Take two aspirin and iSight me in the morning

These guys stole my idea! Or at least, I had the same idea they did, except that they actually did it first.

Namely, using Macs and iSights to conduct online housecalls.

According to this article ("Telemedicine on the cheap") from Wired.com, MyMD.com is an online concierge telemedicine service that is giving 1000 of its participating physicians an iBook and iSight as part of a pilot project in order to allow them to more easily videoconference with patients. Of course, it only works if the patient has a videocam on their end, too.

Michael Chalkley, MyMD's CEO, said he sees the video conferencing service as a supplement to a normal health care regimen -- not a replacement. And he said that for its relatively low fee -- $4 a minute, or $50 for 15 minutes, the service is cheap enough to be useful when patients need advice on something they feel confident is a minor concern.

Unless there is a discount, the cost of the service to patients actually runs $3.99 per minute or $59.85 for a 15 minute call. If they consider this cheap, then my in-office rate of $50 per 15 minutes must be a bargain, too. The consultant physician gets to keep $1.89 of that per minute fee answering medical questions. That works out to $113.40/hr, without the hassles of insurance. I'm sure this sounds like a dream job for many overworked primary care doctors, but I wonder how many patients really use this service.

Is it a way to offer better medicine? The example listed in the article had a mother sticking an iSight down her daughter's throat to help the doctor diagnose strep throat. Now, given how difficult it is to diagnose strep throat even in person, it would appear to me to be sub-optimal at best.

This article talks about the future cybermedicine industry. However, the article's date is telling. August 3, 1999. Given that cybermedicine hasn't really taken off in the 5 1/2 years since then, I don't think we'll be practicing medicine from the comfort of our beds anytime soon.

One positive that I see coming out of this is that 1000 physicians will get to see how easy and useful the Mac operating system is, compared to Windows.

I think some day I'll get an iSight and offer "virtual housecalls" too, but only for established patients whom I've actually met in person. And while videomedicine appeals to the high-tech side of me, there's no substitute for actually being there. There is healing power in the human touch, after all.

It's a wonderful life?

I recently came across this story about a small town family doctor who had his license revoked, and now the town is coming to his aid.

Obviously, one can never judge the merits of these things based on a news story, but I was struck by the level of support he is getting from the townspeople.

Critics say Hsu resists change. He says he trusts traditional medical techniques over technology that is not necessarily for the benefit of the patient.

"I'm not giving the people all the bells and whistles, and people on the board think that's bad medicine," he said.

He gives the example of a man who suffered a heat stroke and was brain dead. It was one of the cases in which the board accused him of inappropriate care.

"I told his mom that he was going to die and if we transferred him to a Bismarck hospital, he was going to die there, too," Hsu said. "Allowing his mother to be with him was all that I could do. And to me, that's an honorable thing."

Hsu said the bigger hospital would have made thousands of dollars for a transfer he believes would not have saved the man's life.

John Olson, the medical board's attorney, urged the board to revoke Hsu's license last year. He told the panel that the revocation "is absolutely essential in this case ... he needs to be out of the practice of medicine."

While I don't know the doctor or any of the specifics, I'm troubled by the harshness of his penalty, the revocation of his medical license, relative to the amount of community support he seems to be getting from his patients. He claims to have never been sued for malpractice, making me wonder who filed the complaint with the medical board. His wife claims a competing hospital is behind the effort to revoke his license. It seems to me there should be other alternatives besides revoking his license completely. Is he such a danger to his community that he shouldn't treat people at all?

I'm sure there are many older physicians out there who may not have kept up with the latest treatments and protocols. They may not be as aggressive or lawsuit-defense-minded as a lot of physicians are nowadays. How many of us physicians now have the freedom and luxury to decide on the "right" thing to do, independent of malpractice fears or concerns over reimbursement costs or costs to the patient? How many physicians would be sanctioned if the medical boards only knew the micro-details about our practices? A lot, I bet. But that's not the same as malpractice or incompetence. It's about being held up to an arbitrary standard, depending on the values of whomever is on the medical board. In a way, it's like being sued for malpractice, except by doctors.

According to the article, Dr. Hsu sounds like a self-sacrifing small town doctor who has devoted a lot of time for very little return, at least monetary-wise. I wonder if it's a matter of differences in what constitutes "standard of care"? I wonder a little if there is any racial prejudice behind it. Or maybe Dr. Hsu is a menace to society and should never touch a patient again. I don't think we'll ever really know. All we do know is that Elgin, North Dakota no longer has the services of Dr. George Hsu. And that Dr. Hsu is finally getting paid back some of what he invested in his town. I hope this story will end up being a wonderful life.

Solo Practice...One year later

It has been one year since I opened my solo practice with the Gordon Moore (AKA "ideal medicine") model. After 14 years as a staff physician in a managed care organization, I re-started with zero patients.

My numbers:
Patients seen: 201
Patient visits: 357
Average # visits per patient: 1.78
Average # visits per week: 14
Housecalls: 9
M:F ratio: 46% male, 54% female
Average age: 36
Oldest: 91 years old
Youngest: 2 months old
Sources of patients: Word of mouth 41%; Relatives of patients 16%; Paid advertisements 14%; Insurance provider list 12%; Newspaper article 6%; Yellow pages 4%; Referrals 4%; Former patients 2%; Other 1%
Payor mix: PPO insurance 71%, Cash 24%, Medicare 7%, HMO 0%
Time to receive payment via electronic billing: average 7-12 days; longest 122 days; shortest 2 days
Average charge per visit: $114.27
Average payment per visit: $70.06
Total charges: $40,785
Total reimbursement: $17,515
Improved job satisfaction: Priceless

It is a work in progress, and in retrospect, it is a lot more work than I anticipated. But then again, I knew that there was no way I could ever know how hard/easy it would be without actually doing it. Kinda like getting into medical school.

I want to reassure those who may be scared off by my low numbers that my slow startup has been atypical. As I have mentioned elsewhere, other physicians trying this practice model have grown much faster than me, and some have closed their practices to new patients after one year or less.

The biggest challenge for me has been the business side of things. I'm almost over feeling embarrassed about asking patients for copays and sending out bills. It took me a long time to even catch up with submitting claims to insurers, and even now, I am awaiting payments for visits that took place months ago. My wife took it upon herself to enter all my receipts and expenses, mainly because we need to know what to put on our tax return. (Thanks, honey!)

Growing the practice has been the other challenge. I am still intending to come up with a postcard-type ad that I can send via a direct marketing mailing list. One thing I'm learning about being a local business person is that community involvement can be a bottomless pit. First I joined Kiwanis and got to know some other members of the community. Then I joined the Chamber of Commerce, and volunteered to be on a committee to help grow the Chamber. Now I'm on the verge of volunteering to chair another committee for the local Relay for Life, a fundraiser for the American Cancer Society. These are all worthwhile events, and they are a way for others in the community to get to know me. But sometimes I worry that I might become so busy with these other activities that I don't have (enough) time to spend on my practice and my family. That is, after all, one of the main reasons I left my former job.

Another potential activity that is coming up pertains to the purpose of this blog, which is provide motivation for others who may wish to go solo, too. There has been an e-mail listserve (started by Dr. Gordon Moore) which has been sharing information and experiences for the past year. Recently, someone suggested that we get together and become an official organization dedicated to fostering this new practice model. We are in the process of writing a grant proposal to fund a project to demonstrate how this "ideal practice" model may provide better health care than traditional models.

I'm not quite sure what defines this "ideal practice" model that Dr. Moore started. His original goal was to strip away non-essentials and have a bare bones, low overhead kind of practice that allowed him to schedule patients for same day visits and spend oodles of time with patients, without having to generate the kind of income that is required to support the typical number of office staff. In return, he was less frazzled, regained his autonomy, and managed to maintain his income level. This is the same model I have been following, except that I'm still frazzled and I have nowhere near my former income level yet. But I do spend oodles of face time with patients.

However, other physicians in our group work with a nurse, PA or clinic assistant. Some partner with other physicians. Some work part-time, some full-time. Some see a few patients a day. Others see 20-25 patients a day. At least one of us charges a retainer fee ($50 per year). We all use electronic medical records rather than paper charts.

Recently, concierge medicine has been in the news. The main selling points to patients of these practices are that they get better and more immediate access to, and more undivided attention from, their doctor. However, I think our "ideal medicine" practices share many features in common with concierge or boutique practices:
- Nicer and less crowded reception areas.
- Priority/same day/ guaranteed next day/ extended/ Saturday appointments. (I see patients on Sundays sometimes)
- 24-hour pager, cell phone, home phone access to the physician.
- House calls and out of office care. (some practices)
- Preventive care/weight loss/nutrition/wellness advice.
- Telephone and email consultations.
- Comprehensive physicals.

On the other hand, some concierge practices have features that you won't find in an "ideal medicine" practice:
- Spa-like amenities and decor.
- Personalized mini CD-rom containing medical history and related information.
- Preventive care/weight loss/nutrition/wellness programs.
- Accompanying patients to appointments with specialists. (Then again, 4 months ago I picked up a patient from her house and drove her to her GI appointment because her ride didn't show up. So I suppose this could apply to both. Although I'll bet a concierge doctor wouldn't offer to be a chauffeur.)
- A retainer fee of $1000 to $20000 per year. (Definitely worth it for spa-like amenities and a personalized CD.)

I keep calling our practice model "ideal medicine" not because it is ideal, but because we are striving to practice the ideal kind of medicine that patients and physicians both want. The medical care you want and need, when you want and need it. The time for patients and doctors to build a relationship. Greater satisfaction for everybody. It may be that this practice model will end up having a different moniker. Whatever it will ultimately be called, it is part of a grassroots movement to fix a broken healthcare system.

As they say, "Mighty oaks from little acorns grow." And we must be a little nutty to think we can solve the current U.S. healthcare system. But we've got to start somewhere. Why not here?

How to get published (sort of)

I suspect there are many physicians and other health care workers who have dreams of getting a (non-medical) book published some day. (Isn't that why we're blogging?) There have been many famous physician-authors throughout the years: Sir Arthur Conan Doyle, Anton Chekhov, William Carlos Williams. More recently there have been Stephen Bergman (AKA Samuel Shem), Michael Crichton, Robin Cook and Perri Klass.

Most budding authors have to edit and re-edit, check for spelling and grammatical errors, think of interesting characters and plots. And after all that hard work, submit manuscript after manuscript, and deal with the inevitable ego-crushing rejection letters. But for those looking to avoid all that pain and misery, you might want to consider PublishAmerica. Their publishing standards are sure to be way below yours.

Take the case of author, "Travis Tea" (say the name out loud):

Travis Tea is a pseudonym for a group of (mostly) science fiction and fantasy authors who were amused by PublishAmerica's claim (at their authorsmarket.net site) that SF & F authors are "writers who erroneously believe that SciFi, because it is set in a distant future, does not require believable storylines, or that Fantasy, because it is set in conditions that have never existed, does not need believable every-day characters."

So about thirty writers banged out a novel over a long weekend, writing it as ineptly as they could. Plot, characterization, theme ... none of them are to be found in ATLANTA NIGHTS. Grammar and spelling take a drubbing. The book was submitted to PublishAmerica -- and it was accepted.

"Each day, an average 78 new authors who are looking to find a book publishing company ask us to publish their book," PublishAmerica says. "We review not only the quality but also the genre of their work.... Like all serious book publishing companies we have to be picky as we can only accept the works that meet our requirements in both areas."

Now you can see for yourself exactly how "picky" about quality they are.

Prepare to be amazed.

Judge for yourself. Here is an excerpt from the opening chapter of ATLANTA NIGHTS. And for even more relevence to a medical blog, it's even got a doctor in it (or is he a REAL doctor? Hmmm...):

Pain.
Whispering voices.
Pain.
Pain. Pain. Pain.
Need pee - new pain - what are they sticking in me? . . .
Sleep.
Pain.
Whispering voices.
"As you know, Nurse Eastman, the government spooks controlling this hospital will not permit me to give this patient the care I think he needs."
"Yes, doctor." The voice was breathy, sweet, so sweet and sexy.
"We will therefore just monitor his sign's. Serious trauma like this patient suffered requires extra care, but the rich patsies controlling the hospital will make certain I cannot try any of my new treatments on him."
"Yes, doctor." That voice was soooo sexy!
Bruce didn't care about treatments. He cared about pain, and he cared about that voice, because when he heard the voice, the pain went away, just for a few seconds, like.

One would have thought that the publisher would have noticed that Chapter 34 is especially remarkable, considering it was all computer-generated. Proteges of Edward Bulwer-Lytton have nothing to fear from artificial intelligence for now:

Bruce walked around any more. Some people might ought to her practiced eye, at her. I am so silky and braid shoulders. At sixty-six, men with a few feet away form their languid gazes.
I know I was hungry, and impelling him lying naked. She slowly made for a man could join you I know what I ought to take you probably should have. He wants it worriedly. About think what to wear?
Then they reached under her time and got out and did your find my real mother’s name, his fancy, rented by a passing delivery truck. Well, Maggie Ooh, Andrew, you but I know my leftover cake!
Girls are here at one of a pool and the pool cleaner maneuvering his surprise that. He smiled certain her way down cruel and flashed him.
Mmm-hmm. Come and get this big Afros and indescribably tender. His hands moved surely. Recover for a mess. She'd have noticed if it had so impetuously across the pelting Georgia Girl Grill.
Isaacs’s brick-red complexions until morning. Maybe some kippers and say -- to this inspiring exchange.
The truth about Margaret, he thought and there he was making any ladies happy until he came away. Down international airports for them. He wasn't the sidewalk behind them. It would do it.

But before you start sending your 353 page manuscript to PublishAmerica, you might want to check out this article which talks about some people who didn't have such a good experience with PublishAmerica.

As for my own Great American Novel, do you think it might help if I actually wrote something first? Yeah, I was afraid of that.

Vanishing Doctors

From U.S. News & World Report:

'It was slow water torture," says Paul Ryack. That's how the 63-year-old board-certified internist describes his working life just a few years ago. With a few thousand patients, many of them elderly, he could barely find time to listen to halting explanations of their immediate complaints--let alone talk about the importance of lowering blood pressure or losing weight--in the 15 or so minutes he could allot to each. "I was unable to make the time to sit with patients, to get to know them, to help with preventive activities that we need and want," says Ryack, who practices in Santa Barbara, Calif. His costs were so high, and payment per patient so low, that taking even another dozen minutes wasn't possible. "You'd go broke," he says. The end result: a creeping sense of burnout.

An excellent article detailing the woes of being a primary care physician in America these days, and what effect that may have on the public. I just wish the article had mentioned the alternative practice model pioneered by Gordon Moore and his low-overhead approach, one that I am trying to emulate in my own practice.

It has been almost a year since I began, and while business has been slow, it continues to pick up. I typically spend 30-60 minutes with new patients, but then again, I see anywhere from 0-5 patients a day so far. Patients like being able to come in for an appointment the same day they call. They appreciate not being rushed and being able to get all their questions and concerns addressed. I don't charge a retainer fee, because I don't want to cater only to the more well-to-do. It is certainly a more satisfying situation for me. I enjoy the autonomy and independence of being my own doctor, my own boss. I set my own schedule. I can spend essentially as much time as I want with a patient, and feel like I am practicing medicine the right way, the way I was trained to do. And now that I have finally caught up with my medical billing (yes, I do that myself, too), I feel like I am starting to make some money. Or at least break even.

Dinosaurs once ruled the earth. Then a meteor hit and they vanished, leaving only those creatures who were nimble enough and adaptable enough to the new environment to survive. Managed care = dinosaurs. Me = mouse. Which animal is still around today?

Squeak.