I worked at Kaiser, although my paycheck didn't depend on it. Just my sense of duty.

The other pressure that doctors (primary care and specialists) feel is that we have to be perfect, even though this is, of course, totally impossible. The recent news stories about Celebrex and Vioxx are clear-cut reminders that there is no such thing as a free lunch. And yet, many patients expect safe and effective drugs with zero side effects. They (okay, I'm generalizing) expect perfect answers, perfect results. On a local news radio show, I heard a woman complain about how she went to the doctor for a UTI, received an antibiotic which made her feel better, but then did a home test on herself 3 days later and found out she was pregnant. The implication is that the doctor was somehow negligent because this was "missed".

In contrast, a few months ago one of my patients developed an allergic rash after taking a sulfa antibiotic for an infection. Even though I could not have foreseen it, I felt badly. I suppose in another kind of patient-physician relationship, the patient's parents might have blamed me. Perhaps even sue me. But in this case they understood that these things happen. They appreciated it when I came to their house to check their son. And fortunately his rash cleared up 3 days later.

I know it's not really fair to generalize about "those patients" as if they are all the same, just as it is unfair to generalize about "those doctors". When you get down to one on one experiences, these generalizations fall away. Because of the trust my patients place in me, I learn to trust them back. I know they value my services by the words of appreciation they give, the smiles and the handshakes. A few of my patients have even called or sent me e-mails reminding me to bill them, so I know they value my services. (Either that or they feel sorry for me.)

One of my physician colleagues commented the other day that he'd read that malpractice lawsuits were unheard of before the advent of x-rays. And ever since then, the number of malpractice suits has risen as we've become more and more technologically advanced.

American society demands perfect medical care, but isn't willing to pay for it. Ultimately, it will cost society more in the long run.