Thursday, April 22, 2010

Me and My Shadow, Part 6

My last two posts have been what medical students have been saying about my micropractice. Now, a short commentary about medical students and the future of family medicine. It has been well documented that fewer and fewer medical students are choosing to enter primary care specialities, such as family medicine. In order to combat this, there has been an effort in some circles to expose more medical students to family medicine, such as by requiring them to do a clinical clerkship in a family medicine office. I guess the logic is that if they see how great and fulfilling it is to be a family doctor, then more of them will want to go into it as a career.

As well-intentioned as this may seem, it has occurred to me that this may actually be counter-productive. There is no better way to turn off medical students from going into primary care than by having them see first-hand how frazzled, frustrated and overworked a primary care doctor's life really is. If you really want students to go into primary care, have them rotate through an office where there is enough time to talk with patients, where doctors are not overworked, and where both doctors and patients are happy. But you won't find many places like that in the current environment. That is why you won't see any signicant increase in primary care doctors until the lives of primary care doctors are improved. And that ultimately means: more money for primary care.

Returning to the present and vowing not to repeat the delays of my last two posts, I will now share what my latest medical student wrote just last week. Analisa just completed her 5 week family medicine clinical clerkship with me and was kind enough to share her thoughts about my practice model. Kudos to her for writing this during her trauma surgery rotation!

The first time I met Dr. S was not as a medical student. I first found his practice as a patient. I was new to the area and needed a vaccination booster. His practice was close by and gave vaccinations. So, I researched this new office discovery. I found his practice model intriguing and the level of care incredibly personal. Three years later, I was back in Dr. S’s office to learn more.

Initially, I knew Dr. S modeled a practice without the usual constraints of time and bureaucracy. Following the ideal medical practice model tenets of efficiency, quality, and care access, Dr. S offered a hope for something beyond the fast paced, quick in and out practice with which I had more experience. In Dr. S’s office, I was able to talk to patients. I was able to carry out a full conversation discussing the spectrum of life experiences that were either aiding or impeding wellness. We did not see many patients a day, and thus, when complications in patient care arose, we were able to be proactive and address concerns before they snowballed into something bigger.

Seeing patients with Dr. S was somewhat like the 1940s TV depiction of the town doctor whose neighbors came by with a cough, an ankle sprain, or anything really. Experiencing the paradigm of neighborhood doctor as confidant, consultant, and medical expert was rewarding.

Further, this personal care was enhanced with the aid of technology. I appreciated the efficiency of Dr. S’s near paperless office were patients could schedule their own appointments online and encrypted patient information was physician accessible, fully incorporated and well organized.

Some patients just needed a quick check up. Some patients needed more. Dr. S was there for his patients, whatever their concerns. I was impressed with the same day appointments, the evening appointments, the occasional weekend appointment, and the consistent email contact. I was impressed by the patient driven care.

As I move forward in my career, the principles of the ideal medical practice will stay with me. Dr. S’s insight into the importance of creating the medical practice for the kind of medicine you believe should be practiced is no doubt a lesson worth retaining.

Analisa Armstrong, MS3
Thank you, Analisa, for your enthusiasm, hard work and desire to learn. (Also your willingness to do administrative chores when things were slow.) You were able to handle anything I threw to you, so I am confident you will excel in whatever you end up choosing to pursue. Best wishes to you!

Wednesday, April 21, 2010

Me and My Shadow, Part 5

As I mentioned in yesterday's post, I am ashamed to say that I have been sitting on a couple of essays from medical students who rotated with me since 2007-2008. I kept meaning to post them but time just sort of slips away and before you know it, it's the next decade. So with apologies to Erin for the late posting, here are her thoughts on her 5 week rotation with me from 2008:
I did not know what to expect when I discovered that Dr. S’s family medicine practice was a “micro-practice”. I had never even heard of a micro-practice and I assumed it was just another word for “concierge service”. My doctor in the Bay Area recently made the change to concierge service. She does not take insurance and charges $400/month; however she recommends having insurance to pay for labs, hospital stays, etc. ($5000 a year + insurance payments!? Is she crazy?). In my opinion these concierge services cater to the rich – and cater to themselves. Therefore, I had an unfounded preconceived notion about Dr. S’s practice before I even got there. I wasn’t upset about working for this kind of practice, I was excited to see something different, and most importantly, I did not have to drive through traffic to get to his office. 
I was certainly wrong about micro-practices. They are not concierge services. A micro-practice is almost a nice blend between concierge and standard practice. You get the outstanding service that a concierge practice offers and the practicality/price of a standard practice (ie: he takes insurance). Moreover, Dr. S does everything himself.. Answering the phone, billing, scheduling, taking vital signs, etc, etc. It is this aspect of a micro-practice that I do not like. 
Honestly, I was annoyed having to take the blood pressure and the heart rate of most patients. I have never had to do this before. I was also embarrassed at my annoyance. When did I become so entitled? Isn’t it my job as a medical student to do these basic skills and be competent at them? Before I worked with Dr. S, I had maybe taken vital signs myself a total of four times. I had gotten spoiled, I had gotten lazy . . . I really needed this kick to bring me back to earth. I am after all, a medical student. 
Dr. S certainly has patience and it makes me wonder if I would have the patience to do a micro-practice. I really like the idea of a micro-practice, but I don’t know if I could make the sacrifices it takes to start one. It really takes faith. His calendar is often empty at the start of the week. I am a very type A personality, so it drove me crazy not ever knowing when we were going to have patients. I also would get nervous that no one would call. How does Dr. S stay so calm? Inevitably, his appointments would fill – but it was the sense of unknowing that was really difficult for me to handle. 
Despite these problems, overall my training was very rewarding. The most satisfying part of this practice was spending time with the patients. I felt I had a lot of autonomy and I really felt like I was part of the health care team. By the end of my time there I was confident in diagnosing and managing basic family care problems. I really loved that I could spend 30 minutes with a patient. I loved not feeling rushed and not having to constantly check my watch and think about how late I was with my appointments. Educating a patient is a very rewarding task. I have never had the opportunity before to really educate the patient about their disease and help them understand what was wrong. Doing this really involved the patient in his or her own health care – which I think is a vital step to success. I actually felt good about myself after many encounters – which is funny because it was almost as if the patient was helping me just as I was helping them. 
In terms of medical training, I think his practice is a fantastic learning environment. There are some down sides that medical students have to accept: the quantity of patients seen is low compared to other practices (however, the quality is equal if not better). If you are a student that learns by seeing the same thing over and over again, then perhaps this is not the best practice for you to learn at. However, if you are a student that learns by discussing the case afterwards in extraordinary detail and following up on it with textbook and literature searches – then his practice is ideal. We always had time to discuss each patient. I really felt like I understood WHY I was prescribing a particular treatment because we would compare the possible options and use evidence based medicine to re-affirm our decision. I really enjoyed this because I felt like I was not blindly giving out treatments because of recognition pattern, but that I was rationally choosing them. I was never afraid to ask a question and the best part is that he always had an answer. 
After my five weeks with Dr. S I am certain about one thing: when I am no longer stuck using student health insurance, I will only go to a micro-practice family medicine doctor. This type of practice is the best option for a patient. The service and quality of care cannot be beat. The uncertainty lies in whether I would ever run a micro-practice. It is definitely a possibility and ideally I would want to. However, idealism and practicality are two different things. Call me in 10 years and I will let you know.

Erin Atkinson, MS3
A belated thanks for your thoughts and insights, Erin.

One positive consequence of posting this 2 years late is that I can look up what has happened to Erin since then. Upon graduation from the USC Keck School of Medicine last year, she was honored with the American College of Physicians Regional Student Award. She is now finishing her 1st year of internal medicine residency at UCLA. Congratuations, Erin! Only 8 more years to go to find out if she has her own micropractice.

Tomorrow: Me and My Shadow, Part 6: Analisa's Clerkship

Tuesday, April 20, 2010

Me and My Shadow, Part 4

Periodically I have a medical student do a clinical rotation with me and at the end, I ask them to write an essay about their experience working with me in my micropractice. I am ashamed to say that I have been sitting on a couple of essays since 2007-2008. I kept meaning to post them but time just sort of slips away and before you know it, it's the next decade. So with apologies to Andrew for the late posting, here are his thoughts on his 5 week clerkship with me from October 2007 (all the more impressive because he wrote this during his surgery rotation!):

I am just starting the fifth week of my surgery rotation at the Keck School of Medicine at USC. These past four weeks have been a very exciting time for me, as surgery has been my career of choice since I applied to medical school. At the same time, when I left Dr. S’s office four weeks ago, I was sad to leave what was an extremely educational experience and what became a very comfortable environment for me. From a medical student standpoint, I must be honest about my initial expectations of family medicine. Not knowing much about the specialty, I unfairly assumed that the patient cases would get repetitive and uninteresting. I figured that the rotation would be simply another roadblock between me and my career as a surgeon.

Now, after completing the rotation, I am thankful of two things. First, that my assumptions were, for the most part, wrong. (Actually, I will say that some of the patient cases got repetitive such as common colds, strep throat, annual physicals, flu shots/immunizations, etc. Such cases may not be as interesting or complicated as the heart valve replacements I have seen most recently, but I suppose even those cases may at some point become repetitive as well.) Second, that my experience with Dr. S changed a roadblock into a gateway. I was introduced to the “art of medicine,” where being a good doctor was not about the ability to diagnose a patient with diabetes but more about the ability to perform a comprehensive examination of each patient while taking the time to connect with patients on a more personal level.

From a medical student’s perspective, I found Dr. S’s practice to be unique and in a way… idealistic. In our first and second years of medical school, we are taught to perform the idealistic patient interview and physical exam that, when done thoroughly, take anywhere from 30 minutes to 1 hour to complete. We are also trained in the skills of bedside manner. When our actual clinical years of training begin during third year, we throw away two years of instruction, and instead fumble through 10-15 minute interviews/physicals. Sad as it may be, that is exactly what happens to most medical students. Fortunately, I was given the opportunity during my family medicine rotation to experience the ideal patient encounter. I can see how this model of family practice provides doctors with greater satisfaction and enjoyment over the style that forces physicians to see a larger volume of patients.

From a personal perspective, learning about micro practices has opened up new career possibilities. More and more I am discovering how much I enjoy life outside of my career. While I am almost certain surgery will continue to interest me, I am equally certain that my family and social life outside of medicine will become (if it is not already) more important to me. Weeks into my surgery rotation, I am realizing that surgery will most likely require my attention full-time or for even longer hours, while family medicine, especially micro and concierge type practices afford much more flexibility in time.

Though I am even more conflicted now about choosing a medical specialty, I am glad to have had such a unique opportunity with Dr. S. So I will close this entry by saying thank you, and I hope in the future to have the opportunity to write of my own experiences with private practice if that is where my career takes me.

Andrew Wong, MS3

A belated thank you, Andrew, for your thoughts and honest opinions.

One positive consequence of posting this 2 years late is that I can look up what has happened to Andrew since then. He was selected as one of the participants in USC Keck School of Medicine Dean's "Year for Research" Program for Medical Students for 2008-2009, doing research in orthopedic surgery in Pittsburgh.

I suspect he is now finishing his 4th year, preparing to graduate from medical school, and getting ready to pursue his dreams. Good luck, Andrew, and I hope you find that ideal balance between career and personal life. This is the wish I have for all physicians. And, of course, especially for solo docs.

Tomorrow: Me and My Shadow, Part 5: Erin's Clerkship