Untold Stories of an FP

The small town where I practice is a favorite place for the nearby entertainment industry to look for locations to shoot various movies and commercials. It's a lot cheaper to film in a pre-existing Craftsman style period house than to construct it on a set, for example. Still, I was surprised to get a call from a location manager looking for a doctor's office to use to film a Nexium commercial. She had gotten my name from the city's film liaison who knows me. (You know filming is big business when your city has a film liaison.)

Sadly, I had to explain that my office was really very small and probably not what they were looking for. She agreed saying how there'd be about 50 (!) people running around for the commercial shoot. So I gave her the name of another local doctor who has a larger office. Hopefully he'll have a good story to tell me.

Speaking of which, Hollywood is all about stories, some good, some not so good, some that are better left unspoken. Some of these stories come from real life, as I found out about a month ago when a producer for "Untold Stories of the ER" called me. He heard about me through this blog, and wondered if I might have any potentially interesting stories that could be suitable for his TV show.

Unfortunately, I explained, I didn't. As a family doctor, most of what I saw in the office was minor and not very exciting (except to the patients themselves) compared to the bloody life and death drama that occurred in the ERs. He agreed that wasn't quite what he was looking for, and I suggested he try contacting some other bloggers with ER experience. I was sorry I missed a chance to have my name in the credits of a TV show, but as I thought about it, I was glad NOT to have experienced very many "interesting" cases (as in the curse, "May you live in interesting times.").

Here are a few of the more memorable stories I have shared with medical students through the years:

1. During internship, there was a guy (whom I'll call Joe) with Munchausen syndrome who went from ER to ER complaining of a heart attack. As residents who rotated through the ER, we all saw Joe eventually at least once. Through the years, Joe had had every single cardiology test they could think of, including angiograms, and they were all outrageously normal. The worst part about it was he wasn't paying for any of it. Joe had no insurance, but the county hospital was required to treat him regardless of his financial status. And his tab was so high that there was no realistic chance of ever collecting a penny from him.

Dr. Raphael, our hospital's cardiologist, was fed up with this guy. He printed Joe's name and photo on a flyer and posted them in every local ER with a brief summary of his history. But even that didn't stop Joe, as no one had the guts to rule him out for an MI without giving him some morphine and running some kind of test. In those days, we didn't have troponin levels so it could take 3 days to rule someone out for an MI. Finally, Dr. Raphael told all the ERs to call him personally the next time Joe showed up. Sure enough, late one night Joe presented at a local hospital ER complaining of his usual crushing chest pain. Dr. Raphael quickly jumped out of bed, drove over and greeted the man. "Hiya Joe. Remember me?" Joe got a quick evaluation, then was quickly discharged by Dr. Raphael as having non-cardiac chest pain. A few days later, he tried a different ER. But who should show up again but his pal, Dr. Raphael. This time, Joe took one look at Dr. Raphael and without a word, stood up from the wheelchair and walked out of the ER. He was never seen in any of the local ERs again, but we knew that he was still out there somewhere complaining of a heart attack that wasn't real.

2. Donor kidneys have always been in short supply and usually given selectively to those who seem to have the best chance of a successful transplantation. Which is why I and my supervising resident were so surprised that Sam had gotten one. Sam was a schizophrenic who had trouble taking his antipsychotics, much less the immunosuppressants that would help prevent organ rejection. By the time Sam got to us this time, he was nuttier than a fruitcake and a danger to himself. He was incoherent and behaving irrationally, so for his safefy he was secured to his bed with a leather arm restraint. We had to get him back on his meds and wait for him to calm down.

One night, my resident and I were making the evening rounds and we looked in on Sam. He had a big goofy grin on his face as we asked how he was doing. "Aw, man, I'm feeling great. Everything's great," he said. "The doctors are great. The nurses are great. The food is great. Even the beer is great." Beer? We looked at each other. He hadn't had any visitors that we knew of. "Where did you get the beer?" we asked. "I don't know. It was just there. Kinda warm, though." Uh oh. "Was this beer kind of yellow and in a plastic container hanging off your bed?" "What? I don't know. I guess so." We looked at his empty urinal container hanging on his bedrail. No wonder his creatinine levels were so high. Sam managed to get better and was eventually discharged. But to this day, I don't drank beer.

3. Esther had was an older woman with diabetes, multiple heart attacks, and respiratory failure to the point that she was on a ventilator machine to help her breathe. She was swollen everywhere like a balloon from her congestive heart failure. She couldn't talk, couldn't eat, but she was awake although how much she was aware of we couldn't say. She had been in the ICU for 6 months, and despite many attempts at weaning her off the ventilator, she was not strong enough to support her own breathing. She was stuck in limbo. She had 2 children, a daughter who lived nearby and visited regularly and a son who lived in another state. After a while, the attending physicians felt that her situation was hopeless. It was left up to us, the residents, to try to secure an okay from her family to withdraw the ventilator so as not to needlessly prolong her suffering. Otherwise, she could continue in her miserable state for who knew how long.

Her daughter, who saw her mother's suffering in person, readily gave her OK. But her son, who never visited her, adamantly refused and wanted us to continue to do everything we could for her. When it was my turn to rotate in the ICU, I also tried to convince the son that keeping her alive like this was not a good quality of life, that turning off the ventilator was not killing her but allowing nature to take its course. On the other end of the phone, he steadfastly refused. After another month, I handed off my ICU duties to Dr. Kuartei (now Director of Public Health for the island nation of Palau). He decided to play hardball. He told the son that he was going to call him every day and give him an update on how his mother was doing. And he did just that, adding in various descriptions/opinions of how much she was suffering day after day. After 8 days of this, the son changed his mind and gave his consent to pull the ventilator. Surprisingly, Esther continued to breathe on her own off the machine, though with a lot of oxygen supplementation. She lasted for about a week before she passed, her suffering finally over. Modern medicine can be a wonderful thing, but it cannot substitute quantity of life for quality of life.

Those of some of the stories that I remember from my residency training days. If you want to share your interesting ER medical experiences with Untold Stories of the ER, they want your untold story. Who knows? Your spleen (or other body organ) might become a star.

Closing My Practice (to new patients)

Although I haven't posted in a while, I am still in business. In fact, I've had to close my practice to new patients for the past 2 months because I am having trouble keeping up with the amount of administrative work. I started my solo-solo practice about 2 years ago as an experiment to see if I could create a low overhead, low volume practice that maximized patient contact time. If I could keep my expenses down, the thinking was that I wouldn't need to see 20+ patients/day in order to survive.

The experiment is over for me. While there are energetic doctors out there who have the discipline and fortitude to keep up with medical billing and other administrative tasks, while also taking care of patients and chart documentation, I've learned that I'm not one of them. I think a practice like this (solo physician, no employees) could succeed in the right environment. This is very doable for a part-time or a cash-only practice.

Medical billing by itself is not hard. 90-95% of the time the electronically-filed claims get paid without a hitch. But the 5-10% of claims that get rejected take more time and energy than I have. Last week I waited on hold 30 minutes to speak to a Pacificare agent to ask why a claim was denied. She said they were waiting for a certificate from the patient because of a "pre-existing condition". Of course, when I called the patient, he didn't know anything about any certificate and said he would call Pacificare back. I will call again next week if I don't hear anything. But I don't have time to do this kind of chasing down unpaid claims.

So I plan to hire someone in the next few months to help part-time with billing. I am not ready to go to a cash-only model, or start charging a retainer or administrative fee, although I haven't ruled them out yet. Let's see if my fledgling practice can grow up a little so that I do less administration and more patient care. Hopefully then I can start adding new patients again.

Gordon Moore Podcast

For those of you who are auditory learners, here is an interview with Dr. Gordon Moore from The Journal of Medical Practice Management.

Gordon Moore is a Rochester-based family physician who pioneered a low overhead, low volume practice model as an alternative to the current medical practice model. An excerpt:

Kent Bottles, MD: Do you think that you're just different than most family physicians in that you like change or that you're more willing to adapt to change?

Gordon Moore, MD: Well, maybe to some extent. You're put me a little on the early adopter spectrum of Everett Roger's Diffusion of Innovation Curve. But I think that's true in a lot of us. There's some aspect in each of our lives where we can see ourselves as early adopters and there are parts of my life where I'm clearly a traditionalist or a laggard. And so I think if we as individuals can tap into that early adopter or early majority part, we can get on the bandwagon and start to effect real and lasting change.

On the other hand, I think they'd be somewhat motivated just by the plain misery of the way things stand currently. It's not a lot of fun out there. I've talked to lots of audiences across the country where the only thing they look forward to is getting a paycheck. And I'm pretty certain that not that many people got into healthcare just for the paycheck. I'm sure it's nice but I think that most people who become physicians have some sense of mission, wanting to help reduce suffering and improve health. And that's a very noble mission that I think has gotten lost because of the fee of finance and overhead and all these other things that have obscured what it is we're really after.

Kent Bottles, MD: Well it sure seems to me as I talk to physicians that many of us are not that happy with what we're doing and I take my hat off to you for at least trying to make your life more interesting and more enjoyable, and make your patients have a better relationship with you.

The Bigger Picture

I am on vacation and enjoying the final chapter of the story known as March Madness, and my alma mater is once again reaching for that National Championship in basketball. It has been a wild but exciting ride, with the Championship game to be played tomorrow night against the Florida Gators. As remarkable as this basketball season has been for UCLA, some things stand out a little more, such as when UCLA overcame a 17 point deficit to defeat Gonzaga. While the comeback was one for the ages, what happened after the game was just as memorable. Adam Morrison, Gonzaga's star player and future NBA draft pick, had crumpled to the floor in disappointment and tears after his team's defeat.

UCLA's Arron Afflalo and Ryan Hollins, in the middle of celebrating their come-from-behind win, went over to Morrison to help up the player who had caused them fits for the previous two hours. The gesture wasn't lost on Morrison.

"At first I didn't realize who it was," Morrison said. "That's just a sign of a great program and great people, as far as they're concerned.

"They had enough guts as a man in their moment of victory to pick someone up off the floor. If I could thank them I would. That's a sign of great people and great players. That's more than basketball."

As the legendary former UCLA basketball coach, John Wooden, used to say, "What you are as a person is far more important that what you are as a basketball player."

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When I used to work at Kaiser I had medical students shadow me, and one day one of them asked me why I was always so persistent in trying to get patients to stop smoking. Did I have a relative who died because of smoking, he asked. No, I didn't. In fact, few of my friends or relatives smoked. But I have known many smokers and ex-smokers through my medical career and have seen what smoking can do to them. I explained to the student that the patient's cold or back pain would be gone within a week no matter what we did. Oftentimes what we did as doctors, the prescriptions we wrote, the tests we ran, wouldn't change a patient's life at all. But if we could get someone to quit smoking, then that could save their life someday. That was the bigger picture.

That is why I was happy to receive this e-mail from a patient recently:

I wanted to send you an email to follow-up with you. I'd like to sincerely thank you for your advice regarding the diagnosis of my shingles and it being caused by stress factors in my life. Immediately following my appointment with you, my husband and I sat down and had a long discussion about our priorities and causes of stress. We decided that the majority of the stress in our lives was from the pressures of owning our home in our current financial position. We decided it was unwise and unhealthy to continue on that path...the health costs were simply not worth it!

After prioritizing our lives, we decided to put the home on the market and live in subsidized graduate student family housing at my husband's university. He also accepted a new position there which had him doing an extensive commute which meant he was rarely home...also adding to the stress factors.

Anyway, I just wanted to follow up with you and sincerely thank you for the time you spent talking with me about the causes of my shingles and how to takes steps to get myself healthy, including minimizing stress factors in my life. I sincerely appreciate your care. You will be glad to know that the symptoms are healing, though I still have numbness. I do feel these are slowly getting better, though.

This person's shingles probably would have resolved with or without my intervention. But her stress was affecting her health and eventually might have led to worse things, such as headaches, depression, obesity (due to stress-induced overeating), cancer (due to a depressed immune system). I'd like to think that I helped her see the bigger picture, and helped her get to where she wants to be. Hopefully, I can do that for others, too.

As a physician, having the time to be able to talk with people about their lives makes all the difference, and I am grateful that I have the kind of practice where I can do that. My wish is that all physicians will someday be able to have the time to do that, too, although I think we still have a long way to go before that happens.

To paraphrase Coach Wooden, "How you treat someone as a person is far more important that how you treat them as a patient."

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Whether or not UCLA wins their Championship game tomorrow, as Coach Wooden used to say, as long as they did their best, they are a success. This team has already demonstrated to me with their class and character that they are winners.

Go Bruins!

Marathon

It was a challenge but I finally made it to the eve of the LA Marathon without getting a cold/flu, which I feel like I've been dodging for the past month in the office and at home. I've been feeling as if I might be coming down with something over the past 2 days, but no fever or shaking chills yet. That may change by tomorrow, though. At least the weather report says it won't rain. The last time I ran the LA Marathon it rained from start to finish, but I finished anyways. I've always finished every marathon I've ever started, but I am not a very fast runner. In fact I usually run the first half, then run-walk-hobble the second half. But once you've finished one, you tell yourself, "I can do this."

That's kind of how I feel my solo practice is turning out to be, a marathon. I started strong and enthusiastic, but now I'm way out there in the middle of the course. I'm a long long way from the start and the end is not in sight. I don't have the same energy I had at the outset. My fingers tend to cramp up more from typing such long progress notes (one of the drawbacks of EMRs is limitless space to write). I struggle to catch up with billing and rebilling and chasing down denied claims. Unlike tomorrow's marathon, though, this race won't be over after tomorrow. But just as I will do tomorrow morning (after I make a 6AM home visit to repack an elderly patient's I&D wound), I will just keep plodding along until I reach my goal.

By the way, how much further do I have to go anyways? That far?

Oh, man. I need some glucose.

Happy Anniversary!

Two years ago today I left my secure but overworked job as a staff physician in a managed care organization and opened a solo family medicine office ala the Gordon Moore hi-tech, low overhead model.

As I've pointed out before, my practice is atypical of most solo practices (even for a Gordon Moore-type practice) so this should not dissuade anyone who might be thinking of going solo. Most of the solo physicians that I know of who are trying this model generate a higher income than me. I am fortunate to have a spouse (Hi, honey!) who has a well-paying job so that I have the luxury of being able to grow my practice slowly. So that being said, here are my current statistics (last year's numbers in parentheses):
Unique patients seen since practice opened: 523 (201)
Patient visits: 1194 (357)
Average # visits per week: 18.1 (14)
M:F ratio: 49.5% male, 50.5% female
Average age: 37.7 years old
Oldest patient: 97 years old
Youngest patient: 2 months old
Sources of patients: Word of mouth 32%; Relatives of current patients 22%; Insurance provider list 19%; Paid advertisements 7%.
Payor mix: PPO insurance 81%, Cash 15%, Medicare 4%, HMO 0%
Average charge per visit: $133.73 ($114.27)
Average payment per visit: $74.31 ($70.06)
Total charges: $112,400 ($40,785)
Total collections: $54,976 ($17,515)

Bottom line, my practice continues to grow slowly but steadily. I have a fairly young patient panel which explains why I've only had to admit 5 patients in the past 2 years. This means very few phone calls in the middle of the night, but I still need 3 more hospitalizations to upgrade my hospital staff privileges from provisional to active. I'm pretty sure I made a profit this past year, but not a big one. This year should be even better. Everyone has said it takes 2-3 years for a new practice to become profitable, so I seem to be on pace.

Medical practices have a life cycle, too. As another solo doctor has observed, "I do remember this major all-consuming time of figuring out how to open the practice, followed by the major all-consuming job of figuring out how to bill, make appointments, get efficient, feed the family, survive. Now, it's just figuring out how to keep up efficiently with the health needs of over 1000 people." I am at the "get efficient" stage.

Time to get to work.

I'm Back

I haven't posted in a while, but I am still here, plugging away in my solo one-doctor Gordon Moore-type practice. Not much has changed since I last posted. I am still seeing about 20 patients/week, although it dropped a little when I temporarily closed my practice to new patients in November and December. I did that in order to catch up with my medical billing, although I seem to have fallen behind again. I have come to the realization that I am not disciplined enough to "do all of today's work today" and am seriously considering getting someone to help me with some of the billing/administrative work. But that's something that will come later.

In the meantime, I hosted another 3rd year medical student (this time from USC) for a 5 week family medicine rotation which just ended last week. Although we didn't have a whole lot of patients (which I feel bad about), hopefully we made up for it with quality over quantity. As with other students who have rotated with me, I asked her to write down some of her impressions in working in this type of medical practice. This time, in response to a previous comment by Dr. Mathew Wang, I made sure that I completed my student evaluation BEFORE receiving her write-up so that it would be as unbiased as possible.

"A completely different type of practice! When I first called Dr. Seto to set up my family medicine rotation, he was hesitant, saying he wasn't sure if I would want to come to his office. He went on to describe that he ran a solo practice, no staff. He said he also usually only saw about 4 patients per day, never more than 8, and sometimes made housecalls. This sounded interesting to me, so I signed up. It was great. The level of patient care he could provide was second to none I have ever seen. The open access model was incredibly appealing. His patients were very satisfied. I thought it was great that a patient could call with a complaint, and Dr. Seto would say, "Can you come in right now?" Amazing. The amount of time spent with the patients was about four times that in most offices I've seen. This was both great for the patient, and great for me. As a medical student I appreciated being able to work through the problems and not rush, and being able to observe Dr. Seto give a truly comprehensive evaluation to the patients. I imagine an outing to the doctor for most people is a one to two hour trip or more. The difference with Dr. Seto is the one to two hours is all with him, not in a waiting room. I felt lucky to be able to get a glimpse of this type of practice is run. Yes, there was downtime, but I always had reading to do. This was when Dr. Seto would do some of his administrative work. I hope to see more practices like this one in the future."

Mariah Baughn
MSIII

Thanks for your comments, Mariah, and for graciously allowing me to post your name.

I hope to see more practices like this in the future, too. That is why this blog exists. Because I believe the practice of medicine can be much better than the way it is being delivered to the majority of Americans right now. I don't know if this is the best way but I think my patients are happy, as am I. How many patients and doctors can say that? I think it's interesting that whenever I run into someone I used to know at my old job, they often ask me, "Are you happy?" to which I always answer a truthful "Yes". So this venture is a work in progress, a story that is still being written. Hopefully, one with a happy ending. Okay, I'm ready to start the next chapter.