Less filling, tastes great

Yesterday I ordered some office furniture from Plummers, which is slightly more upscale than Ikea. Since my office is really small (an 8 x 8 foot room), I had to make sure everything fit and optimized my space. It isn't the cheapest stuff, but also not the most expensive. It still came out to about $1500 though.

A recent article in American Medical News talked about getting seed money to startup new practices, and the consultants in the article gave figures of up to $150,000 in startup costs for a solo family physician. Yikes! I'm more like this guy. It depends what kind of practice you want. I'd rather have one that's less filling (than tastes expensive).

Countdown: 19 days until target start date

Old fashioned values, 21st Century gear

Things are progressing as I slowly move towards opening my solo practice.

I started moving in a week ago, much to my pleasant surprise. I thought the acupuncturist might end up staying past his 30 day notice, but he did not. The sink fit, but the carpet got soaked from the installation. No matter, as that is going to be replaced.

The cable installers came today, and installation was a breeze. I assigned myself an email address to be used exclusively with the practice. I had originally thought that HIPAA required that any email communication had to be via a secure encrypted server, which meant going with a free service, like the ones offered by the California Academy of Family Physicians or by Medem. Or you could pay $50/month for secure email through RelayHealth.

The problem with CAFP's site is that it is not fully compatible with Macs (my platform of choice), so I and my Mac-using patients would be left out of some functions. Since I am in California, I hope that CAFP can fix the website to allow full functionality for Mac users. In fact, I'm going so far as to volunteer to be on an advisory committee on technology issues for CAFP to make sure that it eventually comes to pass.

Medem is advertiser-supported, meaning your free website has to display ads, unless you choose the non-sponsored version which costs $30/month. The email service is called an "online consultation" and permits physicians to charge a fee if they want to or not. My reading on the subject so far has been that very few patients are interested in paying for email communication (or phone calls) with their doctor.

RelayHealth looks like a great site and I have used their eScript prescription refill service at Kaiser. It works well. But they do charge quite a bit, basically $600/yr. If I ever consider hosting my own website, maybe I'll consider them again.

My interpretation of HIPAA is that while secure email is best, unsecured email is permitted as long as you disclose to the patient that this form of communication is not totally confidential, and that as long as they understand this and agree to this avenue of communication, then a physician is not going to be penalized for using regular email. We'll see how well things work.

How will I get patients in my new practice? I hear this question a lot.

Word of mouth, of course. I am getting more and more requests from people/friends as to when my practice will start, and what kind of insurance I will take. We had a Christmas party last weekend, and one friend said she already has 5 families lined up for me whenever I'm ready. I even handed out some homemade business cards my daughter made on the computer, just so people could get the word out.

One of my daughter's friend's father is a graphic designer who just recently left a big graphics design firm to start his own business (just like me!), and he offered to help me design something for free (although we eventually agreed we would barter his services for a complete check-up). He showed me his designs today for identity logos which blew me away with how professional they looked. To paraphrase an old movie line, "I could be somebody!" with business cards that looked like they belonged to a Fortune 500 company, rather than a one doctor operation in a small suburb. The hard part will be trying to decide among the 6 great designs he came up with and choose which one will represent me.

Email. Business cards. Logos.

It is all part of an image I will be trying to present to my target population. That of a caring, community-oriented, small-town family doctor who is also extremely accessible and technologically savvy. Old fashioned values, 21st Century gear.

Countdown: 21 days until target start date

What's in a name?

I got the keys to my new office today. I guess I should say, our new office. I am sharing a 4 room suite with a psychologist (my landlord) and a chiropractor, who each have one room. I have 2 rooms. Two *small* rooms: a 9'7" x 9'5" exam room and a 8 x 8 foot windowless room, which will serve as my office.

The pedestal sink I bought was incompatible with the plumbing fixtures, so the landlord and I made a quick trip to Home Depot to buy a cabinet style sink which looks just fine. There are holes in many of the walls where a bunch of cabinets used to hold large quantities of pungent and bitter-smelling Chinese herbs. The landlord said that he and the chiropractor both lost patients because of the smell, so he is glad that I am moving in.

The landlord also kept telling me how busy the previous tenant, an acupuncturist, was. But he chose not to renew his year-long lease, instead going on a month to month lease. That was what enabled me to take his space, because the landlord wanted a tenant with a long-term commitment. I'll try not to make that mistake when my lease renewal is due. This is assuming my practice is a success.

What to do next? I have to get furniture for my tiny office, and chairs. Bookshelves. I don't know how I'm going to be able to fit everything in my office, since I would prefer not to leave anything out in the common area, at least nothing of significant worth. I know my wife wants to have some say in the color of paint, and wall decorations.

A major project will be ripping up the carpet in the exam room to lay linoleum tile. This is to allow for easier cleanup (and a more sanitary environment) just in case someone has an "accident". After all, besides being my own nurse, receptionist, biller, and office manager, I also will be my own custodian.

I also have to figure out how to fit a refrigerator/freezer in to store my vaccines.

And business cards. And newspaper ads. And business stationary.

The phone installer is coming between 8AM-5PM tomorrow. Talk about a "narrow window". Good thing I have the whole day off. And the cable installer is coming next week to hook me up for cable modem internet access (which I've found to be faster than DSL for home use; plus I hate the local phone company that provides DSL service).

A lot of things to juggle. As a family physician, I am used to that.

The landlord asked me how I wanted my name printed on the signs outside. "No middle initial?" he asked after I told him. No, I preferred a simpler identity. First name, last name. M.D. But then I wondered what to put after that. "Which sounds better? Family Practice or Family Physician?" I asked him and his wife.

I had recently read about the American Academy of Family Physicians voting to rename the specialty "family medicine" instead of "family practice" ; and "family physicians" instead of "family practictioners".

"While it may be semantics to some, perception is everything," Lindholm said. "I specialize in family medicine. If our own colleagues in medicine don't understand that we're specialists, I don't think our patients can (understand), either."

It is something all family physicians have to put up with, I think. Our patients don't know what kind of doctors we are. Many assume I am an internist, or a pediatrician (when I see a child), or a general practitioner. This mirrors the findings of focus groups questioned by the Future of Family Medicine Project, which found that a third of patients who saw a family physician didn't know their doctor was a family physician.

The landlord and his wife both thought "Family Practice" sounded more familiar to them, so I told them to put that after my name on the sign. But now that I think about it, I would rather be known as a family physician than a family practitioner. Time to think different, just like my solo practice model.

So tomorrow morning, i will call the landlord and tell him to put "Family Physician" after my name. Because that's what I am. And proud to be.

Countdown: 28 days until target start date

An end (and a beginning)

I did something yesterday I had never done before. I attended the funeral of a patient. Except that Charlie was not exactly a patient in the usual sense.

At Charlie's funeral, a crowded affair at his Mormon temple, I learned some things about this man whose life briefly touched mine. He was a devoted family man with 5 children, very active in his local community helping out with T-ball leagues, was very spiritual in his faith. He worked as a mortician, which struck me as somewhat ironic. The many stories and remembrances shared by his family and friends reminded me that we tend to lionize those who pass away, and yet I wondered if I could ever be as good as man as Charlie seemed. I suppose even the most accomplished person still has some regrets when he/she dies.

After a period of waiting, things seem to be rolling ahead again with my solo practice venture. The current tenant of my future office space is indeed moving out on time, and I hope to be able to start moving in starting tomorrow. I bought an inexpensive pedastal sink at the local hardware store for less than $100 to be installed in the one exam room, and a handyman is scheduled to install it tomorrow.

I had been told by the malpractice insurance agent that I had been approved for coverage last week, but still had not received the official notice yet. That was because they had mailed it to my future office address, and I did not have access to it yet. Luckily, the landlord held the letter for me which I opened today. Surprisingly, the annual premium was less than what I expected, about $5000 for the first year. It will go up gradually every year for 5 years, as I increase my patient panel (and presumed malpractice risk). I have to mail back a check and then I will be covered.

I finally received my EMR program last week, too, after ordering it a month before. First it was delivered to the wrong address. Then by the time I got the disc it turned out to be the version to upgrade the program rather than the software for a new installation. I have been playing around with it, but of course, I won't really know how well it flows until I start charting a real patient encounter.

I've ordered some hardware. A Palm Tungsten C loaded with Epocrates Pro, InfoRetriever and some shareware medical programs. I have a demo of Bluefish Rx, too, which is a prescription writing program. It allows printing and faxing of prescriptions, but I think it costs $20/month for the fax service. In the interest of keeping costs down, I think it will still be cheaper to handwrite prescriptions for a while. But the *Wow Factor* of being able to fax prescriptions from my PDA is certainly intriguing and fits into my model of a smalltown practice utilizing 21st Century technology.

I bought both a black and white laserprinter, and a multifunction inkjet color printer/fax/scan/copy machine so that I could save on some space, which I won't have a lot of in my new (small) office.

I hope to finally start moving in to my new office space tomorrow. Such is the natural cycle of life. Some things come to an end while other things begin anew.

Goodbye, Charlie.

Countdown: 29 days until target start date

There is no medicine like hope

Charlie died last night. At home, in the presence of his loving family, peacefully.

He and his wife had seemed resigned, accepting of the inevitable when I met them 4 days ago at his home. Sitting upright in an armchair, hooked up to an oxygen tank, he was having a hard time breathing then, because of the mets to his lungs and the resulting fluid buildup in the pleural space. But he had been at peace, spending his time meeting friends and family who dropped by to say hello, and a final goodbye. The hospice team was wonderful, they said, and couldn't have been kinder. It occurred to me that Charlie was lucky in a way, because he had had a chance to say goodbye to those nearest and dearest to him before he died. How many people, I wondered, got a chance to do that?

That day I explained again the information I had found about the clinical trials on pancreatic cancer, and encouraged him to enroll in the study. Also, I told them that I had ordered a bottle of enzymes for him to try, but unfortunately it was "out of stock" and wouldn't arrive until the day after Thanksgiving. Charlie and his wife were very appreciative of my concern and efforts on his behalf, even though I wasn't his doctor, or even his friend. I just wanted to help him buy a little time, and have a little hope when there was little chance of either. I guess I didn't know it at the time, but I was trying to practice "chivalrous medicine". Coincidentally, the current issue of Family Practice Management has an article on this subject:

Chivalry is not merely a civil duty meant for young men of yesteryear. Rather, it is a lost art that physicians - both male and female - can practice today. Being chivalrous requires effort, self-sacrifice and giving of oneself without expectation. A chivalrous physician respectfully places patients' concerns before his or her own (within reason). Fundamentally, being chivalrous demonstrates to others that you are a person who actively pursues the moral high road and realizes your character, perpetually evolving, is linked to your deeds. Chivalry is simply acting with kindness.

I brought the bottle of enzymes by two days later, on Friday evening. Charlie had had a rough day and could barely speak because he was so short of breath. As I handed the bottle to his wife, she asked me, "What do you think?" And I said, "You've got nothing to lose." She nodded her head with a hopeful smile. "What do I owe you for this?" she asked. "Nothing," I said, and I meant it. "Thank you so much," she said as I left. "It's my pleasure." And it was. The next night, he passed away.

It occurred to me that I might have done a disservice to Charlie and his family by offering false hope when there was none, instead of allowing him to accept his eventual death without a fight. Normally, I don't believe in futile treatments. But there was something about Charlie's situation that made me want to try to help him no matter what. Probably because he was so young, a few years older than me, and I could identify with him more than usual.

I believe that even though I didn't help Charlie live one second longer, I still helped him with the only treatment I had left: Hope. As Orisen Swett Marden said, "There is no medicine like hope, no incentive so great, no tonic so powerful as expectation of something tomorrow."

This website on bladder cancer discusses end of life care and the value of hope as a treatment option:

Some practicing oncologists consciously uses hope as a treatment tool. In ancient times, when medical technologies were more limited, the physician's appreciation of the therapeutic uses of hope was much more refined than it is today.

Even if one has no difficulty accepting the prospect of death, human beings need hope. To hope for a miracle is something we are capable of doing until the very end. There is no such thing as false hope.

This is the kind of medicine I want to practice, medicine that doesn't end when pills and drugs and knives can't do any more good.

Charlie, I hope you're doing fine.

Countdown: 36 days until target start date

Medicare: Opt in or Opt out?

I spoke with Charlie's wife today (see previous entry). He is hanging in there, helped with some steroids. But he is very weak and getting out of bed is very hard for him. They haven't pursued any other course of treatment, I suspect because it is all so overwhelming. I got info from the clinical trial using pancreatic enzymes, and while it looks like he could be a candidate, I'm not sure he can wait for them to reply if we sent in all the info now. His family is more or less resigned to the inevitable and are trying to enjoy their time with him.

So I went ahead and ordered some pancreatic enzymes myself ($300) and am having them shipped overnight. I believe it's worth a try, and if it buys him some extra time, then it would worth more than $300. I charged it out of my business charge account, so I figure I can write it off as a business expense even though I don't intend to ever make any money from this. I have arranged to go over to Charlie's house on Wednesday since I have never met him, and just wanted to say hello (and I figured that would be a good time to bring over the enzymes, too). Isn't this what being a doctor is all about? Helping others for the sake of helping, rather than financial gain. Wouldn't that be a wonderful world if it could work just like that all the time?

This is my final (regular) work week at Kaiser. After this week I am taking a "terminal vacation" until my final resignation day on Jan. 5th, although I did agree to work 3 days in December as an urgent care doctor to help handle the expected spike in colds and flus. I am looking forward to the end of this week very much, mainly because it is the beginning of the end for me. I'll be able to finally catch up on everything, without accumulating any new patients or labs or calls.

I'm in a holding pattern with my solo preparations. Awaiting to hear from the malpractice insurance company, so that I can tell the hospital credentialing department, so that I can submit my applications for participation in Aetna/Blue Cross/Healthnet, etc. I've been waffling back and forth over Medicare participation. I'm not so concerned about the low reimbursement; it's more the fear of being prosecuted for minor unintentional violations of one of Medicare's regulations.

From a 1997 article in Family Practice Management:

The Medicare reimbursement system for physician services is complex, contradictory in the dual worlds of fee-for-service and managed care, and dangerous for those who would ignore its pitfalls. Because the rules continually change, Medicare offers a full plate of management challenges for physicians who seek its benefits but also must guard against its threats. Although the prospect is daunting, preventing false claims is manageable when taken in small bites. Physicians who had to be good students to become doctors need only approach this system the same way.

And that's from a positive take on Medicare. There are lots of negative opinions on Medicare such as this. But I have to say, this "fringe" group of the Association of American Physicians and Surgeons (who are these guys anyways?) would seem more credible if they didn't also call for a halt to requiring new vaccinations.

On the other hand, I do want to help elderly patients with their healthcare. But not at the cost of my future livelihood or career. Maybe I'll be like Gordon Moore and just not charge Medicare patients. Which way to go? Opt in or opt out? I'm getting a headache.

OK. This doesn't look so good. Medicare's Resident and New Physician Guide is only 168 pages long. Migraine alert!

I asked one of my patients at Kaiser last week what he would consider to be a reasonable fee for a regular office visit (if he didn't have insurance). He said he thought $40-50 would be a fair price. And that seems fair to me, too. I have a hope that there might be enough patients in my local area who may or may not have insurance but feel that $50 is a fair price for a 15 minute office visit, too. And if I opt out of Medicare, perhaps that is not too much for seniors to pay? I could offer a senior discount. That is something I could not do if I accepted Medicare. Even if a Medicare patient wants to pay me more than the reimbursement limit of their own free will, I would be forbidden from accepting it. How much sense does that make?

Part of the reason I'm leaving Kaiser is for greater autonomy. I'm trading Kaiser's job security for professional freedom. It would appear that in accepting Medicare, I lose both security and freedom. Perhaps it's not such a tough choice after all. Now where's my Extra-strength Tylenol?

Countdown: 43 days until target start date

Time = Medicine

I went into work today, even though the clinic is closed. This is a time when I can go in undisturbed and call patients back ("I didn't expect you to be calling on a Sunday, doc"), take care of abnormal test results, catch up on all my charting. But today I spent about 3 hours trying to help someone who isn't even my patient.

The parents of one of my daughter's classmates have a brother-in-law who was diagnosed a month and a half ago with a tumor, and it wasn't until a couple of weeks ago that a 2nd biopsy showed that it was metastatic pancreatic cancer. I got involved because he has Kaiser insurance, and his relatives were hoping that, as a Kaiser physician, I could help him figure out the best way to get action. I guess they felt like they weren't getting enough communication from his doctors.

I've never met Charlie. The only time I spoke with him about a month ago, he sounded pretty normal and he was grateful that I could answer some questions for him. My wife is a pathologist and she also reviewed his biopsy slides as a favor, but she could only confirm his diagnosis. When she saw him he appeared strong and healthy. Today he requires an oxygen tank because he gets short of breath with even mild exertion. Such is the nature of pancreatic cancer, one of the deadliest cancers because it is so hard to identify. Most of the time, by the time it is diagnosed, it is too late to treat because it has already spread to other parts of the body. In medical school, we were taught that most patients with pancreatic cancer have less than 6 months to live.

In his case, I think Charlie would be grateful if he could last another 6 months. His doctors told him that they didn't think chemotherapy could help him at this stage, plus he is already weak and short of breath. His wife told me today that he doesn't want to spend his remaining time suffering from the effects of chemotherapy, especially when it is unlikely to help him anyways.

This is so unfair. Charlie is only 49 years old. As his wife said, they know there is a reason for everything, but right now they can't understand why this is happening. I don't think anyone can.

I remembered one of my patients who was diagnosed with liver cancer a few years ago. Probably because he is Chinese, he also consulted with a traditional Chinese medicine doctor who treated him with herbs and acupuncture. His cancer regressed and has not shown any signs of return ever since. His hepatologists and oncologists can't explain it, and have used his remarkable case as a topic of discussion at their conferences. I called him up so I could get the name and phone number of his Chinese medicine doctor. Charlie's wife was grateful to take the information. At this point, what did they have to lose?

I also remembered reading about a small study from a few years ago. A doctor treated 11 patients with inoperable pancreatic cancer with high dose pancreatic enzymes. The average survival time was 17 months, or three times the usual survival time. The longest survival time was 4 years. It was intriguing enough to warrant further study, so now there is an NIH study looking at the use of nutritional therapy to treat pancreatic cancer. I left a message with the principal investigator to see if they were still enrolling patients.

I dug deeper on Google and located a website that claimed to have the exact same formula as the enzymes used in above study, and was selling them for $275 for a bottle of 360 pills. The "ideal regimen" requires 6 bottles a month. I also sent this info to Charlie's wife today and told her that there was no way to know if this enzyme therapy really works, or if the pills being sold were the same ones used in the study. But because doing nothing is equivalent to accepting death, I told her that if it were me, I would try it.

This reminds me of Laetrile, a controversial anti-cancer treatment that we used to discuss in a medical ethics class in college. What can you do when modern medicine has no answer? Is it right to recommend treatments that are unproven, yet expensive, for a terminal condition? Are they just taking advantage of the desperate? Perhaps.

And yet, this is also about hope, a necessary part of medicine and healing. If I hadn't been able to spend 3 hours researching this stuff, I would've had to shrug my shoulders and say, "I'm sorry, but there's nothing more that can be done." I like to give people choices. I want to be able to spend this much time finding those choices for all my patients, not just the sickest. I want time to think, to look up evidence-based answers to clinical problems. Time is what is in short supply in my practice now.

This is another reason why I want to start a solo practice. To have the time to practice better medicine, to know that I've tried my best. Because everybody deserves the best. Especially Charlie.

And now, there is only one other investigational medical treatment I can do for Charlie, and that is to pray.

Countdown: 50 days until target start date