"This Work Just Isn't Sustainable"

Last week I went with my wife to the Kaiser Annual Holiday party where they honor retiring physicians and recognize longevity milestones for those who have stuck around. If I had continued at my previous position, this would've been my 22nd year. It was nice to see some old familiar faces.

During the course of the evening, they announced the winners of the Walter Lusk Distinguished Physician Award with touching videos profiling each physician and the excellent job they do caring for their patients. One award winner repeated a quote that Dr. Lusk was fond of saying: "Patients don't care how much you know until they know how much you care."

A week later, someone pointed me to this article by Dr. Lydia Dugdale about the crisis in primary care:

But primary care is broken across the board. The work is unsustainable. I'll tell you why. 

For a start, the pace is manic. In our clinic, we see established patients roughly every 15 minutes. This flows well when the patient is a young healthy woman on no medications coming in for the common cold. But what about the 70-year-old man with diabetes, high cholesterol, high blood pressure, and prostate trouble? He sees four specialists and takes 17 medications, is retired and enjoys chatting. Even though he keeps in his wallet a list of his pills, he forgets to update it. We spend six minutes fixing his medication list, eight minutes reviewing the recommendations of his sub-specialists, and he hasn't yet mentioned the reason for the visit. You don't need to be a mathematician to calculate why your doctor is always in a rush.

This is why I left Kaiser. On top of seeing a patient every 15 minutes, there is "the work no one sees":

If the primary care doctor's only task each day were to see patients within a very limited time frame, it might be doable, but unbeknownst to many outside of medicine, the doc does so much more. How much? A recent study in the Archives of Internal Medicine looked at clinics just like mine -- academic general internal medicine practices -- and for the first time ever attempted to quantify "the work no one sees." The researchers found that in a typical clinic day, the general internist completes electronic orders for 70 laboratory tests, images, and consultations; writes and signs 31 prescriptions; responds to seven patient care-oriented messages; and reviews, edits, and signs 19 electronic medical documents. Most of this occurs outside of face time with patients, and -- they postulate -- this estimate is conservative.

Dr. Dugdale proposes 2 suggestions to fix this:
1. Provide greater incentives so more people choose primary care.
2. Provide greater resources to primary care physicians to handle the workload.

I think she didn't go far enough in her suggestions, as neither one addresses the underlying problem which is the workpace. Primary care's most important tool is the doctor-patient relationship, and for that to develop, one needs time. Without enough time, the relationship is stunted or broken. Without a strong doctor-patient relationship, patients are less compliant with taking medication or making lifestyle changes. Consequently, they don't get better and they continue to need lots of time taking care of their health problems. But they don't get enough time, and it becomes a vicious cycle.

My suggestions to fix primary care:
1. Pay primary doctors a higher reimbursement rate. This will attract more medical students into the field, and allow primary care doctors to spend more time with patients without taking a financial hit.
2. Increase the amount of time allotted per patient to 30 minutes. This will result in fewer patients seen per day, but the most time consuming visits are from those with chronic healthcare conditions who make frequent visits. If you take more time with them, they might actually get better and not have to come back so often.

Alternatively, there's my previous suggestion to separate high-needs patients from regular needs patients.

As I have said before, this isn't specific to Kaiser's model. Allotting 15 minutes per patient is standard throughout the healthcare industry. In fact, some places are even worse, allowing only 10 or even 5 minutes per patient. But Kaiser is such a leader in the medical field that if they were to institute a change, others would follow.

Patients don't care how much you know until they know how much you care. And they know how much you care by how much time you spend with them. 15 minutes just isn't enough time.

The 80-20 Rule

I am currently in San Mateo, CA in anticipation of watching my UCLA Bruins take on the Stanford Cardinal for the Pac-12 Football Championship tomorrow. Winner gets to go to the Rose Bowl!

I mention this to remind people that despite having a solo micropractice, I am able to take time off for vacations and other frivolities thanks to the kindness of my fellow family doctors back home. And I am happy to reciprocate for them whenever they need time off.

On the long drive here, I was discussing (what else) the current state of medicine with my friend who is a physician working at Kaiser, where I also worked before going solo.

While we both admire Kaiser's organization, efficiencies and high healthcare quality scores, we both lamented its rigid "one size fits all" 15 minute per patient structure, and how this leads to a unnecessarily high physician burnout rate.

I observed that part of the problem was how every doctor has a few patients that are very time-intensive, and have a problem list a mile long. These patients always take longer than 15 minutes to manage, and there are usually a lot of psychosocial issues that go along with their complex cases. After a visit with these patients, the result is usually dissatisfaction from both the patient who didn't get all his/her problems addressed, and from the doctor who didn't have time to take care of everything and is now running late.

There is a concept called the Pareto Principle that states that 80 percent of the effects come from 20 percent of the causes. Put another way, 20 percent of patients account for 80 percent of the work. Based on this idea, I suggested to my friend that Kaiser should have two tracks for patient care.

For the "slow track", Kaiser could identify that subset of patients who are more complicated to care for and pair them with physicians who are interested in caring for them. These doctors are then given longer visit times (e.g. 30, 45, 60 minutes) in order to do an adequate job addressing all their relevant concerns, and providing counseling to make lifestyle changes or help with coping skills.

For the "normal track", this is the way patients are seen now: 15 minutes per visit to address 1-2 straightforward problems. I think most physicians would welcome a schedule change like this.

To compensate for the longer visits, the doctors on the "slow track" would see fewer patients per day. One might argue that if these doctors are seeing fewer patients, then they should be paid less than someone seeing more patients. But the amount of work may actually be equivalent depending on the complexity of the patients. I will bet you that every doctor has a patient on their schedule whose visit takes as much work as 3-4 others. Nevertheless, I bet there are plenty of doctors who would accept a lower pay in exchange for seeing fewer patients per day. I know I would.

The results of this 2 track system would be:

• happier "slow track" patients because they get more time with their doctor and get all their problems addressed
• happier "normal track" patients because their doctor is running on time
• happier "slow track" doctors because they get more time taking care of their needier patients and because they don't have a crushing workload
• happier "normal track" doctors because they are running on time and don't have to try to wedge complicated patients into 15 minute time slots

It's a win-win for everyone.

However, it makes so much sense that I doubt that Kaiser or any large healthcare organization will ever implement it. Then again, improbable things sometimes happen. I mean, who ever thought the US government could pass healthcare reform?

If UCLA beats the odds tomorrow, and somehow beats Stanford, then maybe, just maybe, there's a chance that something improbable like this could happen, too.

Go Bruins!

Me and My Shadow, Part 7

I host medical students from time to time at my practice, although I haven't been doing so as much in the past 2 years. The reason is because it takes extra time/work to teach, demonstrate, observe, supervise, and come up with jobs for the students to do, and then critique them. However, I couldn't say no to Kevo because his older brother rotated through my office 6 years ago.

Unlike my previous medical students, Kevo wrote his essay about working in my office before I got a chance to ask him to. But like my other students, he agreed to let me publish his thoughts here in my blog about his 5 week experience spent working at my little micropractice:

As I near the end of my Family Medicine Clerkship I have nothing but great things to say about my experience. Throughout the first two years of medical school I was fortunate to have mentors that were family medicine physicians as well as other mentors from different primary care specialties. Through talking to these mentors I had an idea of what working in a primary care clinic had to offer, but after having gone through this rotation my experience was even better and more enjoyable than I expected it to be. 

The reason my experience was so enjoyable had to do with several variables, however, the most valuable variable was the opportunity to work with Dr. S. Dr. S runs a very unique type of Family Medicine clinic. Dr. S used to work for Kaiser for many years and as a result of their medical system, he used to only get a very short time with patients on average and felt that this was not optimal for himself as the physician and was not optimal for his patients either. That is why he started what is called an “Ideal Medical Practice.” 

There is a small but growing community of physicians who are a part of these “IMPs” and Dr. S was one of the first physicians to pioneer this type of medical care delivery system. The whole concept behind this type of practice is to offer patients a very individualized, personal, high quality system of healthcare. Dr. S spends a lot of time with his patients, which allows him to get to know the specific needs of each one of them and allows him to build a strong rapport with them as well. The effect this has seems to be immeasurable in my estimation, as it has allowed Dr. S to have an extremely cohesive relationship with his patients. Dr. S’s patients know that he is willing to take extra time for their office visits, and he even accommodates the busy schedules of his patient by allowing same day scheduling of appointments. Such accommodation of patients by a physician seems to be a very rare trait in today’s medical climate and Dr. S’s patients definitely recognize this. 

There were several occasions throughout my rotation where a new patient would present for their first visit with Dr. S and when asked how they heard about the practice the patient would always reply by saying that they were persuaded to come see Dr. S by a current patient of the practice who had raved about the intimate, personal care they have received from Dr. S. 

One particular example comes to mind. A middle-aged gentleman who had recently moved from the Central Valley came in to the office. The patient had heard about Dr. S from a neighbor and came in for a physical exam. During this visit, Dr. S took the time to meticulously go through the patient’s past medical problems, medications, social history and a plethora of other topics that the patient wanted to discuss. It was especially nice to see Dr. S show great compassion when the patient discussed the recent death of his brother. Dr. S ended up spending almost two hours with the patient and it was obvious that such attention to detail towards the patient’s medical issues and the genuine empathy expressed was not lost on the patient. Observing that type of care is what I think sets Dr. S’s practice apart and why my experience was so valuable during these past several weeks. It was extremely refreshing to see that patients could have a doctor who cared for them as a person and not just a number. 

I am positive that there are many hard working, compassionate and dedicated physicians practicing medicine today but in my opinion the current medical environment does not always allow these physicians to spend as much time with their patient as they want, which is a shame. This is a concern for me as I go through my medical training. I may be an idealist, but I think spending more time with patients is a part of medical care that should not be sacrificed. Spending time with Dr. S helped me see that there are still doctors that go to great lengths to give their patients the time that they deserve, and that gives me hope for the future. I know that there is a huge possibility that I will not be able to run a practice similar to Dr. S’s in the future, but the fact that practices like this exist and the fact that more and more “IMP” practices are popping up I think is a great thing. 

Kevo Hindoyan
Class of 2014
Keck School of Medicine

Thank you, Kevo, for sharing your thoughts about the IMP model, and for your hard work spent working at my office. I know I made you super nervous when I went into "fly on the wall" mode to observe you in action talking with and examining patients, but I was impressed by your growth, humanity and confidence in your interactions with patients. I know you will become a great physician as long as you remember to be true to yourself. 

Which is also true for just about every doctor. If only we had the time and resources to be true to ourselves, and were allowed to do what we have been trained to do, without third-party interference, our healthcare system would be much better off than it is now. 

Reboot

 

You must be the change you want to see in the world.  
-Mahatma Ghandi 

On this Election Night, I ponder the future of our nation, which I have little control over besides my one vote, and my solo practice, which I have much control over. Although it has been 2 years since I last posted an entry, I am still doing pretty much what I was doing 2 years ago with a few changes.

I still have a solo micropractice in the same small office in the same small town. It has been about 8 years since I opened my practice. I still see a small number of patients per day (0-12). I still take PPO insurance but not Medicare. For the past 4 years, I have been charging an extra Non-covered Medical Benefits Fee per family per calendar year. It started out at $120, and this past year I raised it to $150.

I resist the term "concierge practice" because most concierge practices that I know of charge about $150 per patient per month or $1800 per year. But I accept that I have a "retainer fee practice" or what I call a "mini-retainer fee practice", and that this small fee helps to pay for the non-covered benefits my practice provides such as same day appointments, 24/7 access to me by cellphone or e-mail, and an unhurried atmosphere.

This small fee, equivalent to $12.50 per month or less than what most families pay for cable TV, has helped my small practice survive, and gives me the freedom to take care of my patients in a slower, more thoughtful pace, as well as giving me the time to get to know my patients better.

There are other physicians out there who choose to practice this way (but maybe without the extra fee), such as Dr. Christopher Wenner in Cold Spring, MN.

As health reform sweeps more Minnesota doctors into large health care organizations, 40-year-old Christopher Wenner is happily swimming against the tide. Three years ago, he decided to try something so old that it's new again: a solo medical practice in his hometown of Cold Spring, Minn. 

He's part of a fledgling national movement that's using technology and an entrepreneurial spirit to try to recapture what some say has been lost in the march toward corporate medicine. 

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Wenner, who used to work for a large medical group, said he grew frustrated with the pressure to see so many patients per hour -- what's known as "throughput." 

"A typical day would be, oh, 25 patients," he said, for an average visit of 10 to 15 minutes. "It was just the most uncomfortable situation when I had five minutes with a patient and they had a big list of questions," he said. "It was never enough." 

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Getting started was harder than he expected. "I had lean years," said Wenner, who has three kids. He took no salary for months, and moonlighted at a jail and urgent-care centers to bring in money. 

On the upside, he was free to make decisions without a committee. He can cover his costs seeing just two patients a day, he said; the rest is profit. A full day is 10 patients; the average visit half an hour. But if he wants to spend two hours with one patient, or make house calls, he can.

The "fledgling national movement" is the Ideal Medical Practice movement, which was founded by Dr. Gordon Moore. It has grown into a grassroots organization with members from all over the country, and has spawned over a hundred small practices from Maine to Oregon. It is this group that has provided me with tons of support and advice to help me keep my small IMP chugging along, like The Little Engine That Could.

I can't change the world. At least not by myself. But I have help.

If you are a physician trying to get off the hamster wheel model of modern medicine, as I once was, this group can help you, too.

Never doubt that a small group of committed people can change the world. Indeed, it is the only thing that ever has.
 -Margaret Mead