What is a micropractice?

From Medical Economics:

For five years before opening her innovative solo practice in Woodland Park, CO, FP Michelle Eads worked in a very traditional, very busy primary care group. Located in Colorado Springs, it employed lots of doctors, operated with an enormous overhead, and processed scores of patients each day.

"I was forced to crank them through as fast as I could," says Eads, whose panel numbered more than 2,000 patients, most of whom she never got to know very well. "After five years of that, I knew I wanted to do something different."

Then she read an eye-opening article by FP Gordon Moore, who practiced in Rochester, NY, and had had his own disillusioning experience with a traditional high-volume, crank-them-through group practice. Moore's article described his odyssey from that frustrating situation to something that both he—and the patients who followed him—found a welcome change. It's a low-volume, highly efficient solo practice that uses cutting-edge technology to keep overhead low and free up time for more doctor-patient interaction.

Eads liked what she read. And—after hearing Moore speak to other FPs about his experience—decided to emulate his model. Today, she practices out of two rooms, totaling 500 square feet. The only other person in the practice is her medical assistant, who quit the group when Eads did. When not taking vital signs and administering simple labs, the MA serves as receptionist, phone operator, and checkout clerk.

At the heart of Eads' practice is her electronic health record, which has built-in practice management software that, as she says, "makes billing quite painless." With a panel of only 400 patients who have access to her 24/7, she's able to give many of her patients one-hour appointments.

"The amount of time I spend at work each week is similar to the time I spent in my previous job," she says, "but my satisfaction is so much higher. I'm happy to be a doctor again."

This was how I got started in my solo practice, too. And like the other doctors mentioned in this article, I am happy to be a doctor again.

Me and My Shadow, Redux

Recently I had the pleasure of hosting another 3rd year medical student from USC who was doing her primary care clerkship. I always warn students before they come that rotating through my office will offer far fewer patients than if they went to a more mainstream type of practice. On the other hand, they'll probably get a chance to spend a lot of time with individual patients and develop their interviewing skills. And as always, at the end of their rotation I ask the student to write about their experience working in this type of practice. She had to write an essay about her experience anyways as an assignment, but I made sure I got her consent before publishing it. This time, I also made it clear to the student that I had completed her evaluation BEFORE she wrote her thoughts, so as to get as honest an opinion as possible.

Dr. S's model of practicing medicine has been inspiring, and has provided me with the hope that I can practice medicine the way I envisioned it, prior to starting medical school. After thirteen years of visits limited by time and having so many patients that he couldn't remember their names, Dr. S decided to give up the security of Kaiser and start practicing medicine the way he thought it should be.

Shortly after I first met him, he told me, in more or less these words, "Healthcare has come to the point where patients barely see their doctors. They go to the office, speak to a receptionist, wait for half an hour, talk to a nurse who takes their vitals, and then wait again for the doctor who is too busy to remember who they are or their problems."

With his new practice, Dr. S has tried to remove all the barriers between a patient and his physician: "All you really need to practice medicine is a doctor, a patient, and a room." This concept seems so simple, but it is one that is too easily lost.

After working with Dr. S, I truly believe that his practice embodies patient-centered care. Patients typically don't have to wait longer than five minutes after arriving in the office. Patients can always make same-day or next-day appointments. Dr. S has an encrypted messaging system so that he and his patients can communicate by email. He does not make patients return to discuss normal labs, saving them the cost of that return visit.

And all of his patients receive his cell phone number; he has an open access practice, meaning patients can call him twenty-four hours a day. (I asked him how that's working out for him, and he said that very few people have called him late at night - I believe it's because of a mutual respect). Dr. S provides all the services that medical concierge practices offer for monthly fees. However, he provides them for free because, as his website says, "I feel good medical care should be available to everyone."

While this concept of a solo practice may seem outrageous and even implausible at first, it doesn't take long to see that it works. Some might not agree. After all, as he told me, he is only now barely starting to break even in finances, and endured net losses his first year in practice.

However, if we measure achievement by patient satisfaction - as medical professionals should - then I am confident that Dr. S already has found success. One patient said to me: "You're working with the best. He does it right. Please try to recruit as many of your classmates as you can to this new paradigm of medicine." Patient after patient expressed similar sentiments.

Another, a recovering methamphetamine addict and recently out of jail, drove from the Inland Empire to see Dr. S because he "feels comfortable with him." Patients were consistently grateful for the attention they received. Truthfully, I had never seen such strong relationships between patients and their physicians. (In fact, I found myself thinking on multiple occasions - why can't I have a doctor like this?!)

This experience has made me think back to our years of ICM, when we were taught how to build rapport, how to take social histories, how to do comprehensive exams, how to show compassion to our patients. It's almost as if when third year started and we were thrown into the "real world," none of these concepts mattered because there simply wasn't enough time. Instead, I was supposed to just cover "the essentials" - figure out the problem and fix it!

Working with Dr. S has renewed my faith that all those interviewing skills that were emphasized in school have a purpose - that simply listening to patients is essential, and can have a large impact on their health. In fact, psychosocial factors were at the root of many of our patient's complaints, and these couldn't have been discovered if we didn't take the time to listen.

This rotation has given me the confidence that the ideal of truly patient-centered care can indeed be reality. I can only hope that one day, when I am practicing, I will be able to make my patients as happy as those I have seen in the past five weeks.

Tiffany Wang, MS3

Thanks, Tiffany. The following week, Tiffany sent me another e-mail:

I actually had to read my paper aloud in our family med wrap-up session; the rotation directors chose it to follow my classmate's paper on idealism vs. realism in the medical profession. They seemed pretty amazed by this type of practice.

It does seem strange that medical schools are spending so much time teaching medical students how to develop rapport and good interviewing techniques in the beginning of their medical training, only to have to get students to unlearn all this when they actually start seeing patients in real world clinical settings because they don't have time for niceties like "getting to know the patient".

The ideal of quality medical care doesn't quite mesh with the reality of modern health care economics. No wonder there have been fewer medical students choosing primary care lately. They come in with a vision of being a caring, personal physician who has time and energy to care for others, only to become disillusioned when they witness firsthand what primary care has become: overworked doctors rushing from room to room, having only 15 minutes to listen, examine, diagnose, analyze, prescribe, explain, counsel, screen, record, with neverending stacks of charts crowding their desk. Of course, not all primary care practices are like this. But way too many are.

I just want physicians and physicians-to-be to know that it doesn't have to be this way, and maybe inspire a few to take a different path.

How to Lose Weight Riding on the Information Superhighway

I found this link via SlashDot about a computer that only allows you to use it as long as you are pedaling.

Just for the record, I thought of this idea a year ago. Someone should do the same for a wide-screen plasma TV and an exercise bike.

Now how many of you reading this now need one of these things?

Pirates of the Health Care-ibbean

One last post for "Talk like a Pirate Day": a humorous music video about Healthcare Pirates from the Foundation for Taxpayer and Consumer Rights.

Who would've thought a sea-shanty called "Go Ahead and Die" could have such a toe-tappin' beat?

From their website: "Half of every dollar spent on health care is wasted on administration, insurance company profits, and overpriced pharmaceuticals." With a total annual U.S. healthcare spending of $1.9 TRILLION in 2004, it sure sounds like there's a whole lot of plundering going on.

And I thought I was just kidding with the pirate bit. Arrgh, indeed.

Talk Like an Insurance Claims Reviewer Day

In recognition of Talk Like a Pirate Day, I though I would give some modern-day examples of Pirate-speak:

Example 1

Avast matey:
Afterrr rrreviewin' th' inforrrmation, ourrr barnacle-co'erred Medical Dirrrectorrr has a fierce fire in his belly that tharrrwe must upbe holdin'th' denial o' co'errrage ferrr 'ese 'errreserrrvices on th' basis that tharrrtherrre be no documentation o' medical necessity ferrr th' rrrequest'd serrrvices or burried trasurrre.

Example 2

Ahoy Thomas Cook:
At yerrr rrrequest, Health Alliance rrreview'd yerrr rrrequest ferrr prrre-authorrrization ferrr Stump Expanderrr Reconstrrruction o' a left pegleg deforrrmity, and a bottle of rum!

We have rrreceiv'd a letterrr frrrom yon Drrr. James Ferguson. Bas'd on rrreview o' this letterrr know ye th' surrrgerrry would be considerrr'd cosmetic and therrreforrre, be not co'errr'd on yerrr plan.

If ye have any questions orrr wish t' submit some additional godforsaken inforrrmation ferrr rrreview, please shout orrr
wrrrite t' th' Medical Management Deparrrtment at th' addrrress and phone numberrr list'd below, ye scurvy dog!
Red Rackham, R.N.

Example 3

Dear William Kidd:
Unit'd Healthcarrre has rrreceiv'd an inquirrry rrregarrrdin' th' eligibility o' co'errrage ferrr yerrr right hookie device.

Because this prrrocedurrre be not a basic health carrre serrrvice and be not considerrr'd medically necessarrry, it be not a co'errr'd benefit b'lowyerrr plan. Co'errrage crrriterrria o' serrrvices is explain'd in detail in yerrr foul blaggarrt Unit'd Healthcarrre memberrrship materrrials.

The Customerrr Serrrvice Deparrrtment be hankerin' tobe answ'rrrin' any questions ye may have rrregarrrdin' th' charrrges ferrr which brrrackish ye will be rrresponsible should ye elect t' have this prrrocedurrre, matey!

Please rrreferrr t' yerrr blasted Unit'd Healthcarrre memberrrship materrrials ferrr inforrrmation, orrr contact th' Unit'd Healthcarrre Medical Management Deparrrtment. Ya horn swogglin' bilge rat!!

Example 4

Ahoy Neddy Teach:
Aye, ye have th' right t' appeal this deterrrmination as outlin'd in yerrr fleabag Summarrry Plan Descrrription.

Me dear ol mum, bless her black soul, tol me ye may initiate an appeal wit' Unit'd HealthCarrre by followin' th' prrrocedurrre outlin'd below. Unit'd HealthCarrre offerrrs two le'els o' appeal, be they th' Skull or Scuppers. At ev'rrry le'el, yerrr appeal will be rrreview'd by a Unit'd HealthCarrre Medical Dirrrectorrr orrr an independent medical consultant (that be me mate, ol Rumpot, who'll swill a pint or two of grog!).

To do so, please submit th' followin' medical inforrrmation within sixty (60) days o' rrreceipt o' this notice, else we'll seize all yer booty. Gar!!!

Plundering insurance premiums or the Spanish Main, what's the difference? Aarrgh!

We're not in it for the money

I have a patient who occasionally e-mails me interesting articles related to healthcare. Recently he (Hi, Mr. S!) sent me an article about how doctors are nickel and diming their patients for things like filling out forms, refilling medications or giving advice over the phone:

When Jill Wolfson called the psychiatrist last year for a prescription refill for her son, she had an unpleasant surprise. Up until then, the over-the-phone refill had been free. This time, she was charged by her doctor for the service, to the tune of $25.

"I was really astounded," says Wolfson, of Santa Cruz, whose son had long been seeing this psychiatrist for attention deficit disorder. "We go in for regular checkups to get his meds looked at, so it's not like we call in for refills without ever seeing him. It just seems like it should be part of the service when you're being charged $100 an hour."

Okay, since she's being charged $100/hr, that either means she doesn't have insurance or, more likely, he doesn't accept third-party insurance, like a lot of psychiatrists. But I see her point: why charge extra for a refill?

Langston and others blame nickel-and-diming on a broken-down, outmoded system of healthcare that rewards physicians only when they have "some skin in the game," meaning face time with the patient, says Dr. Daniel Sands, an assistant professor of medicine at Harvard Medical School.

"The only kind of healthcare that is valued [by insurers] is the care delivered in the office," says Sands, who lectures on physician trends. For example, he says, doctors have been "giving away" care over the phone for years, unable to bill insurance for the time. Medical intervention by phone or e-mail, he says, is time-consuming, requires solid medical judgment, carries the usual malpractice risks - and is completely uncompensated.

Here is another perspective on rising health care costs, and who has to pay:

Many patients are lumping doctors in with insurance providers and pharmaceutical companies as greedy components of the escalating heath-care crisis, but in many ways, doctors are simply struggling to keep their practices afloat. Rising overhead costs, lower reimbursement amounts from insurance providers and delays in receiving payments due to haggling over bills, among other things, have put considerable pressure on them.

"The burden of running the health-care system has been shifted over to physicians," said Daymon Doss, CEO of the Petaluma Health Care District. "Insurance companies have created very complex billing systems that often deny reimbursement for services. So, doctors and their staffs have had to become very skillful at filling out forms."

Despite the financial burdens and dangers, there are still some of us who swim salmon-like against the healthcare system stream:

Some physicians, such as Petaluma primary-care doctor Eric Holmberg at 108 Lynch Creek Way, prefer solo practice, despite the mounting obstacles. He returned to a solo private practice more than two years ago.

"In a large, clinical-practice setting, patients are juggled between physicians and nurse practitioners, so doctors don't get to know patients very well," he said. "As a solo physician, I am able to provide better, more personal care. I don't try to run a lot of people through my office."

That's what medical micropractices are all about.

Holmberg has had to run a very tight ship, though.

"I've kept my overhead expenses as low as possible, partly by cutting down my staff to one employee, who serves as a medical assistant and front-office worker," he said. "If I had the financial capacity, I would hire another person."

I know what Dr. Holmberg is talking about. I have been trying to manage a solo medical practice on my own for the past 2 1/2 years, and while I have enjoyed the freedom of spending as much time as I need to in a visit with a patient, it has been a struggle for me to get paid for the work I do. Therefore this week I finally hired someone to help me with the medical billing and chasing down denied or "forgotten" payments from insurance companies.

So if you think you are paying too much for health care and aren't getting your money's worth, you're absolutely right:

For the fifth year running, Blue Cross of California has spent less than 80 percent of premium dollars on patient care, according to a report released by the California Medical Association.

Blue Cross, the state's largest for-profit health insurer, spent 78.9 percent of its premium dollars on patient care in fiscal year 2004-2005, with 21 percent to profits and administration, according to CMA's 13th annual report examining annual health plan expenditures.

"Vital patient care is being short-changed by for-profit HMOs that send ever increasing portions of premium to Wall Street instead of spending it on patients," said Michael Sexton, M.D., CMA president. "If a substantial part of these profits were kept in the health care system, it would help make Californians healthier, stabilize the endangered emergency care system and ensure that all patients get access to the care they expect and deserve."

So where is the money going?

Wellpoint Health Networks, the parent company of Blue Cross of California, paid CEO Larry Glasscock more than $5.4 million in salary and other compensation. Thomas Snead Jr., another Wellpoint executive, received more than $5 million in compensation. Neither figure includes stock option amounts or values. These compensation amounts were several million dollars more than the average compensations earned by other health plan executives.

Last year, WellPoint reported that CEO Leonard Schaeffer received more than $11 million in total stock, salary and other compensation.

You know, $11 million could pay for a lot of school forms and medication refills, not to mention childhood immunizations and cancer screening tests.

It's gotten so bad that doctors have to resort to doing things like this ("Boost productivity? Walk less") as a way to make more money. Money that is often needed for a practice to survive.

Anyways, like most doctors so far, I do not charge extra for filling out forms, answering questions by e-mail or refilling medications over the phone. But that could change in the future, depending on what changes come about in physician reimbursement from insurance plans. Even so, it's not about getting rich. I just want to be able to make a living doing something that can help others.

If I really went into medicine to make money, I could've done something like this.

Triumph or Tragedy?

I have been following the story of Dr. George Hsu over the past year, and like a Hollywood movie, it is finally approaching the climactic ending, though I still don't know if it's going to be one of triumph or tragedy. Here's the timeline version:

March 2004 - Dr. Hsu, a small town family physician in Elgin, North Dakota, has his license revoked by the State Board of Medical Examiners based on an anonymous complaint. He is accused of inappropriate care in 10 cases.

November 2004 - Rather than accept a hearing judge's less punitive recommendation to monitor Hsu's practice, the medical board revokes his license instead. At the urging of his patients, who are local farmers and ranchers, Dr. Hsu files an appeal.

Rolf Sletten, the board's executive director, said monitoring would have been too intense to be practical in Hsu's case. He said the board said it believed the breeches in Hsu's medical care were too serious and that, coupled with Hsu's attitude and prior history of being disciplined by the board for untimely charting of patients' medical records, revoking his license was the best course of action.
----
Hsu said he also is frustrated because the 11-member medical board voted without comment, and he has never heard its explanation for taking the most serious disciplinary step it can take against him.

Sletten said Hsu's attitude worked against him.

He said that when Hsu addressed the board, he complained about the investigation and review process and only talked about being monitored when "nudged by his attorney.
----
Sletten said he can't remember when a district court has overturned the board's decision to revoke a medical license.

January 7, 2005 - Medical Board denies a rehearing.

January 29, 2005 - The townspeople of Elgin organize fundraisers to help out the financially-strapped Dr. Hsu.

Klein said people are finding it difficult to replace Hsu.

"It's about trust and that's something you can't get in a pill," she said.

Hsu said he's deeply moved by the response from the community.

He said his practice was characterized by carrying one of the nation's top patient loads, even while his personal income was in the bottom 10 percent of family physicians.

"I have not been able to save a lot of money and the legal costs have drained my personal resources," Hsu said.

February 2005 - Hsu files an appeal in state court. The national media pick up his story.

Hsu's supporters write Letters to the Editor in the local newspaper criticizing the Medical Board's decision. [1] [2]

March 22, 2005 - Dr. Hsu writes his own Letter to the Editor, entitled Price of defensive medicine is steep.

March 2, 2006 - One year later, it's over. Elgin Doctor Back in Business

The state's medical watchdog panel was wrong to revoke the medical license of an Elgin doctor accused of improper patient treatment, a district judge has ruled.

South Central District Judge Sonna Anderson's order said George Hsu should have his medical license reinstated if he agrees to additional monitoring prescribed by the state Board of Medical Examiners, which licenses and disciplines doctors.

"The record does not support a determination that the departure from the standard of care is so serious as to justify the revocation of Dr. Hsu's license," Anderson's order said.
----
Hsu said he has been working as an auto mechanic and has started a highway striping business with his son.

He said he has not had a haircut in the nearly two years since the board first barred him from practicing medicine.

"It was a protest, I suppose," he said. "I'll probably get my hair cut now."

March 21, 2006 - Then again, maybe not. Elgin doctor's case still up in the air.

April 4, 2006 - Board revokes license again:

George Hsu was ready to get a haircut and scrub his successful highway striping business in western North Dakota to return to work as a rural doctor.

But Hsu, 62, of Elgin, learned that the state's medical watchdog panel would rather have him painting highway lines in a pony tail than seeing patients.

April 25, 2006 - Judge orders board to reinstate doctor's license

In a sternly worded order received by attorneys Monday, a judge says the medical license of George Hsu, a doctor in Elgin for some 20 years, should be reinstated if he agrees to additional monitoring.

It is the second time South Central District Judge Sonna Anderson has ordered the state's medical watchdog panel to reinstate Hsu, who was accused by the state Board of Medical Examiners of improper patient treatment.

Anderson said her first order, issued in February, may not have been "crystal clear to the board."

"The (board's) order revoking Dr. Hsu's license was reversed," Anderson wrote. "If it was not explicitly clear in the earlier order, let it be clear now."

She used bold letters in part of the order to emphasize her point.

Doug Bahr, an attorney for the medical board, said Anderson's earlier order "at least in the board's opinion, was unclear.

"She has made it clear," Bahr said Monday. "People won't be guessing."

April 28, 2006 - Board to appeal to State Supreme Court

Mar 3, 2006 - The Bismarck Tribune writes an editorial questioning whether an taxpayer-funded appeal is justified.

April 20, 2006 - Dr. Hsu writes another Letter to the Editor: Disregarding Truth and the Law

In 2002, Sletten informed me that a "confidential panel" was not satisfied with my response to a complaint involving three cases, and unless I agreed to some form of discipline, my license would be revoked. I did not understand what it was that I had done wrong, and I asked if I could meet with the board face to face. "If after that, they can look me in the eye and tell me that I was wrong, I'll comply with any discipline they feel is appropriate." But that was "not possible."

I asked what my options were. Sletten told me, "You can fight this and go before an administrative law judge, but it doesn't matter what he decides, because we'll do what we want anyway."

I did not believe this was possible, but the facts speak for themselves. The board's case against me was weak, but the three complaints increased to six, then seven, and finally to 10, even though not a single one originated from a patient or family member.

May 2006 - More Letters to the Editor in support of Dr. Hsu [1] [2][3]

July 6, 2006 - Board ordered to pay court costs, attorneys fees of doctor

The state's medical watchdog panel must pay attorneys' fees and court costs for an Elgin doctor it accused of improper patient treatment, a district judge has ruled.

South Central District Judge Sonna Anderson awarded George Hsu $26,602 in an order dated June 30.
----
"It's no surprise," Rolf Sletten, the board's executive secretary, said of Anderson's most recent order. "It was clear that's what she was going to do - there is no news in that. In truth, the cost issue will be decided by the Supreme Court."

Hsu said Wednesday that he expects the medical board to appeal the award of attorneys' fees and court costs to the state's high court.

"I think it will just give them another black eye," he said.
----
Court documents show that the board has spent $39,400 in attorneys' fees, court costs and its investigation of Hsu.

Totally fictional yet based on real life movie adaptation version: Psychologically scarred Vietnam and Gulf War vet becomes a maverick, sometimes arrogant, old-fashioned doctor with a heart of gold. When he gets cited for a minor infraction, his bad attitude ticks off the crotchety, iron-fisted Medical Board Executive Secretary who vows to show the rogue doctor who's boss and put him out of business. He misleads the Medical Board with selective evidence and they have no choice but to revoke the small town doctor's license. The once untrusting but now loyal townspeople come to the doctor's aid and despite the overwhelming odds, they win their appeal. But Mr. Executive Secretary refuses to accept defeat and takes the case all the way to the Supreme Court where........a decision will be made. Triumph? Or tragedy?

We must wait for the final chapter.

Primary Care is Where It's At

I found yet another article about a micropractice, this one in Rhode Island, which serves as a rebuttal to some recent opinions that primary care is dead.

Ho has no receptionist or other staff members, so immediately after greeting a patient, the two enter into a conversation about the patient's health, a physical examination, and discussion of next steps. The relatively small size of Ho's practice allows her to spend a relatively large amount of time with each patient: at least an hour for a first visit and a half hour or "as long as it takes" for subsequent visits.

As the visit draws to a close, the doctor handles all of the administrative details, including billing and scheduling the next appointment, herself. The results of focusing so much on her patients are clear: although Ho estimates that she's forced to spend more than 60% of her time on administrative tasks, she has over 600 patients, and will soon have to close her practice to new patients that are not family members of existing patients.

Dr. Ho is on the Map. I suspect there are a lot more micropractices out there than anyone thinks. Hopefully we'll start reading more about them as the word gets out.

More Micropractices

It's always a pleasure to hear about other physicians who are choosing to go smaller and return to a simpler way of practicing medicine via micropractices. For one thing, it gives me hope that the American medical system can be transformed/reformed into something that makes some sense. For another, it makes me feel like I'm not the only crazy one for trying it.

Here is a recent article from the Santa Cruz Sentinel about someone else who took the leap:

SANTA CRUZ - There's something different about the office of Dr. Maria Greaves.

Sure, there's a tastefully furnished waiting room with a burgundy leather sofa and a toy box. But there's no receptionist, no nurse, no insurance paperwork to fill out.

"I'm everything," said Greaves with a smile.

She is the first physician in Santa Cruz County to adopt a new style of medical practice pioneered by Dr. Gordon Moore in Rochester, N.Y., five years ago.

Here is another article about 2 doctors from Oregon who also decided smaller is better:

Quillin is part of a growing national trend of physicians breaking away from high-volume practices characterized by short office visits.

Tired of seeing more than 20 patients a day and staying on top of the well-being of 2,500 people every year, they are paring down their practices to a few hundred patients, who get a lot more of their time.

Smaller practices can come in different forms. Some are completely solo like Dr. Greaves and myself. Others look like a traditional practice with a medical assistant and nurse. I accept 3rd party insurance like most practices. Dr. Quillen charges a $400 annual enrollment fee plus $75 per additional family member. You can be full-time, or part-time, like Dr. Wible:

Wible worked in several clinics in Eugene and in Washington state before opening her own part-time practice in April.

Her biggest complaint about working in established clinics was similar to Quillin's: not enough face time with patients.
"I like to talk and my patients like to talk. They want to get to know me, and I want to get to know them. You can't do that in 15 minutes," she said.

When she decided to go solo, she conducted several community meetings that attracted about 100 people. She asked them what they wanted from their primary care physician and three consistent themes emerged.

People wanted more time with their doctors. They wanted to be listened to and they wanted to play a role in their own health care.

Wible knew she wanted more time with her patients, the opportunity to help transform the health care system, and more personal time to explore other activities.

To get there, she stripped down the overhead. She employs no one, and does all the accounting and business work in her home office. She sees clients three days a week in an office she rents at the Tamarack Wellness Center in south Eugene.

Because she carries no debt and lives simply, Wible says she doesn't need the typical physician's salary. But she believes that her low overhead will allow her to exceed her previous full-time salary.

So if this is a growing trend, where are all these micropractices?

Well, you could start by looking at this website where 33 55 78 micropractices are listed. And the list is growing.

You may already have a micropractice near you. Or if not, maybe a micropractice will be starting up in your town soon. Then you'll have a choice between the new way of seeing a doctor:

• call to make an appointment and be surprised when the doctor answers
  
• get an appointment for 2PM that same day
  
• barely spend any time reading the magazines in the empty waiting room as you are directed to the exam room
  
• talk to the doctor who sits down and looks you in the eye and actually listens
  
• spend enough time to make sure everything gets brought up and even some things that you had forgotten about
  
• receive a thorough physical examination
  
• leave with all questions answered with an appropriate follow up date (if any is needed)
  
• since it's only 2:30PM you have time to go to the bank/post office/whatever

Or the current way of seeing a doctor:

• call for an appointment and wait on hold
  
• get an appointment for 2PM a week from now
  
• wait in crowded waiting room with sick people
  
• finally get called 30 minutes after the appointment time
  
• wait another 10 minutes for the doctor in the cold exam room
  
• spend 5 minutes with doctor who is busy looking through your chart or writing notes while you talk for 22 seconds before being interrupted
  
• received a rushed and abbreviated physical examination
  
• be left with unanswered questions because the doctor is late for his next patient
  
• spend another 10 minutes trying to reschedule another appointment because there wasn't enough time to talk about everything you wanted
  
• lather, rinse, repeat

Then we'll see who the crazy ones really are.

Untold Stories of an FP

The small town where I practice is a favorite place for the nearby entertainment industry to look for locations to shoot various movies and commercials. It's a lot cheaper to film in a pre-existing Craftsman style period house than to construct it on a set, for example. Still, I was surprised to get a call from a location manager looking for a doctor's office to use to film a Nexium commercial. She had gotten my name from the city's film liaison who knows me. (You know filming is big business when your city has a film liaison.)

Sadly, I had to explain that my office was really very small and probably not what they were looking for. She agreed saying how there'd be about 50 (!) people running around for the commercial shoot. So I gave her the name of another local doctor who has a larger office. Hopefully he'll have a good story to tell me.

Speaking of which, Hollywood is all about stories, some good, some not so good, some that are better left unspoken. Some of these stories come from real life, as I found out about a month ago when a producer for "Untold Stories of the ER" called me. He heard about me through this blog, and wondered if I might have any potentially interesting stories that could be suitable for his TV show.

Unfortunately, I explained, I didn't. As a family doctor, most of what I saw in the office was minor and not very exciting (except to the patients themselves) compared to the bloody life and death drama that occurred in the ERs. He agreed that wasn't quite what he was looking for, and I suggested he try contacting some other bloggers with ER experience. I was sorry I missed a chance to have my name in the credits of a TV show, but as I thought about it, I was glad NOT to have experienced very many "interesting" cases (as in the curse, "May you live in interesting times.").

Here are a few of the more memorable stories I have shared with medical students through the years:

1. During internship, there was a guy (whom I'll call Joe) with Munchausen syndrome who went from ER to ER complaining of a heart attack. As residents who rotated through the ER, we all saw Joe eventually at least once. Through the years, Joe had had every single cardiology test they could think of, including angiograms, and they were all outrageously normal. The worst part about it was he wasn't paying for any of it. Joe had no insurance, but the county hospital was required to treat him regardless of his financial status. And his tab was so high that there was no realistic chance of ever collecting a penny from him.

Dr. Raphael, our hospital's cardiologist, was fed up with this guy. He printed Joe's name and photo on a flyer and posted them in every local ER with a brief summary of his history. But even that didn't stop Joe, as no one had the guts to rule him out for an MI without giving him some morphine and running some kind of test. In those days, we didn't have troponin levels so it could take 3 days to rule someone out for an MI. Finally, Dr. Raphael told all the ERs to call him personally the next time Joe showed up. Sure enough, late one night Joe presented at a local hospital ER complaining of his usual crushing chest pain. Dr. Raphael quickly jumped out of bed, drove over and greeted the man. "Hiya Joe. Remember me?" Joe got a quick evaluation, then was quickly discharged by Dr. Raphael as having non-cardiac chest pain. A few days later, he tried a different ER. But who should show up again but his pal, Dr. Raphael. This time, Joe took one look at Dr. Raphael and without a word, stood up from the wheelchair and walked out of the ER. He was never seen in any of the local ERs again, but we knew that he was still out there somewhere complaining of a heart attack that wasn't real.

2. Donor kidneys have always been in short supply and usually given selectively to those who seem to have the best chance of a successful transplantation. Which is why I and my supervising resident were so surprised that Sam had gotten one. Sam was a schizophrenic who had trouble taking his antipsychotics, much less the immunosuppressants that would help prevent organ rejection. By the time Sam got to us this time, he was nuttier than a fruitcake and a danger to himself. He was incoherent and behaving irrationally, so for his safefy he was secured to his bed with a leather arm restraint. We had to get him back on his meds and wait for him to calm down.

One night, my resident and I were making the evening rounds and we looked in on Sam. He had a big goofy grin on his face as we asked how he was doing. "Aw, man, I'm feeling great. Everything's great," he said. "The doctors are great. The nurses are great. The food is great. Even the beer is great." Beer? We looked at each other. He hadn't had any visitors that we knew of. "Where did you get the beer?" we asked. "I don't know. It was just there. Kinda warm, though." Uh oh. "Was this beer kind of yellow and in a plastic container hanging off your bed?" "What? I don't know. I guess so." We looked at his empty urinal container hanging on his bedrail. No wonder his creatinine levels were so high. Sam managed to get better and was eventually discharged. But to this day, I don't drank beer.

3. Esther had was an older woman with diabetes, multiple heart attacks, and respiratory failure to the point that she was on a ventilator machine to help her breathe. She was swollen everywhere like a balloon from her congestive heart failure. She couldn't talk, couldn't eat, but she was awake although how much she was aware of we couldn't say. She had been in the ICU for 6 months, and despite many attempts at weaning her off the ventilator, she was not strong enough to support her own breathing. She was stuck in limbo. She had 2 children, a daughter who lived nearby and visited regularly and a son who lived in another state. After a while, the attending physicians felt that her situation was hopeless. It was left up to us, the residents, to try to secure an okay from her family to withdraw the ventilator so as not to needlessly prolong her suffering. Otherwise, she could continue in her miserable state for who knew how long.

Her daughter, who saw her mother's suffering in person, readily gave her OK. But her son, who never visited her, adamantly refused and wanted us to continue to do everything we could for her. When it was my turn to rotate in the ICU, I also tried to convince the son that keeping her alive like this was not a good quality of life, that turning off the ventilator was not killing her but allowing nature to take its course. On the other end of the phone, he steadfastly refused. After another month, I handed off my ICU duties to Dr. Kuartei (now Director of Public Health for the island nation of Palau). He decided to play hardball. He told the son that he was going to call him every day and give him an update on how his mother was doing. And he did just that, adding in various descriptions/opinions of how much she was suffering day after day. After 8 days of this, the son changed his mind and gave his consent to pull the ventilator. Surprisingly, Esther continued to breathe on her own off the machine, though with a lot of oxygen supplementation. She lasted for about a week before she passed, her suffering finally over. Modern medicine can be a wonderful thing, but it cannot substitute quantity of life for quality of life.

Those of some of the stories that I remember from my residency training days. If you want to share your interesting ER medical experiences with Untold Stories of the ER, they want your untold story. Who knows? Your spleen (or other body organ) might become a star.

Closing My Practice (to new patients)

Although I haven't posted in a while, I am still in business. In fact, I've had to close my practice to new patients for the past 2 months because I am having trouble keeping up with the amount of administrative work. I started my solo-solo practice about 2 years ago as an experiment to see if I could create a low overhead, low volume practice that maximized patient contact time. If I could keep my expenses down, the thinking was that I wouldn't need to see 20+ patients/day in order to survive.

The experiment is over for me. While there are energetic doctors out there who have the discipline and fortitude to keep up with medical billing and other administrative tasks, while also taking care of patients and chart documentation, I've learned that I'm not one of them. I think a practice like this (solo physician, no employees) could succeed in the right environment. This is very doable for a part-time or a cash-only practice.

Medical billing by itself is not hard. 90-95% of the time the electronically-filed claims get paid without a hitch. But the 5-10% of claims that get rejected take more time and energy than I have. Last week I waited on hold 30 minutes to speak to a Pacificare agent to ask why a claim was denied. She said they were waiting for a certificate from the patient because of a "pre-existing condition". Of course, when I called the patient, he didn't know anything about any certificate and said he would call Pacificare back. I will call again next week if I don't hear anything. But I don't have time to do this kind of chasing down unpaid claims.

So I plan to hire someone in the next few months to help part-time with billing. I am not ready to go to a cash-only model, or start charging a retainer or administrative fee, although I haven't ruled them out yet. Let's see if my fledgling practice can grow up a little so that I do less administration and more patient care. Hopefully then I can start adding new patients again.

Gordon Moore Podcast

For those of you who are auditory learners, here is an interview with Dr. Gordon Moore from The Journal of Medical Practice Management.

Gordon Moore is a Rochester-based family physician who pioneered a low overhead, low volume practice model as an alternative to the current medical practice model. An excerpt:

Kent Bottles, MD: Do you think that you're just different than most family physicians in that you like change or that you're more willing to adapt to change?

Gordon Moore, MD: Well, maybe to some extent. You're put me a little on the early adopter spectrum of Everett Roger's Diffusion of Innovation Curve. But I think that's true in a lot of us. There's some aspect in each of our lives where we can see ourselves as early adopters and there are parts of my life where I'm clearly a traditionalist or a laggard. And so I think if we as individuals can tap into that early adopter or early majority part, we can get on the bandwagon and start to effect real and lasting change.

On the other hand, I think they'd be somewhat motivated just by the plain misery of the way things stand currently. It's not a lot of fun out there. I've talked to lots of audiences across the country where the only thing they look forward to is getting a paycheck. And I'm pretty certain that not that many people got into healthcare just for the paycheck. I'm sure it's nice but I think that most people who become physicians have some sense of mission, wanting to help reduce suffering and improve health. And that's a very noble mission that I think has gotten lost because of the fee of finance and overhead and all these other things that have obscured what it is we're really after.

Kent Bottles, MD: Well it sure seems to me as I talk to physicians that many of us are not that happy with what we're doing and I take my hat off to you for at least trying to make your life more interesting and more enjoyable, and make your patients have a better relationship with you.

The Bigger Picture

I am on vacation and enjoying the final chapter of the story known as March Madness, and my alma mater is once again reaching for that National Championship in basketball. It has been a wild but exciting ride, with the Championship game to be played tomorrow night against the Florida Gators. As remarkable as this basketball season has been for UCLA, some things stand out a little more, such as when UCLA overcame a 17 point deficit to defeat Gonzaga. While the comeback was one for the ages, what happened after the game was just as memorable. Adam Morrison, Gonzaga's star player and future NBA draft pick, had crumpled to the floor in disappointment and tears after his team's defeat.

UCLA's Arron Afflalo and Ryan Hollins, in the middle of celebrating their come-from-behind win, went over to Morrison to help up the player who had caused them fits for the previous two hours. The gesture wasn't lost on Morrison.

"At first I didn't realize who it was," Morrison said. "That's just a sign of a great program and great people, as far as they're concerned.

"They had enough guts as a man in their moment of victory to pick someone up off the floor. If I could thank them I would. That's a sign of great people and great players. That's more than basketball."

As the legendary former UCLA basketball coach, John Wooden, used to say, "What you are as a person is far more important that what you are as a basketball player."

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When I used to work at Kaiser I had medical students shadow me, and one day one of them asked me why I was always so persistent in trying to get patients to stop smoking. Did I have a relative who died because of smoking, he asked. No, I didn't. In fact, few of my friends or relatives smoked. But I have known many smokers and ex-smokers through my medical career and have seen what smoking can do to them. I explained to the student that the patient's cold or back pain would be gone within a week no matter what we did. Oftentimes what we did as doctors, the prescriptions we wrote, the tests we ran, wouldn't change a patient's life at all. But if we could get someone to quit smoking, then that could save their life someday. That was the bigger picture.

That is why I was happy to receive this e-mail from a patient recently:

I wanted to send you an email to follow-up with you. I'd like to sincerely thank you for your advice regarding the diagnosis of my shingles and it being caused by stress factors in my life. Immediately following my appointment with you, my husband and I sat down and had a long discussion about our priorities and causes of stress. We decided that the majority of the stress in our lives was from the pressures of owning our home in our current financial position. We decided it was unwise and unhealthy to continue on that path...the health costs were simply not worth it!

After prioritizing our lives, we decided to put the home on the market and live in subsidized graduate student family housing at my husband's university. He also accepted a new position there which had him doing an extensive commute which meant he was rarely home...also adding to the stress factors.

Anyway, I just wanted to follow up with you and sincerely thank you for the time you spent talking with me about the causes of my shingles and how to takes steps to get myself healthy, including minimizing stress factors in my life. I sincerely appreciate your care. You will be glad to know that the symptoms are healing, though I still have numbness. I do feel these are slowly getting better, though.

This person's shingles probably would have resolved with or without my intervention. But her stress was affecting her health and eventually might have led to worse things, such as headaches, depression, obesity (due to stress-induced overeating), cancer (due to a depressed immune system). I'd like to think that I helped her see the bigger picture, and helped her get to where she wants to be. Hopefully, I can do that for others, too.

As a physician, having the time to be able to talk with people about their lives makes all the difference, and I am grateful that I have the kind of practice where I can do that. My wish is that all physicians will someday be able to have the time to do that, too, although I think we still have a long way to go before that happens.

To paraphrase Coach Wooden, "How you treat someone as a person is far more important that how you treat them as a patient."

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Whether or not UCLA wins their Championship game tomorrow, as Coach Wooden used to say, as long as they did their best, they are a success. This team has already demonstrated to me with their class and character that they are winners.

Go Bruins!

Marathon

It was a challenge but I finally made it to the eve of the LA Marathon without getting a cold/flu, which I feel like I've been dodging for the past month in the office and at home. I've been feeling as if I might be coming down with something over the past 2 days, but no fever or shaking chills yet. That may change by tomorrow, though. At least the weather report says it won't rain. The last time I ran the LA Marathon it rained from start to finish, but I finished anyways. I've always finished every marathon I've ever started, but I am not a very fast runner. In fact I usually run the first half, then run-walk-hobble the second half. But once you've finished one, you tell yourself, "I can do this."

That's kind of how I feel my solo practice is turning out to be, a marathon. I started strong and enthusiastic, but now I'm way out there in the middle of the course. I'm a long long way from the start and the end is not in sight. I don't have the same energy I had at the outset. My fingers tend to cramp up more from typing such long progress notes (one of the drawbacks of EMRs is limitless space to write). I struggle to catch up with billing and rebilling and chasing down denied claims. Unlike tomorrow's marathon, though, this race won't be over after tomorrow. But just as I will do tomorrow morning (after I make a 6AM home visit to repack an elderly patient's I&D wound), I will just keep plodding along until I reach my goal.

By the way, how much further do I have to go anyways? That far?

Oh, man. I need some glucose.

Happy Anniversary!

Two years ago today I left my secure but overworked job as a staff physician in a managed care organization and opened a solo family medicine office ala the Gordon Moore hi-tech, low overhead model.

As I've pointed out before, my practice is atypical of most solo practices (even for a Gordon Moore-type practice) so this should not dissuade anyone who might be thinking of going solo. Most of the solo physicians that I know of who are trying this model generate a higher income than me. I am fortunate to have a spouse (Hi, honey!) who has a well-paying job so that I have the luxury of being able to grow my practice slowly. So that being said, here are my current statistics (last year's numbers in parentheses):
Unique patients seen since practice opened: 523 (201)
Patient visits: 1194 (357)
Average # visits per week: 18.1 (14)
M:F ratio: 49.5% male, 50.5% female
Average age: 37.7 years old
Oldest patient: 97 years old
Youngest patient: 2 months old
Sources of patients: Word of mouth 32%; Relatives of current patients 22%; Insurance provider list 19%; Paid advertisements 7%.
Payor mix: PPO insurance 81%, Cash 15%, Medicare 4%, HMO 0%
Average charge per visit: $133.73 ($114.27)
Average payment per visit: $74.31 ($70.06)
Total charges: $112,400 ($40,785)
Total collections: $54,976 ($17,515)

Bottom line, my practice continues to grow slowly but steadily. I have a fairly young patient panel which explains why I've only had to admit 5 patients in the past 2 years. This means very few phone calls in the middle of the night, but I still need 3 more hospitalizations to upgrade my hospital staff privileges from provisional to active. I'm pretty sure I made a profit this past year, but not a big one. This year should be even better. Everyone has said it takes 2-3 years for a new practice to become profitable, so I seem to be on pace.

Medical practices have a life cycle, too. As another solo doctor has observed, "I do remember this major all-consuming time of figuring out how to open the practice, followed by the major all-consuming job of figuring out how to bill, make appointments, get efficient, feed the family, survive. Now, it's just figuring out how to keep up efficiently with the health needs of over 1000 people." I am at the "get efficient" stage.

Time to get to work.

I'm Back

I haven't posted in a while, but I am still here, plugging away in my solo one-doctor Gordon Moore-type practice. Not much has changed since I last posted. I am still seeing about 20 patients/week, although it dropped a little when I temporarily closed my practice to new patients in November and December. I did that in order to catch up with my medical billing, although I seem to have fallen behind again. I have come to the realization that I am not disciplined enough to "do all of today's work today" and am seriously considering getting someone to help me with some of the billing/administrative work. But that's something that will come later.

In the meantime, I hosted another 3rd year medical student (this time from USC) for a 5 week family medicine rotation which just ended last week. Although we didn't have a whole lot of patients (which I feel bad about), hopefully we made up for it with quality over quantity. As with other students who have rotated with me, I asked her to write down some of her impressions in working in this type of medical practice. This time, in response to a previous comment by Dr. Mathew Wang, I made sure that I completed my student evaluation BEFORE receiving her write-up so that it would be as unbiased as possible.

"A completely different type of practice! When I first called Dr. Seto to set up my family medicine rotation, he was hesitant, saying he wasn't sure if I would want to come to his office. He went on to describe that he ran a solo practice, no staff. He said he also usually only saw about 4 patients per day, never more than 8, and sometimes made housecalls. This sounded interesting to me, so I signed up. It was great. The level of patient care he could provide was second to none I have ever seen. The open access model was incredibly appealing. His patients were very satisfied. I thought it was great that a patient could call with a complaint, and Dr. Seto would say, "Can you come in right now?" Amazing. The amount of time spent with the patients was about four times that in most offices I've seen. This was both great for the patient, and great for me. As a medical student I appreciated being able to work through the problems and not rush, and being able to observe Dr. Seto give a truly comprehensive evaluation to the patients. I imagine an outing to the doctor for most people is a one to two hour trip or more. The difference with Dr. Seto is the one to two hours is all with him, not in a waiting room. I felt lucky to be able to get a glimpse of this type of practice is run. Yes, there was downtime, but I always had reading to do. This was when Dr. Seto would do some of his administrative work. I hope to see more practices like this one in the future."

Mariah Baughn
MSIII

Thanks for your comments, Mariah, and for graciously allowing me to post your name.

I hope to see more practices like this in the future, too. That is why this blog exists. Because I believe the practice of medicine can be much better than the way it is being delivered to the majority of Americans right now. I don't know if this is the best way but I think my patients are happy, as am I. How many patients and doctors can say that? I think it's interesting that whenever I run into someone I used to know at my old job, they often ask me, "Are you happy?" to which I always answer a truthful "Yes". So this venture is a work in progress, a story that is still being written. Hopefully, one with a happy ending. Okay, I'm ready to start the next chapter.