Monday, May 02, 2005

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.

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.

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.

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.

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.

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.

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".

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.