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.