Complexity, confusion and catching up

Alan Hoffman wrote me a comment that I'll answer as a blog entry:

"How are things going now? It is nearly one year later and I wonder if you have gotten overloaded and you need to fight to keep things smaller and personal? I read your web site with interest after stumbling on to it. I am a psychologist in private practice and have a sense about your fears and probably successes now. While I am not solely relying on the private practice ( I am a university professor, too) I do rely on the additional money it brings in. Now that I am about to retire and want to cut down my client load, I have found it difficult to do, both because I love to see new people and help them, but the referals keep coming in, no matter what I have told people. Good luck to you and I hope this catches on with others."

It has been about 11 months since I hung out my shingle, and I am far from overloaded in terms of patients, but way overloaded in terms of work. I have been seeing about 40-45 patients/month for the past 4 months, so that's a real trend that I hope will continue to increase. That works out to about 2-3 patients/day. I enjoy the relaxed pace, and my patients like being able to spend as much time as they want with me. For those of you who are contemplating going solo, I should say that my practice is not typical of a new practice. I have written before about others' experiences in opening their practices.

However, I have violated one of the Cutting Edge, Open Access, Low Overhead, Minimalist Doctor's creeds: Do Today's Work Today.

When I first started seeing patients with insurance, I did not submit their medical bills, reasoning with my procrastinator's habit, "I'll have plenty of time to do that later." I mean, I'm only seeing 2 patients a day. Well it turns out that this was a mistake. I am now working through a backlog of unbilled visits, the oldest unpaid visit dating back to March 2004 (this was for a family friend, however, so I won't mind so much if I don't get paid). I have submitted my insured patients' visits up through September, and the subsequent payments from the various health plans have let me see the joy in making deposits into my meager business checking account. I have also started billing the most recent visits, too, trying to get in the habit of billing right after charting. Even after I submit everything electronically, I'll have to go back and take care of the rejections and EOBs (Explanation of Benefits) that don't make sense.

For instance, in the summer I saw a 9 year old boy for a physical. Three weeks later, I see his 13 year old brother also for a physical. My bill for the 9 year old's physical is rejected as a non-covered benefit. However, the same health plan pays for his older brother's physical. Why? Because I happened to give the 13 year old a Hepatitis A shot at the same visit. The health plan representative was perplexed, too, but that's what private health insurance is all about. Complexity and confusion. This is the price I choose to pay for autonomy and freedom. It is a deal that I still consider worthwhile.

I hope someday to become as busy as Alan, and have the luxury of having too many patients asking for my services. Slowly and steadily, patients are finding out about me, through word of mouth, and by virtue of being the only family doctor listed in my city. If I do get too busy, my plan is to hire a receptionist/medical assistant to help with administrative duties and/or close my practice to new patients. I still believe it will happen someday. I keep a weekly log of how many patients I see per week/month and have used the "trendline" function in Excel to extrapolate and predict the number of future patient visits. According to the trendline, I will average 15 patients per week by the week of April 10, 2005, which is my break-even point. I'll let you know how close I get, Alan. Thanks for visiting and for your comments.

Ring or finger?

In a New Year's Day conversation I had with relatives, someone mentioned the story of an American soldier who was injured in the Iraq war. He had injuries to his hand and the doctors wanted to remove his wedding ring to save his finger. However, the soldier refused and told them to save the ring and sacrifice his finger instead. They did as he requested, but somehow the wedding ring was lost anyways. Fortunately for him, his wife was (eventually) supportive, and his story has generated some donations from sympathetic people.

While it is a romantic notion to choose to save a wedding ring over a finger, everyone in our discussion agreed that this was a foolish thing to choose since a ring can always be remade, but a finger cannot. Other people seem to agree, claims of heroism notwithstanding.

(To me this seems like a metaphor for America's involvement in the Iraqi War. What are we fighting for in Iraq? Democracy or the people of Iraq? Are we trying to save the ring and sacrificing the finger, only to lose both?)

Of course, we don't have all the facts, but I wonder what his doctors were thinking. Doctors let patient make bad medical decisions for themselves all the time, since patients have that right. Someone with acute chest discomfort who refuses to go to the hospital. A patient with severe allergies who refuses to get rid of a beloved cat. The out of control diabetic who refuses to start insulin because he can't stand the thought of injecting himself. The woman who chooses alternative therapy for her breast cancer because she doesn't want to lose a breast. But should doctors perform a surgery they believe isn't in the patient's best interest? Was it in the patient's best interest?

Luckily, I don't operate, but tonight I visited with an 80-something year old woman at her son's home. She has a compression fracture in her lumbar spine, has been hobbling around with a walker and feels she is perfectly capable of going back home and taking care of herself. On top of this, she has a mild dementia which prevents her from recognizing how limited she really is. Her family really wants her to either stay with them or get a live-in helper, but she just wants to maintain her independence.

Like the soldier, this woman values something so strongly that she would risk her health to keep it. I'm afraid that if she gets her way, like the soldier, she will lose both. Sometimes, doctors have to NOT do what patients want them to do, in order to do the right thing. This is a kind of thinking I would never have considered a few years ago, being accustomed to always abide by the patient's wishes.

I told her relatives they had a choice, to either respect her wishes and let her resume her life alone and suffer the consequences. Or they could keep her with them, constantly delaying her return home, a "permanent vacation" for the rest of her life. It isn't totally honest, but it would be far safer for her and give her family some peace of mind. Her dementia would probably keep her from realizing just how long she is actually staying with her son. And since she is arguably mentally incompetent, this isn't a violation of ethical principles. At least, not mine.