Sunday, October 15, 2006

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.

Monday, October 09, 2006

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?