Yes to No Free Lunch

I haven't come across their booth yet here at the AAFP meeting, but I applaud AAFP's decision to allow No Free Lunch to host an booth here in the exhibit hall.

I have come to the conclusion many years ago that the pharmaceutical companies do not have America's health as their number one goal, that free drug samples end up costing the public more, that doctors can indeed be bribed with as little as free luggage tags.

That is why I do not stock drug samples in my office, nor do I have drug reps come visit me in my office. I confess that I did accept a couple of computer mice (my daughters thought they were cute, and of course they each had to have their own), assorted pens and pads and a laser pointer (which I will offer my wife, as she often gives presentations).

Freebies cost money, and that money comes from all of us. And for some of us, we pay that extra tax called "guilt". Truly there is "no free lunch" (except when I treat my medical students).

We Meet at Last

Tonight 19 of us got together for dinner. For most of us, it was the first time we had ever met face to face, even though we had been communicating for over a year. We are physicians who participate in the Practice Improvement listserve, an e-mail group started by Dr. Gordon Moore, father of the low overhead, high tech practice model. We also happened to be in San Francisco attending the Annual Scientific Assembly of the AAFP.

It was very nice for us to meet Gordon Moore, the pioneer who started it all, along with each other. Some have booming practices in Albuquerque, NM, Lexington, KY or Bellevue, WA. Others are getting ready to make the leap, or at least try to muster up the courage to do so. We shared experiences and stories, and encouraged each other. We all agreed that open access rocks, that we love surprising patients by answering our own phones and telling them we can see them today, instead of making them wait 3 weeks (or more). We shared tips about billing, electronic medical records and computers. We talked about how much we enjoyed being able to go home at a decent hour and spend time with our families. We loved being able to do the right thing for patients, and in a way that made medicine fun again.

As one person said, "This is probably the largest concentration of happy family doctors in town tonight." I think he is not far from the truth.

Stumbling over the truth

My solo practice has been busy lately, despite "closing" to new patients about a month ago. More of a filter than a barrier, I am still agreeing to see relatives of pre-existing patients. This has resulted in 16 new patient this past month, or about half of the number of new patients I was getting before.

This week has been especially busy. On Monday (2 days ago), I saw 9 patients in the office, the most I've seen in my practice in one day. In addition, I had 2 in-patients to see, too. I'm thinking it's a good thing I closed to new patients when I did otherwise I don't think I could have handled it.

Plus, it was an abbreviated work week for me. I am currently in San Francisco attending the American Academy of Family Physician's Annual Scientific Assembly. It will be the longest time I've spent away from the office since going to Canada last summer. Fortunately, a couple of local family physicians agreed to cover for me while I am away. Nevertheless, I am still checking my answering machine every few hours and getting back to people. Since I carry my EMR with me in my PowerBook, I can look up anyone's chart just about anywhere.

Today I attended a lecture, "Cardiovascular Disease Treatment with Evidence-Based Nutritional and Lifestyle Changes". The lecturer, a family physician and certified nutritionist, went through the current thinking about CAD (coronary artery disease) and plaque formation. A couple of telling statistics:

• 500,000 new cases of CAD diagnosed annually in the US
  
• In 2000, we spent about $200 billion of CAD therapy but only 6% on medical treatment and prevention.
  

*Gets on soapbox*
This seems to be the American way of thinking with a lot of issues. We'd rather spend money jailing criminals and drug abusers than on dealing with the social causes of crime and drug abuse. We'd rather spend billions of dollars and the lives of our soldiers fighting terrorists than try to figure out political solutions to stop terrorism in the first place. We'd rather spend billions of dollars rebuilding New Orleans than on developing an adequate flood control infrastructure.
*Gets off soapbox*

Anyways, the lecturer goes on to describe how to fight CAD. As he's going along explaining the lifestyle changes, I'm thinking, even I don't follow most of the dietary recommendations he's talking about. I've always figured that as long as I exercise regularly (1 hr of basketball twice a week), keep my weight normal and have a normal cholesterol level (total <200 with an HDL > 60), I figured I'm okay and can continue to eat junk food. But as a doctor, I know that people can have coronary artery disease even with no risk factors. It's tough to think that I have to go on a "diet" when I'm not having any health problems. It's also an admission that I might be getting old.

Anyways, the lecturer talked about fish oil supplements, folic acid, Co-enzyme Q-10, flaxseed, garlic, hawthorn, magnesium as having some benefits for heart disease prevention. Some had better evidence than others. He talked about the recent studies which showed that vitamin E could be HARMFUL to those with low HDL levels who are also taking a statin and niacin.

He gave a quote by Winston Churchill: "Everyone stumbles over the truth from time to time, but most people pick themselves up and hurry off as though nothing ever happened."

My take is that with science and medicine, there have been many truths presented through the years that upon closer scrutiny have turned out to be something less. The formerly widely held belief that vitamin E could help reduce the risk of CAD is just one example.

So I hope that if I stumble over something, I'll check it carefully for some truth before I hurry off to see my next patient. Before I go recommending supplements to all my patients, I'm going to have to do some more reading and examine the evidence myself. I may even find something that convinces me to take fish oil supplements. At any rate, I will try harder to discuss with patients the many ways they can prevent heart disease through nutrition and lifestyle changes.

Intellectually, I know that I should eat healthier. Besides, I know if I don't then I am practicing what I just preached against: waiting to deal with the problem after it happens instead of doing something beforehand to prevent it from happening. I guess I'm as American as the next guy. *sheepish grin*

A Resident's View

One of the mantras we learn during medical training is "See one, do one, teach one." To that end, over the summer I had 2 medical students and one family medicine resident visit me to learn what a minimalist solo practice is like. I figure even if they never set up their own solo practices, they might at least tell others about this crazy/unique (depending on your point of view) practice model. After they've seen what my practice is about, I ask them to write their thoughts so that others may learn from a different perspective.

About a month ago, David Liu, a 3rd year resident from the Kaiser Orange County Medical Center Family Medicine Residency Program, visited my office for 2 weeks. Here is what he wrote:

I first heard of Dr. S through my med school classmate, Beth. She told me that she had chosen a new family physician who was just excellent. He spent a lot of time with her during their initial consultation and answered all her questions and concerns. I was in the middle of my second year of residency in family medicine at a Kaiser program. I had already begun thinking of what I wanted to do with my career after graduating. I had grown accustomed to the Kaiser way of doing things. It was daunting thinking of my future with 15 minutes per patient and the constant feeling that I had to rush with my patients to get done on time. I knew part of this was due to my lack of experience and knowledge. With time it would get better, right? I wasn't so sure.

Thus, I decided to use some of my elective time early in my third year to shadow different private physicians, to see if there was another way of doing things that fit me better. I had already done a rotation with a "holistic" physician and with a small group practice. Dr. S's practice was next. My friend told me that he had been a former physician in Kaiser and just started private practice after many years with the organization. I thought it would be perfect to see how a former Kaiser physician was doing in private practice.

My experience with Dr. S over the course of 2 weeks was illuminating. On my first day with him, Dr. S explained that he was utilizing a low volume/low overhead model of practice. He explained how he did everything, including answering the phone, taking the vital signs, administering vaccines, etc. He did not have any staff. Patients needed binding arbitration agreements and insurance forms filled out. He used an Electronic Health Record and scanned all documents for the patients into his Apple notebook computer.

Every time he saw a patient, he would bring his notebook computer with him and interview them. With patients he could take an hour or more if needed. He never seemed rushed. I could tell that patients he saw appreciated how much time he had available to investigate all their problems. In addition, it was easy for them to make same day appointments with Dr. S. He was also easily accessible because he gave each of his patients e-mail, cell phone, office number.

He was very open about showing me how his practice worked--including costs, earnings, number of patients, building location, and marketing. In his fledgling practice, Dr. S has had to take a big pay cut from his former Kaiser salary. However, this was in exchange for practicing in a manner that suited him better.

There was also the potential for growth. He typically saw about 8 patients per day. [Actually it's anywhere from 0-8 patients per day.] This was a lot compared to when he started where often he would have no patients. He said that if he wanted more patients, it would be easy to accept HMO insurance, do more admissions at the hospital, etc. But, he felt that for him, it was preferable to take it slow and not take on too much too fast. He thought about how he saw the practice growing and that if he wanted to recruit more patients, there may be a need to hire an assistant. In the foreseeable future, he could be taking over the entire suite of the building he occupied. Then expansion would be possible.

There were inefficiencies. Often, Dr. S would have to leave the exam room to see if a new patient had arrived so they can begin filling out paperwork. Without staff, if a patient needed a lot done, it could take some time to do everything that a patient needed--UA, EKG, vaccines, etc. I could see how it might be easy to fall behind if there ever were any sick patients that needed close attention. Taking care of all the insurance paperwork, organizing his finances, and all the business aspects took time. Dr. S said there are days that he is forced to take work home with him. There was also the logistics of how to best keep track of patient labs and preventative measures. However, given his small volume of patients, I never saw any compromise in patient care during my time with him.

Dr. S was quick to point out to me that his model was still a work in progress and had its pluses and minuses. For a young physician like myself, who still needed seasoning in the practice of medicine, he thought Kaiser or a group practice might be better ways to go--more stability, more patients to see and to learn from, and in Kaiser, less worries outside of the practice of medicine.

I can see how it would be difficult for a brand new graduating resident, in terms of money and experience, to start a practice such as Dr. S's. Conversely, I also feel that perhaps starting young and learning from my mistakes now may be the way to go. From following Dr. S, it has definitely given me insight into a special type of private practice. He also exhibited excellent bedside manner with his patients--always calm and organized, which instilled confidence in his patients. There are definitely aspects of his practice and dealings with patients that I hope to be able to incorporate.

It's hard for me to predict what I will be doing in 5 to 10 years. I do know that I hope to practice medicine in a manner where I will be able to give my patients optimal care to the best of my abilities while being able to maintain a balanced life outside of work. Is Dr. S's way of practice the best way for me? It is hard to say. However, I do hope to follow his lead in striving to practice medicine in the way that best suits my patients and me.

David

Thanks, David, and best of luck in finding out where you want to be.

(This part is for David and Phil Nivatpumin, one of my former students.) I do think that for a new physician coming out of residency that working at Kaiser is an attractive environment to work in. There is minimal administrative paperwork. You have set hours. Once you are off duty, you are off. No worries about being called by a page operator. You can go on vacation and know that someone is covering for you. Call coverage varies for primary care physicians. Depending on which Kaiser facility you work at, call can range from staying in the hospital overnight to working a 4 hour shift in Urgent Care to nothing. At the clinic I used to work at, we didn't work any extra duty for several years.

As a Kaiser physician, there is relative autonomy. You can order almost any medication or test you want without having to have it pre-approved. Of course, that has been changing over the past few years I was there to place more restrictions on the more expensive drugs/tests. I often had to re-educate patients who assumed that physicians were under orders to practice medicine the "Kaiser way".

The salary and benefits were very good. My annual salary was higher than I ever thought it would be as a family physician. Once you become a partner (after 3 years), it's almost impossible to lose your job. Plus I learned a lot, just because of the variety and volume of patients that I saw. For myself, working at Kaiser was a good place for me to be just out of residency.

So why am I no longer at Kaiser? You can read my older entries for a longer explanation. I guess you could say I grew in a different direction. I saw, I did, I taught. Now I want to see, do and teach something new.

Published Pith

The always pithy and often poignant Dr. Charles has published a book of his fictitious (but based on real-life) patient stories, titled "Legends of the Examining Room". I have found his stories to be sometimes humorous, sometimes sad, always reflective of the relationship between patients and healers. We all wish we could write as well, but at least we have Dr. Charles to represent the physician-writer.