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

I Remember

[From Roger Ebert's Journal by way of Daring Fireball.]




OK, I don't post often lately. But I think remembering is important. Voting is, too. I encourage you to do both.

Really cool

I see that Practice Fusion is showing a "sneak preview" of their iPhone app on their Facebook page.

How cool would that be if I could access my patients' charts with just my iPhone? Especially when I'm on vacation like now.

Answer: Really cool.

Location:Unseo-dong,Incheon,South Korea

On Vacation

I'm currently in Seoul, South Korea waiting for our connecting flight to Beijing. I'm taking a 2 week trip to China with my family. I thought this was an optimal time to go with my aging parents, who are from China, and my two teenage daughters, one of whom will be headed to college next fall. There won't be many chances for us to do this again.

I want to show that even though I have a solo micropratice, that I can still take vacations. All it takes is a friendly colleague willing to cover for me (thanks, Tom!), and Internet access. Free, if possible.

I'll post more details later on how I take care of business even when I'm out of the country. Assuming my hotel has free wifi access, that is.

Location:Unseo-dong,Incheon,South Korea

Really Retro

To match my retro solo family practice, I figure I should get myself one of these. Right after I get my iPad, that is.

And my iPad comes as soon as Practice Fusion can port their EMR over to the iPad. Even though it currently requires Adobe's Flash to run, Practice Fusion is hopefully coming to the Flashless iPad soon. According to their Facebook feed:

We'll be testing a wide variety of hardware and systems in the lab - including the iPad once our mobile strategy is closer to launch this year.

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!

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