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."
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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.
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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."
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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.

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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.

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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.