Where do future family doctors come from?

I came across a recent news article describing how Tulane University is fostering future rural family doctors. There is no question that there are many medically underserved areas in this country. It is also a well documented trend that fewer and fewer medical school graduates are choosing to go into family medicine. It would seem wise to me that instead of focusing on just taking the "best" applicants, medical schools should make a more concerted effort to take the willing, those who want to practice in underserved areas.

In my 2nd year of medical school, I was one of the student representatives of the admissions committee, and we all did our best to find those applicants who appeared to be "doctor" material. Our tools: GPAs, MCAT scores, letters of recommendations, the application form with its one page essay, and for those who made the cut, the live interview. It was always interesting to come across wonderfully articulate essays, and later discover during the interview that the alleged author had at best a weak command of the English language. I learned that lukewarm letters of recommendation ("Joe was a competent student who displayed satisfactory knowledge of the subject material.") could be worse than having none at all. It was then that I realized that anyone who could appear not to be psychotic for at least 15 minutes (twice) could become a physician. This method of selection turned out not to be foolproof, as least at my school.

But it would take some kind of concerted and institutional effort by medical schools to instruct their admissions committees, most of whom are not in primary care, to go after students who showed promise and interest in practicing primary care in underserved areas. A difficult, if not impossible, task. But if our admissions committee had been given specific criteria on what to look for, I'm sure we would have complied. At least, I would have.

From the article:

The school is looking for students like Dr. Margeaux Coleman Walker, who has known she wanted to be a doctor since she was 11 or 12 and helped her grandmother clean the doctor's office in Church Point, a town of 4,700.

But she wants much more than a medical practice. "Hopefully, when I want to retire, I'll be able to say, 'I worked hard and I made a difference in people's lives."

And more:

"If you're looking for more of a 9-to-5 practice where you can sign out and someone's going to cover for you," rural medicine isn't for you, said Dr. James E. Devlin, a graduate of the program.

He's a solo practitioner in Brockway, Pa. (pop. 2,500), checking his hospitalized patients seven days a week. It's hard to find someone to do that if he wants a vacation. But he knew growing up that he wanted to go into practice with his father, who has since retired.

He said he loves being a big fish in a little pond. But more, he loves knowing his patients as friends, as church members, as people. Being part of their community. "I wouldn't trade that for anything," he said.

That's the heart of the matter for Coleman Walker, too. She has done month-long medical school rotations with the current doctor in Church Point, and wants the sort of bond he has with his community.

"He's not only the family doctor - he's a teacher, kind of like a big brother, a dad, because he has to reach out to the young kids and help them, guide them," she said.

OK, I'm not a rural doctor in an underserved area. But I'm trying to bring a similar kind of close patient-physician relationship back to the suburb where I'm at. I think there's a need for this kind of care anywhere. We need to find more doctors and future doctors who are willing to serve people in need. Like in family medicine.

**********

In the meantime, I've been spending a lot of time trying to catch up on my medical billing. I'm learning if it is worth it to wade through telephone trees and wait on hold for 15 minutes (or more) just to get the health plan to give me 10 more dollars for an injection administration fee that I forgot to bill. Or to find out the reason they denied the $160 charge for a well child exam is because it is a non-covered benefit. For now, I guess it is, because I've got nothing else better to do as I continue to wait for my patient panel to grow. And fortunately, it is growing.

The newest medical tool: an iPod

How's this for convergence? Radiologists at UCLA (Go Bruins!) have figured out an excuse a way to use iPods in their medical practice. Their (free!) product is called OsiriX and helps to manage medical images on the iPods hard drive.

Now if only some bright person could come up with a medical application that primary care doctors could use on an iPod, then I'd have an excuse, uh, I mean, justification to buy one of those little guys. Besides listening to music, that is. C'mon, Epocrates! Port your drug reference over to the iPod, and you are guaranteed an instant market.

Merry Christmas, Happy Holidays, and Happy New Year!

From (flu shot) famine to waste

Like many doctors, I had my order of flu vaccine cancelled because the company I ordered through was selling the Chiron product. Luckily, I had ordered some pediatric doses of flu vaccine just a few days before the bombshell news so I eventually got 10 pediatric doses. Since I didn't have any eligible patients under 3 years of age, I combined 2 doses to make enough for an adult dose and was able to give it to 5 eligible patients. However, I was surprised that even in my small practice, I was having trouble finding patients to give it to. Some of my patients who need it the most still refused to get it, saying they didn't believe in it, or that they had gotten it once and it gave them the flu.

Before I got my small shipment of flu vaccine, I received many frantic calls from patients, both high-risk and not, looking for flu shots, I recall reading about people going across the border to Canada just to get a flu shot.

Now on top of news that the US has secured additional flu vaccine, I'm not surprised to see reports that some flu vaccine may get wasted because either the restrictions were too effective, or many eligible patients are declining to get flu shots.

-----

I'm still in solo practice, just not blogging. I've been steadily seeing about 40-45 patients/month for the past 3 months, so I've reached some steady state for now. I think I'll need to try direct mail advertising to reach ALL the local households if I want to quickly grow my practice. We'll see how I manage that in the coming holiday weeks.

SpringCharts on a Mac

While researching whether I should upgrade to version 7.0 of SpringCharts, I found this article about another family doctor who also uses SpringCharts with a Mac. (Besides me, that is.) I keep thinking that as smart as doctors are supposed to be, why don't more choose the intuitive, hassle-free Mac platform, rather than the buggy, insecure Windows platform?

"I hear it all the time from other doctors," says Michael Marlow. "They'd like to move to an EMR system, but their partners aren't ready." To convince his own partners that SpringCharts on Macintosh was a sound business solution, Marlow used a number of very logical - and ultimately, persuasive - arguments:

Affordability. "It's far less expensive, in the long run, to own and run anything on Macintosh. Because it lasts longer. The software technology doesn't outpace the hardware technology - or vice versa - within sixteen or eighteen months, like it often does in the Windows environment. And the cost of technical support is minimal."

Ease. "It's easy enough for someone with average skills to install the network, the hardware and software. You don't need an IT support person to come in and do it for you. You may choose to, because you're pressed for time. But if you have the interest; you can do it yourself."

Security. "When you're dealing with confidential patient information, Mac is a far safer choice. It's extremely difficult for someone to get into my network from the outside. But for them to get into my Power Book is almost impossible. And viruses? With Mac OS X, they simply don't exist on the Mac."

While the other two physicians in Marlow's practice have yet to make the leap themselves - "they're still scribbling notes on paper," he smiles - they are impressed with "the oohs and aahs they hear from patients when they see what I can do with my PowerBook."

Come to think of it, I'm still scribbling my notes, too, then retyping everything in later. Maybe I should skip a step and just type everything in at once. I'm proficient enough of a typist where I can type and maintain eye contact at the same time. I'll try it on my next few patients and see if anyone oohs or aahs.

The Ideal Doctor

Found this great NY Times article by way of Medrants.

In my idealistic zeal (okay, what little I have left), my first thought after reading this tale of two interns was that I would rather be like the caring but overworked intern than the efficient but emotionally detached one. In fact, that has been my practice style for the past few years, with the typical results: my self-respect intact but my life an eternal Sisyphean struggle.

As I thought about this more, I realized that these are not the only two choices. Couldn't it be possible to take the best from both practice styles and meld them into one? An efficient, unoverworked, caring and careful doctor who still has time for family, friends, patients, self and sleep? Who not only feels valued and respected, but is also able to generate a reasonable income that is sufficient to pay off school loans, raise a family and live comfortably too? A good doctor who is also a happy doctor? Am I dreaming?

And then I got to thinking, what would be an ideal doctor anyways? It depends on who you ask.

Patients want a doctor who listens, is compassionate, and treats them with respect. Some people have specific criteria or a checklists of things they want to see in an ideal doctor. But many of these things, such as having a courteous staff, or not being rushed because of an overbooked, may be out of a doctor's control. So when people say they want an ideal doctor, they really mean an ideal health care system.

And even though people want a patient and caring doctor, they also expect a doctor to be knowledgeable and clinically competent. Makes sense. Various medical organizations expect an ideal doctor to meet certain endpoints as a surrogate for knowledge and competency.

Many people's ideal doctor is someone like Marcus Welby, M.D. But you know what? Robert Young, the actor who identified closely with the role he played, suffered from depression and had an alcohol problem. If that is what happens to a fictional ideal doctor, imagine how hard it must be to be a real one.

Other television shows have inspired others as to what an ideal doctor should be like. When the British Medical Journal was conducting a survey of the best doctors of all time, real or not, Medpundit wrote:

My vote would be for Dr. McCoy. Despite living in a high-tech world where diagnoses could be made with the pass of a scanner, he never lost sight of the essential requirement for a good doctor: keeping the humanity of his patients at the forefront. He treated enemies and crew members with the same dignity and respect and competence. He was a hands-on doctor, and compassionate. Unlike later Star Trek doctors who spent more time beside their computers than at the sides of their patients, he was always at the bedside, keeping an eye on his critically ill patients. In many an episode he pulled all-nighters to come up with a cure for the latest alien malady to strike the crew. He never hestitated to stand up to his captain if his orders were contrary to his medical ethics. And, I suspect, he was the inspiration of many a child from my generation to go into medicine. (Although you won't find it admitted on any medical school application essays.)

And what about doctors themselves? Most doctors and doctors-to-be recognize the importance of emotional and financial self-preservation.

Patch Adams, MD had this to say about what he values as a physician:

My God, its friendship. Remember, I make my patients my friends. I can't distinguish between them. I don't want a patient that isn't my friend. I want to be intimate with every person that dares be intimate with me. I'm very confused about my boundaries. I literally want to fall in love with every person I'm with. I want that kind of relationship because I love friendship. It's just such a magnificent creation.

And I am curious about people. It doesn't matter where people come from for me. I just want to be with people and enjoy it. The magic of being a physician is that they will let you into their lives. If they perceive you care, they will let you into their lives in ways you cannot dream. People spend their lifetime with a friend trying to get what I can get on the first encounter with a patient. It's pretty breathtaking.

Okay, I'm not going to be best friends with all of my patients, but he's got a point. It's not about being an ideal doctor, isolated in a vacuum. Doctors can only be doctors if there are patients. So it's the relationship that we want to be ideal. All doctors have patients who love them and others who hate them. It's about the right personality match.

It's not about being a perfect doctor, because no one can be perfect. Personally, I think malpractice lawyers (intentionally or unintentionally) continue to foster the myth of a perfect doctor so that they can continue to blame doctors when they prove to be only human.

Patch Adams again:

Also, malpractice is wrong. Malpractice insurance set up an adversarial relationship with your patients. You get afraid if the patient is your adversary. The doctor says, "God, I made house calls, but then my hunch said don't get an X-ray, so I didn't get an X-ray, and they sued me to the wall". We do not carry malpractice insurance. We will not practice in fear and mistrust. In addition, the whole malpractice thing inadvertently reinforces the doctor-as-God concept. If we can't make mistakes, we must be perfect. It also implies that the doctor is responsible for the cure and the patient is the passive recipient of it.

Perfect is the enemy of good. As long as we expect perfection, nothing will ever be good enough. As long as people continue to die or have imperfect outcomes or are unhappy because they feel disrespected, there will be malpractice lawsuits. Which result in higher judgements because of injury inflation. Which means higher malpractice insurance costs. Which means doctors have to see more patients to pay for their premiums, and have to order more tests to protect themselves. Which means higher health care costs for everyone. Which means people expect even more for their hard earned money. Like perfection. Which keeps the cycle going.

For me, I think being an ideal doctor is about being trying to be a decent human being, treating trying to treat others as you would like to be treated, and balancing these with accepting that I can't do everything for everybody and that it's okay to say, "No". All while sharing an experience called life together. Let's see if it works.

Making Contacts

I haven't posted in a while but I'm still here, still in business, still slowly growing, still behind on medical billing, still finding it hard to find time for blogging.

I've gotten a number of calls from doctors who read the article about me and my solo practice in American Medical News, some to ask me questions about how I'm doing things (and how I'm doing, financially). A few have called to say that they've already been there, done that, and offered encouragement to hang in there. It makes me wonder how many other doctors are out there already doing what I'm doing, but who haven't been publicized. Quite a few, I think.

One particular local general internist has gone out of his way to help me. He went solo 7 years ago and now has a booming practice. He has been closed to new patients for the last few years. He read about me in AMN, then called me to see if I wanted to meet for lunch. I visited his office, and he gave me a copy of his original business plan (which was better than mine but similar in many ways), and gave me pointers on how he started his practice.

After residency, he had been working for a group of older internists and he was very busy, and getting busier. The older partners weren't that interested in working as hard, so the younger doctors saw a lot of patients. Since they were thinking of retiring, they offered to sell the practice to him and the younger doctors for more than he was willing to pay. They ended up lowering his pay, so he decided to quit and set up his own solo practice. However, he decided not to sign up with any HMO contracts, which at the time was considered very radical. He was called crazy by his colleagues and written up in newspaper articles and interviewed on national news networks.

(Arizona Republic; 03/21/99)
Now is the winter of doctors' discontent. Across the United States, doctors are complaining that the era of managed health care has robbed them of autonomy, income, time, prestige - even self- respect.

"This is life in hell," says Rex Greene, a Pasadena, Calif., oncologist and president of the Los Angeles County Medical Association - and he says he's an optimist.

A growing minority is rebelling - dropping health-maintenance- organization contracts, seeking clout in professional alliances or unions, filing lawsuits, retiring early, going out on disability or moving out of markets colonized by managed care.

Consider the San Diego gastroenterologist who slapped his physician group with a lawsuit after he was fired for spending too much time or money on patients. Or the cardiothoracic surgeon from the same city who moved to South Dakota, where managed care is nearly non-existent. Or the Pasadena internist whose frustration forced him to cut all ties to HMOs.

"I have been unneutered, restored to my vigorous self," said internist Andre Ettinger. "I can take care of patients rather than having to punt the ball all the time."

Times have changed. Managed care is no longer the main game in town. I have personally chosen not to sign up with any HMO or capitated plans, and this is no longer fodder for national news.

Hopefully, like this doctor, I will succeed without any HMO contracts. The key to his success, he feels, was in introducing himself to other doctors on the hospital staff. In other words, networking. He would have lunch in the doctor's dining room, and chat with the doctors who were there, and later that afternoon get a call from a patient who was referred by one of the doctors he had lunch with. Eventually, he had more than enough patients and he was on the road to a successful practice. Perhaps too successful as he now finds himself staying late, squeezing in extra patients, etc.

He said he is grateful to the many doctors who helped him get started, with no gain for themselves, simply because they wanted to help him out. Now he wants to "repay" their kindness by helping new doctors like myself out, and I'm very grateful for his help.

I hadn't really considered other doctors as a major source of patients. I figured other primary care doctors might see me as a competitor. And I thought specialists only received referrals FROM other doctors, not made referrals TO other doctors. But there appears to be a collegiality among all the doctors I've met so far. Since this doctor's practice is closed to new patients, he said he is actually glad to know of another doctor he can refer new patients to. And apparently, lots of specialists see patients who are looking for a primary care doctor and hope for a recommendation from their trusted doctor.

So this week, he introduced me to a dermatologist. Next week we're meeting an Ob-Gyn and an orthopedic group.

Apart from his contacts, I'm finding out how important networking is. I just mailed a practice brochure and business cards to another Ob-Gyn who contacted me after reading about me in AMN and, feeling a kinship because of our mutual solo status, requested some business cards. And a gastroenterologist I referred a patient to also asked for some business cards. At this rate, I'm going to need to order more business cards. I hope this translates into new patients, but it certainly can't do any worse than my ad in the local church bulletin: $400 annually for a weekly ad = 2 patients (so far).

Going Solo Together

There are probably as many ways to configure a high quality, low overhead practice model as there are physicians. Greg and Heather Sharp are a physician couple who have set up a shared practice. The following describes how they did it:

-----------

Practice Design
On Sept 6th we opened our practice in Woodland Park, CO. Some of you may recognize this as the home of Michelle Eads, who has been a wonderful help and encouragement to us and pointed us to this listserve group initially. We are a husband and wife pair of family doctors who are sharing one full time practice. We are drawing from Gordon Moore's low-overhead, high-quality model of practice, my Father's home office in Houghton Lake, MI and the SimpleCare approach to practice billing. We have one insurance contract and offer a 25% discount for anyone who pays at the time of service by cash, check or credit card. We hope to attract the uninsured, those with high-deductible insurance/HSA, and anyone who doesn't meet their plan's annual deductible and wants accessible, personal, and affordable care. That being said, over two thirds of our first month's patients (28 in all) have had the one insurance we contracted with. In the name of simplicity, and to fully commit to a discounted fee for service model we have opted out of Medicare and Medicaid. This has been a challenging decision and we are not sure yet if this will be a permanent decision, but we would like to give a hassle-free approach a fair try.

Space
We remodeled 750 sq ft in a professional building next to the town post office with a small office, one exam/consultation room (10x14 is a nice size), one procedure room, a restroom, and waiting room. We are paying $12/sq ft/yr plus triple net expenses that comes to just over $1000/month for a two year lease. The landlord split the remodeling costs with us 50/50 but this had to be negotiated. We are quite happy with the amount of space that will allow both of us to be in the office from time to time.

Technology
We are using Amazing Charts for EMR (and eagerly awaiting the next version), but are not using much beyond the patient record and prescription/order writing features. We have had good results with "printing" orders and scripts to the fax machine and have them sent directly to pharmacy, lab, etc. We are using Microsoft outlook to store patient demographics and business contacts which helps with storing fax numbers for use with sending faxes as described above as well as improved mobility with patient contact info in our PDA, and emailing with patients which Amazing Charts messaging does not support. In order to allow us to schedule appointments remotely, we are using the calendar within Outlook which also will interface with a PDA. We looked into PDA/cell technology that would allow real time synchronization with the office Outlook remotely but don't feel the technology is quite there yet.

We bought one new Dell desktop with hyperthreading processor and it has handled everything well so far. We enjoy our dual flat-screen monitors as well, which make running several programs simultaneously so much easier. We wired our office with Cat5e cable for additional computers and bought a network ready Brother printer (HL5170DN) with extra paper tray that has worked extremely well. The additional tray is used for a green security paper for printing prescriptions out of amazing charts when we can't fax them to the pharmacy. Our current network of the computer and printer only required a netgear VPS318 router that is VPN ready (Virtual Private Network for home access).

We just purchased a Visioneer one touch 7300 USB scanner this week and am happy with the one-touch scanning to PDF files which can then be marked with comments/highlights on the computer and stored to a patient file library on the hard-drive allowing us to go paperless. This requires the full adobe acrobat program, not just the free acrobat reader. We have a CD-RW drive which we are using to backup our files weekly.

Phone
We currently have one cell phone, one voice line at the office, and one fax line. We tried to put the fax and phone on the same line with a distinctive ring feature, put this was not practical because we wanted to forward calls. We are forwarding calls after one ring to the cell phone while one of us is with a patient so that the other one at home takes the call. We have voicemail on the cell phone. For office calls that aren't answered (when call forwarding is off) we have an answering machine with a message that includes our cell number for urgent issues. With only one person in the office, we also ordered call waiting so that we can avoid patients getting a busy signal if we are on the office line.

Billing
We are using QuickbooksPro2004 for our practice accounting as well as patient billing. We are also using the Quickbooks card swiper and merchant services for credit card service (VISA, MC, Discover, Amex). No problems so far with credit cards. The swiper was cheap, it auto-enters everything into Quickbooks, it takes up minimal space on our desk and there is a discounted card-swiped rate for transactions. For insurance claims, we are producing HCFA 1500 forms with the EZClaim software and then printing them and mailing them in or giving them to patients for reimbursement from insurances we don't participate with. EZ Claim also has an EZ Link module which exports the HCFA 1500 data to Quickbooks as invoices so that we can track our accounts receivable/insurance payments. At my Dad's recommendation we also purchased FlashCode which has been very helpful in building our fee schedule and exporting CPT and ICD-9 codes to Amazing charts, EZClaim and Quickbooks (for invoices/cash and credit receipts). The FlashCode customer service has been the best I've seen. I am still waiting on the Quickbooks Customer Manager software which should eliminate double entry of data between Quickbooks and Outlook.

Equipment
We were fortunate to get used exam room equipment from our former employer when they sold the practice to the local hospital. We were able to get exam tables, an autoclave, surgical instruments, mayo stands, trash cans and procedure lights from them for a good deal. We also had some exam instruments left over from medical school. Most of our new medical equipment purchases have been for disposable items. These supplies have cost roughly $2650. I have our inventory lists as an Excel file for any of you who might be interested.

Marketing
As has been said on the listserve before, word of mouth seems to be the primary method of marketing that works. We had an article about our practice in the local paper business section that was also very productive. Newspaper ads have been disappointing, but without a listing in the phone book they probably serve a purpose. Most of our patients have come from personal contacts around town, and the local chamber of commerce has been a great help. They are holding a ribbon-cutting ceremony for us in a couple of weeks. We left a full practice 3 hours away to come to a new town, so we knew that we would have to count on slow growth. We have actually been quite happy with how our model has been received and with our panel of 28 patients after one month. The female aspect of our male-female team is undoubtedly an asset in marketing to the community. Our future plans include arranging talks at the senior center, to civic groups and hopefully in the schools to spread the word about what we are doing. Dr. Eads' practice has already made the public here more receptive to a non-traditional format of practice.

With the help of my brother and the websites of others on this listserve, we do have a practice website which describes our practice philosophy in more detail. It's www.idealfamilyhealthcare.com. We hope to make it more interactive for patients in the future.

Financing
We hopefully have the bulk of our startup costs behind us and have currently borrowed $26,000. We don't plan on having a salary for a few more months. We are paying student loans with the proceeds from the sale of our previous home in Alamosa and living with family until the practice is established. We have a cash-flow projection that has us paying off our start-up loan by the end of our first year and a joint salary of $70,000. Only time will tell how close this is to reality. We have planned for the long haul with advisors telling us to count on up to 18 months to break even. I don't think it will take that long because thanks to low-overhead, it's no longer that hard to break even. We are enjoying this new pace of practice and the freedom of setting up a new business immensely.

Thanks again to all of you. I hope this is helpful. We really appreciate the encouragement of you like-minded pioneers out there.

Greg and Heather Sharp MD
Ideal Family Healthcare, PC
PO Box 4918
Woodland Park, CO
719-686-8844

----------

Congratulations to Greg and Heather for taking the leap! While I don't expect this practice model to replace what's out there now, the fact that more and more physicians are trying this shows that there is a unfulfilled need for this kind of simpler and more personal kind of medicine that is greatly satisfying to physicians and patients alike. This isn't how most of primary care medicine is delivered now, but perhaps it should be.