Terribly Inefficient for Society

Gerald left the following comments:

I read about your idea several years ago. Here's the deal, that bugged me from the start, and still gets to me.

While on the one hand you do spend more time with patients, and likely make better decisions, you also miss out on a crucial element of civilization. Division of labor! Why on earth do you have to waste hours at a stretch calling insurance companies yourself, or waiting for patients to fill out forms and stuff? Also, simple tasks like bp and blood draws and injections and a host of other things can be done just as effectively by a nurse. I mean, what's the point in about 11 years of education, otherwise?

Basically, it seems like there is in principle a good reason why a medical practice almost always has at least a couple of employees. Course, if you hired two people (a nurse and a receptionist/biller) then you'd have to see more patients to pay the additional overhead.

Furthermore, hiring 2 employees and so forth makes a business have a lot of overhead (which would be less if there were 2 doctors and shared staff). Also, we haven't discussed the fact that you could also do a lot more with advanced medical equipment, which costs stacks of money. Ultimately, once it is all said and done you see why the basic clinic with several doctors, shared support staff, ect is the minimum "cell size" for most medical practices.

Ultimately, it's a circular argument. I see why you do what you do, even though "in theory" it's terribly inefficient for society.

Thanks for your comments, Gerald.

First of all, I believe that one size does not fit all, and that it is OK that some people prefer doctors who answer their own phones and enjoy getting to know their patients, while other patients prefer doctors who have huge medical offices with lots of employees. Kind of like how some people prefer The Parkway Grill while others go for McDonald's. It's just food, after all, right?

Second, the more advanced medical equipment you have, the more you want to use it in order to make enough money to justify buying it in the first place. Then after you've paid it off, you want to make more "stacks of money", so that you can buy even more advanced medical equipment, which you then want to use so you can make enough money to pay for it, etc.

That is one of the premises of the book, "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer", which one of my patients told me about (thanks, RS!).

Is a CT scan always necessary after your child suffers a bump on the head? Should you think twice before undergoing surgery for lower back pain? Are your elderly parents going to be allowed to die at home, or will they spend their last few weeks in a hospital, hooked up to machines and tubes, subjected to painful, unnecessary procedures?

These are the kinds of questions you may find yourself asking once you’ve read Overtreated. Each year, our medical system delivers an enormous amount of care that does nothing to improve our health or lengthen our lives. Between 20 and 30 cents on every health care dollar we spend goes towards useless treatments and hospitalizations, towards CT scans we don’t need, towards ineffective surgeries—towards care that not only does nothing to improve our health, but that we wouldn’t want if we understood how dangerous it can be. This is the surprising and deeply counterintuitive message of Overtreated.

Of course, almost everything in our personal experience says just the opposite, that far from delivering too much care, our medical system isn’t giving us enough. Forty-seven million of us don’t have coverage, and even those of us who do have health insurance feel as if our insurers and doctors are continually trying to deny us treatments and tests and drugs that could help us.

Yet as award–winning journalist Shannon Brownlee shows in this remarkable book, much of what we think we know about health care is simply wrong. With probing insight and facinating examples, Brownlee unveils its topsy-turvy economics, where the supply of medical resources—beds, specialists, intensive care units—determines what care we receive, rather than how sick we are and what we actually need.

I have been tempted to do EKGs on otherwise healthy men and women during their physicals, just because I know that it can generate another $30 to help pay for my $2000 EKG machine. But I don't because I know there is no indication or evidence to justify it. What if I had a $35,000 DEXA scanner? You bet I would screen for osteoporosis a lot more, in women AND men.

Lastly, I wonder which of the following is the most "terribly inefficient for society", hypothetically speaking?

1. Doctors who spend 90-100% of visit time with a patient in order to get to know them better so that they can provide their patients with the medical care they want and need in an enjoyable and sustainable practice.

2. A doctor who uses 3 part-time nurses and a medical assistant to take histories, document encounters, instruct the treatment plan so that he can "see" an average of 38 patients a day, liberating him to spend an average of about 5 minutes per patient (and boosting his income by 70 percent!).

3. A healthcare system that takes money from patients, then uses 1/4 of it to pay people to do their best to give as little of the rest of the money as possible to the doctors who actually take care of patients, forcing them to hire people to waste hours at a stretch calling the first group of people who explain that they won't pay the doctor because they entered the wrong code.

4. Killing all persons with defective genes, selectively breeding people to be smarter, stronger, more resistant to disease, forcibly limiting population size so as not to overuse limited natural resources, having a central world dictatorship that eliminates all wars, famine, poverty, crime and reality TV shows. In other words, world peace.

I vote for number 3.

Congressional Order of Merit Scam

You may be getting a phone message like this in the near future (as I did a few days ago):

"My name is Carl Sibley and I'm with Congressman Tom Cole and the National Republican Congressional Committee in Washington. For your role as a business leader in California, we want to recognize you with our highest honor, the Congressional Order of Merit. I need to speak with you about it as soon as possible. Again my name is Carl Sibley and my number is 888-383-4164. Please call me as soon as you get this message. Thank you. Goodbye."

If you call back, you will be told that to get the award, you have to listen to a pre-recorded message from Rep. Cole, agree to add your name to an advisory committee, and you have to make a donation. The worst part is, there is no such award as the Congressional Order of Merit that is recognized by the US Congress. It is something made up by the National Republican Committee to raise money.

No free lunches. No free awards.

This is the kind of behavior we see from someone who is supposed to be responsible for fixing our broken healthcare system. This is how it got broken in the first place

The Greatest Healthcare System in the World

Unfortunately, that title doesn't belong to the one in the United States.
(Comic by Ted Rall)

Medpundit Goes Micropractice! (sort of)

Medpundit had a taste of the micropractice way of life, but doesn't sound like she enjoyed it. That's probably because she was seeing her usual amount of patients with less help (ie. short-staffed) rather than the smaller volume (less than 10 patients/day) that most micropractices enjoy. So all the pain but none of the joy of a micropractice = bad experience.

The truth of the matter is that micropractices work only for micropopulations. Most people who practice that way limit themselves to 200-500 patients, whereas traditional practices handle 1500-2000. So which is better for the public good? A practice that can treat more patients and provide jobs or one that sees few patients and has no employees?

I don't know who decided that 200-500 patients is a "micropopulation" while 1500-2000 patients is a "normal" population. When I was at Kaiser, I knew some FPs who had patient panels of 3000, which I thought was ridiculous. Is that a macropopulation? Wouldn't it be more efficient to have a patient panel of 10,000 and have physician extenders do most of the grunt work while the physician supervises?

The truth of the matter is that micropractices work only for those who value a slower-paced, unrushed, more thorough patient-physician encounter. Not everyone wants to eat at McDonald's; some people prefer the little old-fashioned restaurant down the street. Not everyone wants to be a patient in a traditional practice where they wait a traditional 30 minutes for their traditional 5 minutes with the doctor who traditionally is running behind schedule.

I maintain that it is better for the public good to have happy doctors and happy patients pioneering a new practice model which can be an alternative to the current model where both doctors and patients are too often unhappy.

We've Been Boarded by Pirates!

What do you get when you cross "Talk Like a Pirate Day" with Universal Health Care? Why, a song, of course!



You also get this video below describing the exploits of the dread pirate, Captain Blue Shield:

Going It Alone

From the Seattle Times: "Doctors find going solo painless":

If patients getting a checkup at Dr. Donald Stewart's clinic in Sammamish feel at ease — like they're visiting the family doc at his home — it's because they are.

On July 28, Stewart began his new life as a downsized solo physician, chucking his previous career running a group clinic.

With high-tech help and by cutting his overhead — such as buying furniture on Craigslist.org — he now can work out of what used to be the mother-in-law apartment in the basement of his home.

"It's the most fun I've had since I started in medicine 25 years ago," said Stewart, who is 57. "Now, I'm having enough time with patients so I can enjoy working with them."

Stewart is part of a small, but growing, trend among family-practice physicians.

They're going it alone.

OK, going solo as a micropractice is not painless but it is very, very fun.

At her Bellevue clinic, Dr. Gwen Hanson also is not accepting new patients. She went solo in December 2004.

Her goal is to let patients make same-day appointments, Hanson said. If patients have to wait more than 15 minutes after arriving, she gives them a $5 Starbucks gift card. If they bicycle or walk to her office, they also get a gift card.

It's not the $5 that matters, Hanson said, it's that patients know she appreciates them.

She has 400 to 600 patients, Hanson said. She works two full days and three half-days. She takes seven weeks of vacation a year. She can spend time with her husband and three teenage daughters.

Hanson said her overhead is around $1,800 a month, which includes office rental and malpractice insurance. After those expenses, her before-taxes annual income is $110,000.

Drs. Stewart and Hanson are both on the IMP Map.

Hmm, 3rd article about micropractices in the past week. Okay, I think this is a genuine trend now.

Smaller is Healthier

Anonther micropractice article from the Lincoln County News in Maine.

It might seem like a good idea at the time, when the thought first enters an administrator’s mind, but layers of bureaucracy and multiple steps in the chain of command can eventually mire the patient-doctor relationship in layers of inefficiency.

The answer is not more bureaucracy.

“The goal is to give patients unfettered access to the doctor,” said Dr. Walter Love of Waldoboro, “to get rid of all the people in between the doctor and the patient.”

Following a new model for Family Medicine that has grown into a national trend over the last few years, Love and his wife, Dr. Margaret Webb, set up a shop as a “micropractice” in Waldoboro last year when they established Medomak Family Medicine.

Drs. Love and Webb are both on the IMP Map.

Not feeling rushed

From the Albany Times Union: "Doctor cuts staff, buys time"

One thing about Dr. John Pramenko's new practice: Patients won't feel rushed.

The 41-year-old family physician is opening one of the region's first micro-practices, a relatively new model in health care that has no nurses, office manager or receptionist. Patients make appointments online, and records are kept electronically.
Without the staff, the practice can operate much more cheaply. And with lower costs, doctors can afford to take fewer patients a day. That means more time for each patient.

"I have colleagues who see 30 patients a day," Pramenko said Thursday. "When you're seeing that many patients, it's really hard to have a good relationship. Every visit, you have your hand on the doorknob."

These days, in my micropractice I rarely ever talk to patients with my hand on the doorknob.

The micro-practice movement began in 2001 with a Rochester doctor named Gordon Moore. Like Pramenko, Moore had been bothered by his limited time for patients. It was his idea to use computer technology to create a self-sufficient practice.
"A lot of doctors are becoming increasingly disenchanted in what they're experiencing," Moore said. "I was about helping patients. A lot of things happening around health care have made it very hard to help patients. We don't have time."
Since he opened the first micro-practice in Rochester, Moore has acted as a spokesman for this new style. Now he sees patients only a quarter of the week, and uses the rest of the time to help other doctors set up similar practices around the country.
Today, more than 100 exist around the United States, including Dr. Padma Sripada of East Greenbush. A computer list-serve on the topic has 475 members, with doctors signing up at a rate of three to four a day, Moore said.

Drs. Pramenko and Sripada are both on the IMP Map.

What makes this even more interesting is that only 2 weeks earlier, the same newspaper published a story about a family doctor closing down his 26 year practice due to poor reimbursement. His office is located about 45 miles away from Dr. Pramenko.

Sometimes I wonder if the Ideal Micropractice movement will really be able to bring about meaningful change in America's healthcare system, or if we're just part of primary care medicine's slow death spiral, and all we are doing is delaying the inevitable. Whatever, whichever, I'm not going down without a fight.

Bad (But Funny) Advice

I saw a patient today who was having heart palpitations, probably due to drinking too much coffee. I basically advised the patient to cut back on caffeine, but had I known, I would have employed visual aids such as the one below:



I know some patients who would benefit from these instructions in "How to Explain Yourself to a Doctor". But he left out "Answer the question the doctor asked you without rambling aimlessly through 3 or 4 other unrelated topics."



More "Basic Instructions" here.

She Loves Her Doctor

Here is a good description of "usual care" vs. micropractice care from a patient's perspective:

I've waited for three hours for an appointment. I have had the temporary "doctor of the day" in a group practice override written instructions left by my midwife (who I can't see because she has to be scheduled five weeks in advance -- in fact my monthly appointments have to be "fit in"). A number of baby books have chapters on "How to select your child's pediatrician". You might as well save your breath. No matter how carefully you research your pediatrician you will see him or her only for scheduled shots. The majority of visits (head bonks, ear infections, weird rashes -- the most important visits from the patient's/parents's point of view) can't wait three weeks, so you will be seen by a rotation of nurse practitioners, none of whom will be working for the office next time you call. I've waited six weeks to see a doctor I'd hand picked to discuss surgery options, only to discover someone had changed my appointment so I'll be seeing the newly minted MD resident instead.

But it doesn't have to be like this. And right now, it isn't. Friends of ours recommended a doctor they "really liked" -- little did they tell me this was going to be a life-changing experience for our family. The first indication was her receptionist telling us that the first appointment would be for an hour...

Any more uplifting experiences with micropractices out there?

Solo on Vacation

One of the things doctors considering solo practice always want to know about is, "What about vacations? Who covers for you when you are out of town?" Some even wonder, "Can solo practitioners even go on vacation?"

In my 4th year of solo practice, I am again on vacation, this time visiting relatives on the East Coast.

In my first year of practice, I had so few patients (plus I didn't know any other solo physicians in the community that year) that I just went on vacation to Banff, Canada and had all my calls forwarded to my cellphone. No one noticed I was even out of town. But then again, I was only seeing about 1 patient a day that first summer. Seeing the Aurora Borealis and going horseback riding with my family are still unforgettable memories for me, and I am glad I was able to be with them.

By the 2nd year, I arranged for a couple of the local solo family physicians to cover for me when I went on vacation, and I agreed to reciprocate when they went out of town. It was mutually beneficial and I never got inundated with calls from the other doctors' patients. I know they didn't get a lot of calls from my patients since I made it clear I would still be accessible by cellphone and e-mail. But the longest trip I took that year was a 4 day trip to San Francisco for the Annual AAFP Conference.

By the 3rd year, I figured out how to access my office computer remotely so that I could receive faxed lab results and other reports as long as I had internet access. Hotel rooms with internet access are pretty common now. I got to go with my family to Walt Disney World and Bar Harbor, Maine last year.

This year is a little different in that I do not have cellphone access where I am staying, so I have to call in on a landline to both my office and cellphone lines to check for any messages periodically throughout the day. Fortunately, there have been few messages, hopefully because all my patients are feeling well.

Summer tends to be a slow time of year for visits to the doctor, anyways. One of these days, I'd like to try doing an online visit using my iSight video camera and maybe I won't ever have to be on vacation at all. But wait, that's probably not a good thing, is it?

Still I wonder which option more people would prefer: seeing their own doctor via online videocamera or being seen by a unfamiliar midlevel provider in a Walmart clinic? Time will tell.

For longer vacations, I have heard of other doctors using locum tenens services. Maybe someday I'll take a long enough vacation to consider that.

I have been able to spend some of my vacation catching up on my reading. I had gotten Stardust before I realized that it was being made into a movie. Luckily I finished reading it before I read any negative/positive movie reviews and my review of the book is Two Thumbs Up. I also plan to try to implement some of the elements of the Getting Things Done system with the donationware iGTD program. One can dream, after all....

In the meantime, I already have 13 patients scheduled for next week. But for now, still on vacation for a few more days.

Another Micropractice in the Pacific Northwest

Dr. Chad Magnuson just opened his new micropractice in Vashon Island, WA. Here is a news paper article about his new venture which is starting to sound very familiar (at least on this website):

In a world of increasingly high-tech medicine and huge practices teeming with professionals, Dr. Chad Magnuson’s new office in downtown Vashon provides a striking contrast.

Walk into his waiting room — a hallway, really, with two chairs — and no receptionist greets you.

Enter his exam room — a freshly painted yellow with maple floors and a richly hued throw rug — and see only Magnuson, his exam table and a computer that holds the latest in practice-management software. There are no nurses, no labs, no large pieces of medical equipment.

“There’s just me,” Magnuson says with a smile.

Dr. Magnuson's website is here. You can find other micropractices at www.impmap.com.

Another Micropractice in New York

Here is yet another internet article about a doctor doing the "micropractice thing".

One thing you're not likely to do if you have an appointment with family physician Dr. Janice Pegels is spend a lot of time in her waiting room.

"I don't like waiting, so I don't like to make my patients wait, either," she says.

You'll also be booking your own appointment online and will get a reminder call from the doctor herself. When you come into the office (housed in a charming vintage home), she'll give you time -- lots of it.

"Appointments for new patients typically last for 60 to 90 minutes, while established patients typically get 30 to 45 minutes," Pegels explains. If your lab results are within the normal range, you'll receive them via an encrypted e-mail service and, if not, the doctor will call you directly.

If you're thinking this doesn't sound like a typical visit to the doctor, you're right. Pegels is one of approximately 100 physicians throughout the country who has adopted a new kind of practice, known as an Ideal Micropractice (IMP). She acts as her own receptionist, office manager and medical assistant. By doing so, she is able to keep her costs down, which translates into longer office visits for her patients.

High and Dry

If I don't answer my office phone for the next few days, it's because my VOIP phone provider (SunRocket) suddenly went out of business. Grrrr!

The problem with being on the bleeding edge of technology is that frequently you get cut.

Now I have to decide if I should go crawling back to the safety of a landline, or take another chance with a different VOIP provider. I'd consider VOIP with my cable provider, but for some strange reason they don't offer VOIP for business users although they do for residential customers.

This recent Google-acquisition looks promising, but they're only in beta. (No financial interest in Google!)

Two More Micropractices

Here's something unusual: TWO newspaper articles about micropractices in one day.

From today's Los Angeles Times: "It's about time, say doctors in vanguard"

In a 150-square-foot tin-ceilinged office in a building that once housed a speakeasy, Dr. Moitri Savard checks her laptop to see whether any patients have scheduled themselves to see her.

Wait, scheduled themselves?

Yes. Savard's patients decide when they want to see her and then let her know by filling in a date and time on a calendar on her website. Patients with no computer access can phone for an appointment.

Savard, 36, a graduate of the Stony Brook University School of Medicine, is in the vanguard of a small number of physicians who are experimenting with a new family-practice business model.

It's called a micropractice.

Savard has no nurse but shares a receptionist with several other solo practitioners and does her own paperwork. Mostly, she runs her office electronically — lowering her overhead because she has no salaries to pay.

And the Idaho Statesman: "Boise physician finds low overhead lets him give patients more time"

Dr. Chris Peine sits behind a desk in his 500-square-foot office. He's alone. The glass doors are dusty and waiting to be wiped clean, but he doesn't have much time to do it today. He is too busy answering phones and e-mails, treating patients, vacuuming and taking out his own trash. Peine doesn't have a single employee.

Peine (PIE-nee) follows a new model of health care called the "ideal micropractice," one of a small but growing number of physicians nationwide who are shucking large offices and big staffs to simplify their medical practices and spend more time with patients.
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Before moving to Boise with his wife in September 2005, he was a physician at a large cash-only practice in Indianapolis that did not accept insurance. He met with a handful of patients every hour, he said, and the lack of face-to-face time strained his relationships with his patients.

"I wanted to really simplify the whole health care experience," he said.

"Complexity interferes with the doctor-patient relationship."

Boy, does it ever. But thankfully, not in a little slice of Queens and Boise.

A Taste of Their Own Medicine

To this day, I still remember what it was like having a rectal exam done on me by a fellow classmate in medical school, and I think it has made me a better doctor. No camping out by the prostate for me. I think that is the rationale behind this idea of having resident physician get a taste of what it is like to be a hospital inpatient.

Clad in hospital gowns and assigned various ailments, six doctors at Presbyterian Intercommunity Hospital were poked for blood tests and had their vital signs checked regularly when they spent a recent night as patients.

"I think it's a really good experience for us," said Dr. Megan Stone, who was attached to a heart monitor for "a sudden onset of chest pains."

The fake illness was part of a special orientation for resident physicians in the Whittier hospital's Family Practice Residency Program. Six doctors from the program pretended to be patients and stayed overnight Sunday to get a taste of what it's like to be a patient, said Dr. Patti Newton, associate program director of curriculum.

"It will stick in your head if you experience it, rather than hearing a lecture," she said.

But if you really want doctors to have more compassion for patients, make them schedule themselves for an annual physical (without telling anyone they are a doctor) and see what it is like.

But the most effective way to improve healthcare in the US: require the President and all members of Congress to use Medicare.

EMR on iPhone

Just what I need: an excuse to get an iPhone. "But it's for work, honey! Honest! Only $5999!"

"Hmmm, okay, maybe just the iPhone then?"

Well, it's worth a try.

Who Killed Health Care?

Found this article by way of Dr. Ben Brewer, a family physician who also happens to write a column for the Wall Street Journal called, "The Doctor's Office".

Is Health Care Making You Better -- Or Dead?

We asked [Regina] Herzlinger, the Nancy R. McPherson Professor of Business Administration Chair at the Harvard Business School, to discuss her latest work and her more than 30 years of research in the health care industry.

Q: What your book points out is that all the players and other parts of the system are interdependent. And although you may have a great doctor with the best intentions, the system may not allow him or her to give the quality of care they would like to.

A: Absolutely. My heart really goes out to physicians nowadays. They're like little hamsters running on a track, and they're measured for their productivity, how many people they see. They have lousy information systems to back them up. And then they have a public policy establishment that more or less continuously deprecates their ideas and squeezes down their income. Not a great occupation to be in.

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There's always a tipping point, and we've hit the tipping point here. I've read reviews of Michael Moore's Sicko. I haven't seen it as yet. But what strikes me is that his diagnosis and my diagnosis are very similar. He diagnoses the same problems—heartless, insensitive, greedy, self-serving status quo—but his cure is a government-run system, I gather from hearsay. I agree with the diagnosis, but my cure is, yes, everybody should have health insurance, but they should control it for themselves. It should be run by the people, not by the government.

I'm an economist; I take economics very personally. My own view is that the economic consequences of our present health care system are disastrous and grievously injure the economy. It's not getting any better, and none of the cures work.

Wow. Maybe health care reform and universal coverage will really happen in my lifetime.

Being There

I'd like to think that every family doctor experiences this kind of moment at least once in their career. For many of us, more than once. For someone who doesn't practice medicine, they may not "get it". But there is power in just simply caring, even when there is nothing else that can be done.

This is the power of a man who cared, and which is so strong, some of his magic still lives in his violin.

This is what being a family physician is all about. This is what has been dying from the modern healthcare system.

We need to bring it back.

Pay vs Worth

As further proof that our healthcare system is totally screwed up, I present the following.

On the one hand, we have a family doctor making $500 house calls in New York City which one patient describes as "ideal medical care". (Hint: it's not.)

Then as a polar opposite we have another family doctor in Chicago who chose to go "bare" (that is, go without any malpractice) in order to maintain his solo practice when his premiums jumped from $10,000/year to $40,000/year. Like Dr. Schleider above, Dr. Macumber doesn't accept any third party insurance. Unlike Dr. Schleider, he charges only $40 per visit.

What do they have in common? It is becoming increasingly harder for primary care doctors to practice "in the middle", and stay within a dysfunctional system that forces them to work long hours with inadequate pay. You either have to cash out and go for the high end, or do something radical like not have any personal possessions worth protecting.

In my former job as a staff physician, I calculated that my actual pay rate worked out to about $56/hour if you counted my actual hours worked. While that sounds pretty good, it makes me wonder why anyone would want to subject themselves to at least 7 years of postgraduate studies, amass mounds of student debt and live with the constant threat of being named in a malpractice suit when they could make $60-70/hour doing this.

More Micropractice Publicity

Another opportunity for me to talk about ideal micropractices, this time on public radio's, "Marketplace". Thanks, Pat!

But I'm even more proud and honored to be mentioned (albeit briefly) in this soon to be literary classic.

Blue Pill or Red Pill?

(With apologies to the Wachowski Brothers)
Dr. Moore: I imagine that right now you're feeling a bit like Alice. Tumbling down the rabbit hole? Or perhaps like you’ve been running on a hamster wheel?
Dr. Neo: You could say that.
Dr. Moore: I can see it in your eyes. You have the look of a doctor who accepts the amount of work he gets because he's expecting to get paid a fair price for his services. Unfortunately, this is far from the truth. Do you believe in fate, Dr. Neo?
Dr. Neo: No.
Dr. Moore: Why not?
Dr. Neo: 'Cause I don't like the idea that I'm not in control of my life.
Moore: I know exactly what you mean. Let me tell you why you're here. You're here because you know something. What you know, you can't explain. But you feel it. You felt it your entire life. That there's something wrong with the world. You don't know what it is, but it's there and you want to use your knowledge to help make people's lives better. But there is something in your way, holding you back. Like a fallen tree across the road -- blocking your path. It is this that has brought you to me. Do you know what I'm talking about?
Dr. Neo: The Medical-Industrial Complex?
Dr. Moore: Do you want to know what it is?
(Dr. Neo nods his head.)
Dr. Moore: The Medical-Industrial Complex is everywhere, it is all around us. Even now, in this very room. You can see it when you look out your office window, or when you turn on your television. You can feel it when you go to work, or when you go to church or when you pay your taxes. It is the world that has been pulled over your eyes to blind you from the truth.
Dr. Neo: What truth?
Dr. Moore: That you are a slave, Dr. Neo. Like every other medical graduate, you were matriculated into indentured servitude, trained inside a prison that you cannot smell, taste, or touch. A prison for your medical career. (long pause, sighs) Unfortunately, no one can be told what the Medical-Industrial Complex is. You have to see it for yourself. This is your last chance. After this, there is no turning back.
(In his left hand, Dr. Moore shows a blue pill.)
Dr. Moore: You take the blue pill and the story ends. You wake up in your on-call bed and believe whatever you want to believe. (a red pill is shown in his other hand) You take the red pill and I will show you a way out. (Long pause; Dr. Neo begins to reach for the red pill) Remember -- all I am offering is the truth, nothing more.
(Dr. Neo takes the red pill and swallows it with a glass of water)

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What happens after you swallow the red pill? You may start posting messages like this one:

I work in an oppressive corporate IPA environment- I am nothing but a worker bee. I spend more time in paper work than patient care. I gotta go!

I am developing my sea legs- gathering information with the hope that I too can be an IMP.

Currently, I have panel size of about 4000 (yes, you read that correctly). I cannot imaging doing "today's work today" - I go crazy everyday w/ an already full schedule and patients wanting and demanding to be seen ASAP. Most of my work is "in the future". When I read Gordon Moore's reply "huge pent up demand that has been consistently shoved to the future and very limited capacity "today," hence poor access.", it struck a cord.

I never wanted to be in the situation I am now, overwhelmed by the demands of patients. I feel as a child who had the experience of accidentally going underwater, not knowing how to swim. Subsequently, being near water is frightening. Not being able to accomodate patients is very scary.

Otherwise, I think I can do an IMP.

Yes, Dr. Neo. You can.

A Practice Update

Well, I had meant to post something on my practice's 3rd year anniversary (Feb 14th) but . . . better late than never.

I recently got mentioned in various media sources: a WSJ article on micropractices, a podcast on the CAFP website. (Perhaps that's why you're here?) So this is an indication to me that word about Micropractices and Practice Redesign is continuing to spread.

Brief background: approximately 3 years ago I left my position as a staff physician in a managed care organization (Kaiser) and opened a solo family medicine office a la the Gordon Moore hi-tech, low overhead model AKA the micropractice model. For the record, I still think Kaiser is a fine organization with many excellent physicians and employees working there. In fact, we still have Kaiser as the health insurance for our own family. But like any large organization, there is a lot of bureaucracy and inconstraints that I found wasn't well suited to the kind of practice I wanted to have. I think Kaiser could benefit from trying a satellite version of a micropractice model.

As I've pointed out last year (and which is still true), my practice is atypical of most solo practices (even for a micropractice) 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 much higher income than me. I am fortunate to have a spouse (Hi, honey!) who has a sufficient income so that I can continue to grow my practice slowly. Here are my current statistics (previous years' numbers in parentheses):
Unique patients seen since practice opened: 719 (523) (201)
Total patient visits: 901 in 2006 (805 in 2005) (265 in 2004)
Average # visits per week: 17.33 (15.48) (5.76)
M:F ratio: 49.8% male, 50.2% female
Average age: 37.8 years old
Oldest patient: 97 years old
Youngest patient: 2 months old
Sources of patients: Word of mouth 31%; Relatives of current patients 23%; Insurance provider list 20%; Paid advertisements 6%.
Payor mix: PPO insurance 79%, Cash 13%, Medicare 4%, HMO 0%
Average charge per visit: $128.48 ($133.73) ($114.27)
Average payment per visit: $83.88 ($74.31) ($70.06)
Total charges: $115,760 ($112,400) ($40,785)
Total collections: $67,105 ($54,976) ($17,515)

Bottom line, my practice is still continuing to grow slowly but steadily. I have intentionally closed my practice to new patients at various times during the year in order to control my practice's rate of growth. Currently I have been closed to new patients since the beginning of the year, but will probably open up again next month.

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 that "get more efficient" stage.

I still rarely get phone calls in the middle of the night, much to the continued relief of myself and my family. I also rarely make housecalls, mainly because no one is asking for them. I am able to take vacation, thanks to local family medicine colleagues who cover for me.

Speaking of traveling, I am currently attending the California Academy of Family Physicians Annual Scientific Assembly in San Francisco and will be one of 3 speakers at a seminar titled: "The New Family Medicine Practice: New Models to Consider". The other speakers will be talking about their concierge medicine practice and insurance-free (AKA cash-only) practice.

The biggest change in my practice in the past year is that I've engaged the services of a part-time biller to take over my billing duties. She is much more efficient at it than me, plus she has the time and tenacity to wait on hold with health plan agents trying to find out why a particular claim didn't get paid. She has also been helping me catch up on previously unpaid patient bills that I hadn't gotten around to mailing out. Hopefully this will make a big difference in my bottom line.

Tony Tarchichi left a comment asking:

"I'm a med student who's very interested in this type of practice. One question that I keep coming up against in all my reading of micropractices is how do all of them make less money than regular practices. What I mean is everyone physician who I've read about in these practices says that they make less than they used to in a traditional practice. Can you explain why this is happening and is a micropractice a reasonable choice for someone who wants to raise a family, pay off student debt & save for retirement. Ideally I'd like to make around 150K but I'm not sure if that could happen in a micropractice. I'm not putting down micropractices by any means, I'm really just looking for information. Thanks for any help you can offer."

Although my practice is essentially a part-time practice right now, it is possible to extrapolate what a comparable full-time micropractice income might be. Based on the following assumptions:
1. Patient panel size = 1000
2. Average daily visits = 0.75% of patient panel size
3. Average payment per visit = $84.00
4. Work schedule = 5 days/week, 48 weeks per year (assuming 4 weeks of vacation)

Avg daily visits = 0.0075 x 1000 = 7.5 visits/day which translates to 37.5 visits/week or 1800 visits/year.
1800 visits/year x $84 per visit = $151,000/year of gross income.
My annual expenses run about $50,000 so that works out to $101,000 of net annual income, if I had a patient panel of about 1000 patients, which I am working towards.

A patient panel of 1500 with the same numbers = 11.25 visits/day and an annual gross income of $226,800.

Compare this to a more traditional schedule in which a patient is seen every 15 minutes:
1. Average daily visits = 24
2. Patient panel size = 3200
Assuming the same reimbursement rate of $84 per visit, and same work schedule, you would have a gross annual income of $483,840. Of course, there is probably no way a solo physician could handle all the associated work of seeing so many patients, so your expenses would increase dramatically as you'd have to hire a receptionist/scheduler, medical assistant(s), LVN or RN, and one or more full-time billers unless you didn't take 3rd party insurance. In short, you'd end up with the typical overworked family physician's office.

I've heard figures quoted that say a typical physican's office has an overhead of about 60-70%. So assuming this is true, a family physician could net between $145,000 to 193,000/year working at this pace. I think a graduating resident who is full of energy and idealism could happily work this hard for this kind of salary for a number of years. I know I did. But as one who has been on this same hamster wheel of medicine, there eventually comes a time when you say, I don't want to do this anymore.

That is how I ended up here, poorer but much happier. You can't buy happiness, but you can trade for it.

And one last thing . . . Go Bruins!

What's a Pound of Prevention Really Worth?

As another example of what is wrong with the current US health care system, here is an article from today's New York Times describing how insurance companies would sooner pay for an expensive coronary stent than for a patient to sit down and talk with their healthcare provider about low cost changes in diet and exercise.

"We have made major improvements in prevention," Dr. Gregg W. Stone, the director of cardiovascular research at Columbia University, says. "But it's difficult. It takes frequent visits, a close relationship between a physician and a patient and a very committed patient."

Which is exactly the atmosphere Dr. Agatston's practice tries to create. Nurses there give patients specific cholesterol goals to meet and help them deal with the side effects of the drugs they are taking. A nutritionist, Marie Almon, meets with patients frequently enough to discuss real-life issues like how to stick to a high-fiber Mediterranean diet even on a cruise or a business trip.

There is only one problem with this shining example of a medical practice: it is losing money.

What's a pound of prevention really worth?

To a primary care doctor, it is the difference between vitality and disability, between having happy and healthy patients vs. long medication lists and repeated hospitalizations.

To a patient, it could be the difference between seeing your grandson's wedding vs. not living to see your daughter's 1st day at school. It could be, to quote a well-known commercial slogan, priceless.

But to many insurance companies, it ain't worth squat.

The Other Shoe Finally Dropped

The North Dakota Supreme Court has finally ruled in favor of that state's medical board and said it had the right to revoke the medical license of Dr. George Hsu because of what it considered inappropriate care.

A quick summary of the case (detailed version here):
An anonymous complaint was made to North Dakota Board of Medical Examiners against Dr. George Hsu. After an investigation they determined that there was poor recordkeeping and that he had a bad attitude when brought before the board. A judge recommended that his practice be monitored. Instead, the medical board revoked his medical license. His patients rallied behind him and with their support, Dr. Hsu appealed. After one year of the appeals process, a district judge ruled that Dr. Hsu's license should be reinstated if he agreed to be monitored. The medical board ignored the ruling and revoked his license again, forcing the judge to order them to reinstate his license. The medical board appealed to the state Supreme Court, arguing that it alone has the right to decide not only what is appropriate care but how to discipline doctors. And the state Supreme Court agreed.

This story brings up a lot of troubling questions for me. Should a doctor lose his license because of bad record-keeping without proof of actual harm? Should a doctor lose his license because of a "bad attitude"? If the answer is yes to both of these, then a whole lot of doctors in this country should be losing their licenses soon.

During the course of the appeal to the state Supreme Court, some startling allegations were made against the process by which Dr. Hsu was prosecuted. The initial investigator in the case may have had a significant conflict of interest in the case. From the appellee brief filed with the North Dakota Supreme Court:

The Board has an obligation to appoint investigators who do not have a conflict with the doctor being investigated. The investigator in this case, Doctor Craig Lambrecht, had a conflict with Doctor Hsu. Doctor Lambrecht's mother was denied a position as an occupational health nurse with the North Dakota National Guard only after Doctor Hsu complained to General Macdonald that Doctor Lambrecht's mother had been sleeping with the command Sergeant Major. In his August 1, 2005 affidavit, General Macdonald confirmed that the accusations were made and that, in his opinion, "...it was inappropriate for Doctor Craig Lambrecht to investigate Doctor George S. Hsu. (See Appellee's Appendix at pages 22-23). An affidavit from a nurse formerly in the North Dakota National Guard also confirmed that Doctor Hsu made the allegations to General Macdonald and that she informed Rolf Sletten of Doctor Lambrecht's conflict of interest prior to the Board hearings against Doctor Hsu.

Dr. Craig Lambrecht also happened to be the chairman of the North Dakota State Board of Medical Examiners that determined that Dr. Hsu should lose his license. Rolf Sletten is the executive secretary of this same Board.

Besides the clear personal conflict of interest described above, Doctor Lambrecht also had the financial motives as described in Johnson. For instance, Doctor Lambrecht is employed by Medcenter One in Bismarck, North Dakota, an institution that had much to gain if the farmers and ranchers in the Elgin, North Dakota area switched from Doctor Hsu's clinic to Medcenter One's Elgin clinic.

........

As the trial hearing counsel argued, complaints should arise from the public and not from the Board's investigator, but the Board could not rely on the public's help in this case as Doctor Hsu has never even had a medical malpractice suit brought against him at any time during his career and has, in fact, enjoyed wide community support during the entirety of these proceedings. (August 17-18, 2004 hearing transcript at page 677 and Appellant's Appendix at page 21).

Doctor Lambrecht's conflicts with Doctor Hsu violated Doctor Hsu's right to due process as protected under the United States and North Dakota Constitutions. N.D.C.C. Art. 1, §9. "A license to practice medicine is a property right deserving constitutional protection, including due process."

As I have said before, I don't know Dr. George Hsu. I've never met him, although he did leave a comment to one of my entries about him. But when there is a shortage of good primary care doctors, you don't start taking medical licenses away because of bad recordkeeping. And in the interest of justice, you shouldn't have anyone investigating or judging him who might hold a grudge against him. I haven't heard it brought up, but I have wondered if Dr. Hsu's ethnicity had anything to do with him getting singled out.

Medical boards serve a purpose. But like the Spanish Inquisition, having the combined power of investigator, judge and jury at the same time seems like a little too much power to me. And you know what they say about absolute power.

Does a medical board alone have the power to decide what is appropriate care/conduct and what the sanction should be? If the medical board decides that a sloppy appearance is unprofessional and worthy of license forfeiture, is that their unquestionable right? What if they decide that pregnancy termination or withdrawal of life support is malpractice? Dating a former patient? Cheating on a spouse? Voting Libertarian? Belonging to the Church of the Flying Spaghetti Monster? Where does one draw the line? Is there a line?

The reason why this story concerns me so much is because, as a fellow family physician, "there but for the grace of God, go I." If something like this can happen to him, it could happen to me or any other physician. Nobody is safe.

Best of luck to you, Dr. Hsu.

Word of Mouth

Date: Monday, January 22, 2007
Radio Station: KSOR, Jefferson Public Radio, Ashland, OR
Program: The Jefferson Exchange

Host: Jeff Golden
Guest: David Carroll, Research Director for the California Budget Project and former director of finance policy for the California Association of Public Hospitals.
Caller: Jan

Jeff: Let's take a call from Jan in Eugene. Jan, you're on with David Carroll of the California Budget Project. Go ahead.
Jan: Yeah, hi, good morning. I just wanted to describe very briefly a doctor I know in Eugene who manages her practice in a very, very different way. She has no staff. When you come into the office, she's the only person there. She's an MD, board certified, all of that. And she has arranged her practice to keep costs down because she doesn't have staff. She wants to enjoy her medical practice. One of her key items is to keep her overhead low, just a small little office, and she passes that on to her patients. I went in there a couple of weeks ago and it was a $40 visit for just a minor item i wanted to have looked at. And she advocates this kind of medical practice. She enjoys her practice a whole lot, she's going to stay in practice because she likes it. She's not burned out because she has to turn her practice into a mill where, according to her, a typical doctor is spending 80 percent of their time over the period of a year just covering their overhead.
Jeff: Mm hmm. So she takes no insurance, she takes basically--
Jan: She does.
Jeff: She does?
Jan: She does. Yeah.
Jeff: How does she...?
Jan: But she provides a discount for people who pay cash.
Jeff: I'm puzzled how she can do this with literally no staff. Do you just walk in?
Jan: (laughs) It's radical. And she loves it.
Jeff: Do you make an appointment?
Jan: Yeah.
Jeff: You do?
Jan: And she'll spend a longer time with you because she doesn't have this huge overhead to cover. And part of it is almost somewhat preventative because patients don't have to feel like they have to rush in and rush out because they've been given, like, 12 minutes. And it's far more personal, far more sociable, and she spends more time. "So okay, is there anything else you need to tell me about?" I found it to be quite an enjoyable experience. I haven't had a medical visit --of course I don't go to the doctor very much-- that was half social and half, you know, what my condition was that I wanted her to look at.
Jeff: Are you hearing more of this, David?
David: No. What's going through my head is, hats off to this doctor. I share your sentiments. It's very hard to imagine many doctors being able to do this given all of the hoops that offices typically have to jump through in order to secure payments from insurance companies. So for doctors that rely heavily on insurance companies and that's most doctors, it's hard to imagine this being very widespread.
Jan: Well, she has been invited to speak at a series of medical conferences where she will be talking with literally thousands of doctors about what she is doing. It's seems like almost a grass roots revival of medical care where the doctor actually has a personal relationship with their patients.
Jeff: She must be a talented multitasker.
Jan: She's very high energy and very excited about what she is doing. When she started out, she actually went around Eugene and holding little small forums to ask people -- and I went to one of these, there were about 30 people -- she asked what would be the attributes of your ideal relationship with your doctor and she's put it into practice.
Jeff: Well, she sounds remarkable.
Jan: Yeah.
Jeff: Thank you very much, Jan.
Jan: Sure.

You can listen to the complete podcast here. The above starts at about 1:33 into the show.

Me and My Shadow, Part 3

As before [1] [2], when I have a medical student do a rotation with me, I ask them to give me a write-up about their experience working with me in my micropractice. Even though he doesn't mention anything about UCLA's defeat of USC in this year's annual football melee (which took place during the rotation), it still shows some insight and thoughtfulness. (Just kidding, Anto!)

Family medicine is a fertile haven where all questions and concerns are welcome. It has been a tremendous experience to be able to take part in such a setting where tremendous gratitude is extolled for alleviating symptoms affecting daily life and solving questions and offering solutions to medical problems that had perplexed patients for prolonged periods of time. I had a tremendous opportunity with Dr S to make an impact in my patients' lives. This opportunity not only allowed me to greatly supplement my medical knowledge but it also allowed me to appreciate the art of medicine.

We have always been told that a physician's words carry a remarkable amount of weight for a patient. I had not really understood what that meant until this rotation. Instead of ending my encounter by presenting to my preceptor and letting him take it from there, I was able to go back into the room and plan a course of treatment for my patient's problems. Most of the time this involved recommending a given medication, however there were times where counseling and caring was enough to alleviate the problem.

I have had a number of valuable experiences throughout my 3rd year. Each rotation made me feel more and more like a true physician. However during this rotation I did not feel like a physician, I was a physician. From GERD to cellulitis, I had a great amount of autonomy, more than I ever had before. Therefore, I was able to inject more of my personality and care into everything I did. To have a patient say: “I came in with a minor problem, but I would have felt comfortable with you if you were treating me with a more severe medical condition” is an indescribable feeling.

I am certain I had such a valuable experience because of the unparalleled patient care and warm atmosphere created by Dr S. It is a place where patients' concerns take precedent over any other matter. It is remarkable the amount of care and attention given to each patient. Prior to my rotating through the practice I was used to 15 minute interviews and physicals with cursory follow ups. There was no time for establishing rapport or treating the patient as a whole. After seeing what Dr S does, I have not seen a better way to practice medicine. To integrate the amount of knowledge he has with the care provided is something I will strive to emulate as I become a physician.

All in all, my experience was overwhelmingly positive. It not only allowed me to expand my knowledge base but it allowed me to appreciate the tremendous value of caring and listening which is often overlooked in providing medical care. I will be ever grateful for the patients I encountered and who impacted my life more then I ever could by recommending a NSAID or antibiotic to relieve their transient pain. During these four and a half weeks I grew more as a person, learning how compassion is just as effective as a given drug. I now have a better understanding of what is meant by the phrase: “the art of medicine.” I owe a great deal of what I learned to Dr S and his practice.

Anto Hindoyan, MS3

Thank you for your thoughts, Anto, and I wish you great success in your future. I wish all medical students, and physicians for that matter, could experience what it is like to have no time constraints and no hurried rushing when talking with a patient about whatever ails them.