The 7 Doctors and the Patient

Once upon a time, there were six doctors in a hospital. One day the admission clerk told them, "Hey, there is a patient in the hospital today."

They had no idea why the patient was in the hospital. They decided, "Even though we have no old chart, let us go and examine the patient anyway." All of them went to where the patient was. Every one of them touched the patient.

"Hey, this is atopic dermatitis," said the first doctor who touched his skin, for he was a dermatologist.

"Oh, no! it is acute lumbago," said the second doctor who touched the back, for he was an orthopedic surgeon.

"Oh, no! it is paroxysmal tachycardia," said the third doctor who touched the chest of the patient, for he was a cardiologist.

"It is temporomandibular joint syndrome" said the fourth doctor who touched the jaw of the patient, for he was an otolaryngologist.

"It is spastic colitis," said the fifth doctor who touched the belly of the patient, for he was a gastroenterologist.

"No, it's lacrimal duct obstruction," said the sixth doctor who touched a tear from the eye of the patient, for he was a ophthalmologist.

They began to argue about the patient and every one of them insisted that he was right. It looked like they were getting agitated.

A seventh doctor was passing by and she saw this. She stopped and asked them, "What is the matter?" They said, "We cannot agree on the patient's diagnosis." Each one of them told what he thought the patient had.

The seventh doctor took a good look at the patient and said, "I know this man. This is Joe, and he is having an acute stress reaction because he just lost his job and his wife is being treated for breast cancer." And she shook his hand, offered some reassurance and made Joe feel better, for she was his family doctor.

Based on a well known story about an elephant.

3 hours vs 36 minutes

That's the difference between how much time my patients get with me per year vs a typical primary care practice, using the same kind of calculation from this article posted at kevinmd.com found by way of the Ideal Medical Practices blog.

Assuming 2 weeks of vacation a year and a patient panel of 500:
50 weeks a year x 30 hours per week divided by 500 patients = 3 hours.

Compare this to the 36 minutes per year patients get in a typical primary care doctor's office with a patient panel of 2500.

"I can see you today."
"I can see you on time."
"We can take all the time you want and need."

This is the mantra of the Ideal Medical Practice model.

A Different Hat

I am currently in Sacramento wearing my California Academy of Family Physicians (CAFP) delegate hat at the Annual Congress of Delegates. Lots of civic-minded, concerned and caring family doctors doing a relatively thankless job. None of us get paid for this. Most family doctors in the state don't even know what we are doing at this meeting or that there is a meeting. But we are just trying to make a difference.

Dr. Lori Heim, president of the American Academy of Family Physicians, was the guest speaker and she gave a quick update of how she sees the current healthcare reform going in Washington, DC. She gives the current bill a 50-60 percent chance of making it into law.

She noted how much has changed since 1 year ago when everyone talked about the importance of healthcare reform and how cooperative and bipartisan the initial talk had been. Fast forward to now and, even after 20+ years of health policy debate and study, it has reverted back to being partisan in the ugliest way.

She outlined AAFP's priorities for health care reform:

• Expand coverage with minimum benefits package
• Increase access/increase primary care workforce
• Insurance market reform
• Tort reform

Massachusetts demonstrated what happens when you increase coverage but don't have enough primary care doctors. Insurance does not equal access. 

To produce more family physicians, we need to resolve the "income differential" between primary care doctors and specialists, many of whom make 2-3 times more than FPs. There is simply no way to increase the number of family physicians when medical students see how much more they can make by going into a specialty instead.

CMS (Centers for Medicare and Medicaid Services) is looking into adjusting overvalued and undervalued CPT codes and has been criticized by specialists who see a loss of income. To counteract this, Heim said we need to write to our legislators to voice support for CMS's efforts.

For instance, some cardiologists claimed that eliminating the consult code would cause them to lose so much income that they would have to stop practicing cardiology and go back to primary care.

"That's okay, I said. They can come to my office and I'll teach them how to be a primary care doctor. Let's see how they like that," Heim said.

She pointed out that we need to bring Medicaid reimbursements up to at least the level of Medicare. "When you're losing money on visits, increasing the volume doesn't help."

Administrative simplification also needs to happen to relieve the crushing red tape and bureaucracy that every primary care doctor has to deal with.

Dr. Heim listed some of the major highlights of the current proposed legislation:

• No public option. Instead there will be state by state insurance exchanges.
• 10% bonus for primary care.
• 94% of population will be covered under the Senate plan.
• Establishment of a Medicare Advisory Board.
• Accountable Care Organizations.
• Dependent coverage up to age 26.

Heim acknowledged that the current bill is not perfect but that "it has a lot more good than bad," adding that healthcare reform will be an ongoing process.

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I will be meeting with my state assemblymember and state senator on Monday to lobby/discuss CAFP's position on various pieces of healthcare legislation making its way through the state Capitol. We all complain about how bad the system is. This is my chance to try to do something about it.

If you want to do something about healthcare reform, you can help by:

• Voting
• Writing to your legislators
• Writing a letter to the editor of your local paper
• Asking your patients to write to their legislators or local papers
• Posting/linking/tweeting/blogging about healthcare reform
• Contributing to FP-PAC, CAFP's Political Action Committee (or your own state's PAC) or FamMedPac, AAFP's PAC so that someone will speak to the legislators for you besides the lobbyists for the insurance and drug companies.

As Dr. Tom Bent, CAFP's president said, "We no longer have the luxury of hiding in our exam rooms, or of just being a good doctor. We have to learn how to talk to the Rotary Club, legislators, the news media and the public."

Blogging's good, too, I assume.

A Sign of the Times

Aaron Blackledge, MD, of CarePractice in San Francisco has a message that he would like to share with the public about the current state of the healthcare system.

Being a primary care doctor these days is becoming more and more discouraging with the current payment system and insurance hassles, so much so that doctors are working less hours as noted in this Washington Post article:

Average hours dropped from about 55 to 51 hours per week from 1996 to 2008, according to the analysis, appearing in Wednesday's Journal of the American Medical Association.

That's the equivalent of losing 36,000 doctors in a decade, according to the researchers. And it raises policy questions amid a looming primary care doctor shortage and Congress considering an expansion of health insurance coverage that would mean more patients.

It's not hard to figure out why.

The overall decrease in hours coincided with a 25 percent decline in pay for doctors' services, adjusted for inflation. And when the researchers looked closely at U.S. cities with the lowest and highest doctor fees, they found doctors working shorter hours in the low-fee cities and longer hours in the high-fee cities.

Unless there is meaningful healthcare reform soon, things will probably get worse before they get better.

New Look

The weather is starting to warm up a little. Spring is in the air. It was about time I spruced up the place.

But mainly it was because the old commenting system I used (Haloscan) went kaput, and I wanted to implement Blogger's commenting system in its place. All the old comments got trashed (sorry) but I had no control over that. Give the new layout a spin. Make some new comments. Click on some links. Go wild while we're waiting for healthcare reform to happen. Yep, any time now.

NCQA wants your opinion

The National Committee for Quality Assurance, better known as NCQA, wants to know what you think are the most important features are of the Medical Home. Go to this link and tell them.

Personally, I thought these listed features were all important, but narrowed it down to my top 5:

1. wait time
2. seeing the same doctor or nurse
3. listens and answers your questions (well, duh!)
4. knows you well
5. access to help without making a visit

Some of these seem so basic, it makes me wonder why they even have to ask.

Happy Anniversary

Ben Chan, a family physician, has just opened his new solo practice and writes:

It has been 8 years since I read Gordon's article. Now, I am sitting in my office in this opening day, waiting for the first patient to call and make an appointment. So this is what you all went through. Emotionally, it has been like a roller coaster ride. At one time, I am happy that I made this tiny leap. On the other hand, there are times when I kick myself and ask, "What are you doing?" For now, only time will tell. At least, at the end of my career, I can tell myself that I tried!

Coincidentally, it was 6 years ago today that I first opened my little office for business. I remember the open house I had on Valentine's Day 2004 to celebrate my new solo venture. We handed out chocolates and flowers and ordered way too much food. On my first day of business, I sat by the phone and waited and waited . . . and waited. I felt like I couldn't leave the office because what if somebody called? I was afraid of missing them. But no one called. 

The days passed, with no patient in sight. I knew it would be slow to start but yeesh— not this slow. I brought no patients with me from Kaiser and was new in the medical community. I placed some ads in the local paper. I asked friends to tell their friends. It was lonely. 

Finally, 2 weeks later, on March 1st, I saw my first patient. I saw him at 8PM, and he had no insurance and forgot to bring cash. I remember that he felt embarrassed and offered to go to the ATM up the street so he could pay me. I felt bad because it was raining, but I thought to myself, I did just provide medical care for him and if he didn't pay me now, who knew when I would ever see him again? Would he even come back after he left? 

He did come back and paid the $40 for my first visit. Six years and 5000+ visits later, I just did the 2 month old well child check for his 2nd son. He still doesn't have insurance, but I'll always remember who my first patient was. So will Ben. 

And Ben shouldn't belittle his accomplishment by referring to it as a "tiny leap". It is a huge leap of faith to leave the safety of a traditional group practice and go it alone. Some would say, it's crazy. But it's like that old Apple commercial:

Here'’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules and they have no respect for the status quo. You can praise them, quote them, disagree with them, glorify or vilify them. About the only thing that you can’t do is ignore them. Because they change things. They push the human race forward. While some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think that they can change the world, are the ones who do.

So here's to many more physicians like Ben who are trying to change THE world by changing THEIR world. It has certainly changed mine for the better and, I hope, the lives of the patients whom I have seen in my little micropractice.

Go get 'em, Ben.