Patient, Can You Spare a Dime?

I found this recent Washington Post story about doctors asking patients for voluntary donations to help offset rising malpractice insurance costs.

Kenneth M. Greene wasn't sure how his 1,500 patients would react when he asked them for a $10 contribution to help pay his $11,000 malpractice insurance bill.

"The medical malpractice insurance crisis has come full force to Maryland," the 47-year-old Towson internist declared in a letter he sent last December. A "small donation . . . is necessary if we are to continue to keep our doors open."

Nine hundred miles away in North Palm Beach, Fla., family physician Ira G. Warshaw launched a similar plan. Warshaw asked his 3,000 patients to send him a check for $125 ($25 if they were under 25) to help defray his $30,000 insurance bill, which has quadrupled since 2002. If patients didn't send him money, Warshaw warned in a letter earlier this year, he might be forced to stop participating with Medicare and some health plans.

"I felt like I was drowning, really," said Warshaw, a solo practitioner who said he felt "some guilt" about his request but was also grappling with a $100,000 debt from a failed venture in group practice. He felt compelled to act, he said, after his income dipped below the national average for his specialty, roughly $140,000.

I am fortunate to have an annual malpractice premium of about $5500, but then again, I'm in California (where malpractice rates have generally held steady) plus this is my first year of solo practice. Malpractice rates are designed to rise as your practice grows.

I think this is a reasonable request for doctors to make, basically to ask patients to help pay for the cost of doing business, especially if insurance reimbursements aren't enough to cover the costs. There is no free lunch, after all. High malpractice judgements = higher malpractice premiums = higher operating expenses which get paid by whom? Insurance reimbursement rates are relatively fixed by the Medicare fee schedule, so doctors can't charge patient more for services. But the money's got to come from somewhere.

Let the doctor pay for it out of their own income, some say. After all, he/she is still making enough money. The public may see an annual salary of $100,000+ and consider that adequate compensation. On the other hand, a doctor who has spent 7 to 12 years of their life in post-graduate training, with huge debts from school loans, who has spent countless sleepless nights of being on call, and who now has a young family with growing children whom he/she can barely spend time with because of long working hours and patient responsibilities would probably consider this inadequate compensation.

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As for my growing practice, I am fortunate to have more patients calling me in the past 2 weeks. I am nowhere near making a profit yet, but I am getting close to the number of patients I need to see to break even: 3 patients a day. Of course, it would help a lot once I start submitting medical bills regularly for reimbursement, won't it?

You can save a life, too

In one of my other lives, I am a Assistant Clinical Professor at the UCLA School of Medicine in the Department of Family Medicine. This is a fancy way of saying I donate my time to help teach first year medical students. I have been doing this for the past 10 years, and it has always been one of the most enjoyable activities that I do as a physician. Specifically, I help tutor a group of about 8 or 9 1st year medical students in the Doctoring course, which mainly teaches students how to conduct a medical interview by using actors who play the scripted role of a "standardized patient".

Last week, as each small group does every year, we visited the home of a family of a child with a chronic illness. This gives the students an opportunity to see firsthand the effects of a chronic condition on the physical, psychological, financial well-being of a family. In previous years, we've visited families of children with Tourette's, Type 1 diabetes, Down's syndrome, and cerebral palsy.

This year, we visited the home of John Paul, a 3 1/2 year old boy with Diamond Blackfan anemia, also known as DBA.

It is a very rare disorder, with about 350 people in the US having the disorder. His mother eloquently described the family's frustrations, hopes and determination in giving John Paul as normal a life as possible. Which is hard to do because John Paul has to get blood transfusions every 2-3 weeks to replace the red blood cells which his bone marrow fails to make. Because of the multiple transfusions, he has developed liver dysfunction due to iron overload and therefore must undergo daily chelation therapy with a portable infusion device attached to him that runs 12 hours a day. Because he is easily prone to infections, his family rarely takes him out and they've had to limit their own socializing for fear of bringing back a virus. On top of all this, his parents both work, and his mother is a tireless advocate for the cause of DBA and the recruitment of blood donors.

Because there are so few people with DBA, there are no government-sponsored funds for research. Instead the Diamond Blackfan Anemia Foundation was formed to help raise money to finance research for a cure.

John Paul's family is truly a brave and remarkable family. The medical students and my co-tutor and I were impressed and touched by their story. On their behalf and on behalf of the many people in need of blood, I encourage all of you to not only donate blood, but to become a regular blood donor. It is one of the easiest ways to save a life.

I'll be rolling up my sleeve this week for my donation.

From little acorns grow mighty oaks

Thanks to the links from MedRants and MedPundit, I've gotten more visitors in the past 3 days than I've gotten in 3 months. If only it were that easy to get patients into my solo practice.

My last entry talked about being interviewed for a newspaper article about my "Gordon Moore type" of solo practice. Here is the article that came out 4 days ago. The newspaper has a circulation of 35,000. The article was also published in a sister publication which has a circulation of 48,000. Since the article came out I've had 6 calls for appointments generated by the article, 2 calls from Kaiser patients who are unhappy with their care and want me to see them at Kaiser (I had to explain that I cannot do this), and 3 other general inquiries: what are my hours? do I accept HMO? (no); and one letter from a patient documenting how the last 10 doctors she saw couldn't help her but she was hoping that I could.

12 responses out of 83,000 potential readers. And that's not counting their websites. What this tells me is that there isn't as pressing a demand for a old-fashioned country doctor as I thought. Or maybe people just don't read the newspaper very carefully. Or maybe they didn't know how to contact me, since no contact information was included. The ones who found me said they just looked me up in the Yellow Pages.

But that's OK. I was plenty busy today. If I had 20 patients call for appointments, I don't think I could've accomodated them. I can't complain since it didn't cost me anything to be interviewed. I think that there is an abundance of primary care doctors in the suburban area where I live. Plus I think that as much as some people complain about the lack of accessibility to their doctors, it's probably good enough for most people. Of course, I may continue to get calls later on. Some people may have clipped that article and saved it for future reference. And the people I saw today will hopefully tell their friends and family about the doctor who answers his own phone and spent an hour with them. This is about planting seeds for a future harvest.

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Since starting this blog, I've found more and more medical blogs out there. In fact, if I read all the medical blogs from this site, I wouldn't have time to do any work.

The subject of blogs came up in a recent discussion about how to disseminate information about a new diabetes project being sponsored by the California Academy of Family Physicians. Well, consider this the first seed.

As part of the CAFP's effort to bring the Future of Family Medicine Project recommendations to fruit, it has decided to try and tackle the improvement of diabetes management. In our focus group last week, we decided that just about every family doctor knows what good diabetes care entails, we just need some help tracking and following up on our patients.

At Kaiser, they are ahead of most doctors. They actually give a printout every 3-6 months to each primary care doctor listing their diabetic patients and what percentage of them have had their retinal exams or microalbumin done, and what percentage of patients have their HbA1C in range. However, it is still up to the individual doctor to then contact any patients who may not have an optimal lab or may be missing labs completely.

We discussed the possibility of creating and distributing software to family doctors that would offer "one-stop shopping" in diabetes management. It would have a database which can track various parameters and allow you to see which patients are due for various labs or tests. The program would also be able to generate e-mails to patients reminding them when it is time to come in for a diabetes check-up. It would have links to up-to-date patient education material that can be e-mailed or given to patients to assist their self-management. In return for providing this software, the CAFP would get information. The database would be able to upload depersonalized aggregate data into a central database to help provide pooled statistics that can later be used to document (hopefully) superior diabetes care.

So hopefully this seed of an idea grows into something big.

Just as I hope this blog can plant some ideas into the minds of doctors who might want a practice that isn't too bureaucratic or just plain too busy to care for their patients. Now where's my trowel?

The Personal Touch

I was interviewed today by a reporter from one of the local newspapers to discuss my "unique" practice. My practice is following the "Gordon Moore model" emphasizing low overhead, minimal barriers, maximum accessibility via cellphone and e-mail. I described how I have no employees, in order to keep my overhead low, and how in return, I am able to spend more face-to-face time with patients. The reporter seemed impressed, so I'm hoping for a positive news story that might generate more patients.

Lately, I've been finding more news articles about physicians trying to "take back" medical care from the hassles imposed by 3rd party insurers and improve the overall physician-patient experience. Here's are two (1)(2) articles about Dr. Michael Stein in Hampstead, New Hampshire, who is starting a retainer fee practice with many of the same goals I have: more personalized care, flexibility in hours, house calls, unrushed doctor visits. His website is at http://www.realdoc.net/.

Dr. Vladmir Lorentz is highlighted in this article which talks about various businesses doing things the old-fashioned way.

This article talks about how rural medicine has a lot to offer, but seems to be dying out.

As a rural practitioner, Haynes said he loves what he does, especially the close relationship with patients.

''I have never had a burnout in medicine,'' he said. ''Every day I look forward to practicing medicine. I know all the families ... know the type of work the husbands do. I interact with the families as friends and as patients."

I think that this is what attracts many to the specialty of family medicine, getting to know people and their families in a personal, even intimate way that only a few ever get to experience. To be able to share in others' lives. I've always been amazed at some of the things people tell me that they would never tell their spouse or priest/pastor. I think this relationship is something that has been endangered for some time by the modern medical system, by appointment systems that prevent patients from seeing their own doctors, by 3rd party insurers that place restrictions on treatment options.

This opinion piece written by a general practitioner in the UK laments the "end of the patient-doctor relationship".

In an ideal system, the physician not only cares for the patient, but cares about them, too. Also, the patient cares about the physician, is respectful of his/her time, concerned for their lives. A couple of days ago, I got an e-mail from the mother of a boy I saw two months ago. She was reminding me that I hadn't billed her yet! How often does that happen???

What happens when there aren't enough generalists?

First, conscientious generalists get overworked, like this doctor:

Working 12-hour days and five-day weeks in her solo practice, she often double or triple books patients.

While most doctors in the area close their books to new patients when they get overloaded, the Aldinga Surgery GP refuses to. "I try to see people within a few days which is at my own detriment," Dr Mayne said. "We try to fit patients in at some stage, within a couple of days.

"Other people (GPs) just say `I am seeing this number', other GPs have a four week waiting time.

"But I have been here 18 years. I don't really want to knock back an 80-year-old woman who has been seeing me for many years."

Dr Mayne said demands on GPs had increased dramatically in recent years.

"The area has grown immensely and there is just no help," she said. "You can't get locums, you can't get people to do sessions, can't get partners in a practice.

"Waiting times for specialists have made people totally disillusioned by the public hospital system, this all puts more pressure on GPs.

"It has got to crisis point. I am sick of it, I don't want to do it for much longer."

A diary kept for The Advertiser by Dr Mayne showed she was seeing an average of 40 to 50 patients a day.

Secondly, frustrated generalists give up:

Christchurch doctors are walking away from their practices as the shortage of GPs spreads from rural areas to the cities.

Increasing paperwork, the growing threat of litigation and the lure of more lucrative positions in other health-related sectors are taking a toll on existing doctors and making the profession unattractive to debt-laden medical graduates.

A New Zealand Medical Association report shows the number of GPs nationally has dropped almost 10 per cent over two years, and with rural communities already in crisis, health professionals are now saying Canterbury's urban centres, once flush with doctors, are starting to suffer.

The West Coast has the lowest rate of active GPs per capita in the country, with some doctors reporting more than 6000 patients on their books.

In Rakaia, residents have been without a permanent GP for months, and the community has formed a trust to take administrative pressures off the doctor and keep the practice alive. The community is served by a locum and are close to securing a permanent replacement.

The Christchurch School of Medicine's public health and general practice department head, Les Toop, said compliance costs and uncertainty within the profession were putting people off taking on even the most sought-after practices.

"It's happened for some time in rural communities but now it's starting to be seen in the bigger centres. Some doctors aren't even bothering to advertise, they're just shutting up shop."

Thirdly, the remaining generalists are under more pressure because there aren't enough physicians. Overwork. Burnout. Rinse. Repeat.

OK, big deal. These news stories are from Australia and New Zealand. This couldn't happen here in the US, right? It already is.

As a retired schoolteacher with health insurance, Dot Goodwin never thought she would have a problem getting an appointment with her family physician.

She became ill and discovered that her doctor of 30 years had joined another practice.

The doctor who assumed his practice wasn't taking new Medicare patients.

"There I was, bad off, and had to go to the emergency room for treatment," she said.

An emergency room worker told Goodwin about a doctor with a new practice in Decatur. A Lawrence County resident, Goodwin got an appointment with the doctor and continues to see him.

She is one of the lucky few who are able to find a primary care physician in Alabama. Sixty-two of Alabama's 67 counties have doctor shortages so severe that the state has declared them Health Professional Shortage Areas.

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Barganier said some primary care doctors in Alabama treat as many as 8,000 patients.

"There is nothing like being the only physician in a town or being only one of two," Midgley said. "It's hard to take a vacation, it's hard to have family time because you're working all the time."

He called it a self-perpetuating cycle.

"It's hard to attract new doctors because they won't have any backup," Midgley said. "What we have said is that our medical schools need to do more to address the problem. They need to turn out more primary care physicians than they do."

I would argue that churning out more primary care physicians won't happen because let's face it: what medical student would want to walk into this kind of situation? One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

What happens when there aren't enough generalists? Patients and doctors suffer.

Good Press

Dr. Gordon Moore recently got mentioned in a news article that highlighted just one of the benefits of his solo practice model -- same day access. The open access model is certainly not unique to solo practice, and many different practice models utilize it, including some large medical groups such as Kaiser. In fact, the open access or "advanced access" model was first developed at Kaiser by Dr. Mark Murray in Northern California.

Here's another recent news article about a family physician in Kansas City, Missouri who is revamping his practice to better serve his patients: Trying to keep it all in the family:

Need to make an appointment? You can call Soper's office in Kansas City, Mo., in the morning and see him that day.

All your medical records will be computerized. Your prescriptions, printed by computer, will be perfectly legible.

"Patients really like it," Soper says of his approach. "And it makes it a little easier for us to survive."

Survival is on the minds of many family physicians, the better-trained version of the general practitioners of a generation ago.

They can rightly claim that they're already an economical source of quality care. But many say the future of their beleaguered field may depend on more doctors changing their practices, as Soper has done.

He sounds like he is doing much of the same things that I and many other doctors are trying, which is to foment a Revolution. I'm not trying to change the US healthcare system, at least not all of it at the same time. I'm just trying to change my little corner of the world, and maybe it'll work and work so well that others will look up and say, "Hey, that's a great idea. Let me try that."

Still, being a Revolutionary would be a lot easier if I could get some press about my practice, too. Coincidentally, I attended a local chamber of commerce meeting today which was also attended by advertising executives from a large local newspaper. I introduced myself and described my kind of "Gordon Moore" family practice: same day appointments, no waiting, 24 hour a day access via cellphone or e-mail, house calls. They said they would pass the word to someone in the editorial section, and maybe I could get a news story out of it.

The local cable TV advertising executive was there also, and he suggested that targeted TV commercials, especially to a female audience (since many women decide who the family doctor is going to be, so he said), could be very effective. Hmmm. I'm not so sure about that. I can't ever remember seeing a TV commercial for a family doctor before. Besides Marcus Welby, M.D., that is. I would be concerned that I'd come out looking like a cheesy infomercial doctor.

I arranged to meet with the cable TV advertising executive two days from now. Somewhat troubling is that when I gave him my office address, he recognized it immediately and said he had worked with another tenant in the building last year. The other tenant was a Chinese herbalist - whose office I took over. If this is a reflection of how well TV commercials helped his business, then it does not appear to be a very promising method of marketing a physician's practice.

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Best quote from Dr. Marcus Welby a.k.a. Robert Young:

According to an article in McCall's magazine, a doctor said to Young at a convention of family physicians, "You're getting us all into hot water. Our patients tell us we're not as nice to them as Doctor Welby is to his patients." Young didn't mince words. "Maybe you're not," he replied.

The Decline of the Family Doctor?

I came across an article that I had seen a while ago, but never finished (until now), troublingly titled, "The Decline of the Family Doctor". It offers a thoughtful and insightful analysis into why the United States health care system is in the trouble it is in, and how a large part of that is due to changes in how primary care has been valued as a society.

"In the early 1990s, managed care attempted to use primary physicians and nurse practitioners to improve access and quality while, at the same time, keeping costs down. There was talk of the primary physician as the coordinator of all medical care. It didn’t work, and the backlash resulted in a decline in prestige, job satisfaction, and income for primary physicians. Many of the young physicians who flocked to the field felt cheated and misled."

I remember that time in the early 90s when FPs were in demand, and were given the role of "gatekeeper". However, it was not a welcome role, as I and this author observed:

"Furthermore, naming the primary physician as a “gatekeeper” whose approval is required by HMOs before patients can see a specialist suggests more of an obstacle than a caregiver. Personally, I have never encountered rudeness like I saw from HMO patients who came to see me because they were required to do so rather than because they wanted to. This is especially true when they had no interest beyond obtaining a referral slip to see a specialist whom they had already chosen themselves. It is difficult to know how to feel toward such patients and to function properly as a physician for them."

I used to think that a single national healthcare system was the answer. But more and more, like this author, I'm thinking that a single-payer system isn't the answer.

"The first principle is pluralism. Imposed one-size-fits-all and one-fee-fits-all solutions are incompatible with the American tradition and will not work. Choice and diversity must be maintained if American medicine is to remain vibrant, creative, and attractive as a career."