Good News, Bad News

The good news is from today's Portland Press Herald: "Smaller is better, say doctors who reduce practice"

Dr. Jean Antonucci says a physician can learn a lot by meeting a patient in the waiting room. She notes how difficult it is for the patient to get out of the chair, how easily he walks, whether his speech is slurred and whether his mind is confused.

Antonucci, a family practitioner in Farmington, does these waiting-room observations every workday.

She has no staff, practices out of one room, performs duties typically handled by a nurse or medical assistant and offers patients a $10 discount for handling their own insurance claims. She also has fewer appointments a day than most of her peers and is available to her patients around-the-clock.

Antonucci says she's never had such a good time practicing in her 21-year career as a doctor.

"It's not only good care for patients. It's just joyful to do it," said Antonucci, who opened her current practice three years ago.

Antonucci is among a small but growing number of doctors who are radically paring down their practices. They reason that if their overhead costs are lower, they can get by with fewer patients.

Besides making practices smaller, another trend for some primary care practices seems to be going "insurance-free":

Dr. Karen Hover opened a new cash-based solo practice in Bangor in July. She uses a menu of services with set fees that charge $50, for example, for a single-issue visit and $100 for a full physical.

"It's supposed to be really simple. They can look at it and decide what they want," Hover said. "That's our contract for the visit. I don't go over that and they don't go over that."

Hover said she was troubled that the uninsured pay more for the same services than insurance companies. Insurers negotiate discounts but individuals are at a disadvantage, she said.

Because billing requires a lot of staff resources, cash payments allow her to cut her expenses. She employs only a receptionist.

I like simple. Simple is good.

Dr. Hover knows how bad our overly complex medical system can get. She wrote this editorial which was published a few weeks ago in the Bangor Daily News about the unfortunate experience of "Jane" who literally fell through the cracks of the system, "How our health care system failed Jane":

As a family doctor, I am reminded daily that American health care is broken. A local administrative assistant, "Jane," was working on her roof on a Wednesday afternoon when she fell. X-rays showed two elbow fractures. She was put in splints that immobilized her arms from the armpits to the fingers. She went home at midnight in the care of a friend with instructions to call her doctor in the morning for home services.

Nobody considered that home services are structured to provide only a few hours of support a day. She recalled: "I couldn’t scratch my nose, or feed myself, or get a glass of water, or pull my pants down." She needed around the clock care. Jane called her insurance company, which told her that her plan included 100 days of skilled care.

Arrangements were made to go to a rehabilitation facility on Friday, which was good because Jane’s friend had to go back to work. When Jane arrived, around noon, administrators told her that the insurance company had denied her claim and that she could not be admitted because she had no need for skilled medical care. After a couple of hours on the telephone, no one had a better idea, so she was sent back to the emergency room. By this time, she needed to go to the toilet, but staff refused to take her because of fear of liability. Her ex-husband helped her.

The good news is that Jane recovered and went back at work. The bad news is that there were no consequences for her insurance company and it is still business as usual for them. That's bad news for the rest of us.

Making Practices Perfect

Yet another article on an Ideal Medical Practice from today's Washington Post: "Making Practices Perfect":

The waiting room of Ramona Seidel's family medicine practice is empty, and she works hard to keep it that way.

After several years in a traditional suburban group practice that blended pediatrics and family medicine, Seidel quit to start her own micro-practice in Annapolis: a low-overhead, high-tech office that gives her more control over how she treats patients and more time to spend with them. She's happier. Her patients are happier. And she's pretty convinced they are healthier having a physician who knows them well.

Okay, no practice can be perfect. But "Making Practices Better" doesn't sound as sexy.

I wish the writer had included a link to the IMP Map because you just know that people are going to want to find something like this near them.

Dr. Seidel's web site can be found here.

What's in a name?

Anonymous recently wrote a comment:

Are you sure you want to call youself "IMP" ? The word imp has a negative connotation in its definition.

Hello, Anonymous. You are absolutely right. From FreeDictionary.com, the definitions of "imp" are:
1. A mischievous child.
2. A small demon.

While it may sound like a medical office run by small demons, IMP (short for Ideal Medical Practices) is a practice model that focuses on enhanced doctor-patient relationships, increased face-to-face time between doctors and patients, reduced physician workloads, and cutting wasted dollars from the healthcare system by reducing overhead and using technology to streamline communication and administrative functions. This is a kind of disruptive technology that is meant to demonstrate an alternative to the usual kind of medical office.

There aren't enough of us to overturn, much less challenge, the current system. We just want to stir the pot, make some waves, shake things up and just get people to see that there is a better way than the direction we are now headed. Medical care doesn't have to suck.

So "mischievous little demons" sounds about right. We're here to bedevil the broken US healthcare system, and hopefully one day put it out of its misery. Heh heh heh! ;-)

Gone Cruising

One common question that comes up with doctors looking into doing an IMP/solo model practice is: how do you take vacation?

This is a problem encountered by all solo physicians, not just those doing the IMP model. For myself, when I first went solo 4+ years ago, I didn't know any FPs in the local community and didn't know who to ask for coverage. So that first summer, I took my own call when my family went on vacation to Banff, Canada for a week. Since I was only seeing about 5 patients a week at that time, I figured no one would even really notice that I was even gone, especially when they could still reach me by phone and e-mail. And no one did. I scheduled patients for physicals the following week while sightseeing, just as if I was back in my own office.

Later on, I met some other solo family physicians through the local hospital medical staff meetings, and asked if they would be interested in doing reciprocal coverage, where I would cover them if they would cover me. It has worked out so far. It helps that our practices generally take the same insurance plans as each other. It also helps that:
1) I have less than 1000 patients so that means fewer calls.
2) My patient population tends to be younger so again that means healthier patients and fewer calls.
3) I still continue to take cellphone calls and e-mail so I can take care of issues quickly and easily that the covering physician might take longer to handle.

Having no employees the first few years of my practice meant not having to worry about paying for their services when I was away. I now have a part-time biller, but she can do her work even when I am away.

This coverage system has allowed me to travel with my family to Palm Springs, Yosemite, Walt Disney World in Orlando, Bar Harbor in Maine, New York City. This summer I have taken my longest vacation yet of 2 weeks. In fact, I am still on vacation, writing this from a Mediterranean cruise ship en route from Sicily to Naples.

While there is Internet access available, it is slow and expensive, so I have not been able to receive and respond to e-mail as quickly as I usually do. Also, I have no cellphone access, so that has resulted in more isolation, which is good for vacationing, but not so good for continuity of care. I know I should be grateful for being cut off from work. There is a tendency among many physicians (me included) to never let go of work, which I am always telling patients that they have to do to reduce stress. I should follow my own advice.

I know there are other solo physicians who take their own call whenever they go on vacation, without arranging for any kind of coverage. I think it depends on how far you go, and what your patient panel is like. If you are a doctor in a rural area with no other primary care physician nearby for coverage, that may be your only option. Hiring a locums doctor is another solution, but I think running a solo IMP model, even temporarily, might freak out your usual locums doctor who is used to the usual set up of having someone else answer the phones, do the scheduling and give the shots.

Since there seems to be a growing number of doctors interested in the IMP model but who are not ready to make the "leap" themselves yet, I think it would be ideal and mutually beneficial for a pre-IMP doctor to do locums coverage for an IMP doctor just to get their feet wet, and at the same time, help out an solo IMP doctor who might not otherwise feel confident about leaving their practice for much-needed R&R time. Something like a Craig's List for IMPs.

Anyways, I hope that all primary care physicians get a chance to take some time to rest, relax and recharge this summer.

Ciao bella!

Comic-con Relief

OK, I meant to post these last week when I went to Comic-con. Better late than never.









Sick, but funny. Trust me, I'm a doctor.

Old Fashioned Touch

From The Olympian in Washington State: "Old-fashioned touch: Micropractice helps doctor humanize modern medicine"

Dr. Marius Laumans strives to run an old-fashioned medical practice with modern-day conveniences.

Need a same-day appointment? Patients can go to his Web site, check his availability and schedule one.

Wondering if an over-the-counter allergy drug could mix poorly with prescription medication? All of Laumans' patients have his cell phone number and e-mail address and are encouraged to use them anytime.

Too sick with a stomach bug to get out of bed and drive to his office? Not to worry, he makes house calls, too.

"Thirty years ago, this was what a regular practice looked like," Laumans said.

The 34-year-old family physician is one of a growing number of doctors who are opting to go solo - without the support of receptionists, nurses, medical assistants, billing clerks and cleaning staff.

Dr. Laumans is indeed part of a growing movement of IMP (Ideal Medical Practice) doctors that seeks to improve quality of care as well as quality of life for patients and physicians alike. However, this article perpetuates the old concept of "micropractices" being completely solo-solo operations. Many IMPs start out without any employees, then add staff later as the practice grows.

And there aren't 500 micropractices/IMPs in the country...yet. But hopefully there will be. To find an IMP, go to http://www.impmap.com.

The Hopeful Future of Medicine

IMP Camp 2008 is underway and full of bright-eyed and bushy-tailed (and even tail-deficient) doctors!

From Soma's blog

I had started my medical practice in Manhattan in the summer of 2006. They say if you can make it there you can make it anywhere…Oh boy is that true. I started my business before I even knew the existence of the IMP group. I didn’t realize that the same concepts and the similar reasons why I wanted to go into business for myself was why several other physicians all over the country did the same. Most of the topics at the conference are things that I have already been developing in my own business. The spirit of the people is what gives me inspiration to continue what I am doing. Some have been in business longer than I have, some work in areas that are considered to be dead-zones for effective health care. But they continue. They get over the hurdles, take every day one day at a time and remain true to their souls. The magic of this is this is something that you cannot learn in medical school. It already has to be there. And most of the people here have it.

Speaking as one of those "dead-zone" doctors, I agree with Soma's sentiments about the enthusiastic spirit and idealism of the 80+ attendees. We want to save the world, one patient at a time.