Ideal Medical Practices

Another primary care practice bites the dust

Annie responded to a question: "Why are you quitting your primary care practice to become a hospital doctor [hospitalist]?"

Hi Katie,
I am happy to share my experience as it develops.  I am not yet in the new job, but can tell you that it was sort of by accident that I have drifted into the hospitalist role.  I did not set out to find such a job.  Initially I was looking for a hospital or community supported outpatient situation in another state to ease a transition back to IMP-dom [Ideal Medical Practice] in a more favorable economic environment (having finally accepted that Lexington IS a very toxic dead zone).  Alas, when push came to shove, my husband, who initially said he would consider moving, dug in his heels and said he wants to keep his practice as is until he retires (he is 64 and thinking of retirement over the next 3-5 years).

So, off to the marriage counselor....decide to stay married after all.......And look for something workable.  Interviewed with the prison system.  YUCK.  Talked with a house call only company in Cincinnati...sounded OK, but too far to comfortably commute daily.Talked with the health department....realized I'd last a few weeks before the bureaucratic headaches drove me insane.     Then got a call from a recruiter about this hospitalist job.  Seven days on, seven days off....hmm...

As I mulled that over, I continued my constant internal "post mortem" on my practice and why I am finally giving up.  Decided that the final straw has been Medicare part D.  The incredible burden of pharmacy management along with the demands of being a "medical home"  (read "unpaid customer service department for every other part of the healthcare system") has meant that I now do three days of free service for every two days of actual patient care, and "consumer directed" health plans have meant that more and more often I never get paid at all, even for the actual patient visits.    All of this adds up to my loss of faith that primary care will survive at all, at least around here.  And since moving to Oregon is off the table, that tipped me into the "I'm not only quitting being an IMP, I'm quitting primary care.  Period."

So I went to the town with the hospital job.  It's an hour and 20 minutes from Lexington.  The hospital is smallish (94 beds) but in good condition, and even has a cool robot that specialists from Louisville use to "consult" (I can't wait to see how that works).  Everyone I talked to seemed genuinely happy and to like each other.  They have one hospitalist now, and he's been doing it mostly by himself with some help from a locums that the recruiter who called me provides.   The census runs around 8-12 most of the time now, and the most he has ever had was 22 on one Saturday.  (the hospitalist I have covered for in Lexington keeps a census of 18 to 30 most of the time, so I have come on board with 22 patients, all new to me, at one time on several occasions.  Can't say I enjoyed that, but proved I can do it if I have to).  Obviously, if it is going to survive long-term, this hospitalist program will have to grow some, but they seem committed to making it a reasonable growth plan.  They don't want to risk starting it and then having the hospitalist docs quit and leave.  The CEO knows that she has only one shot at satisfying her local primary care community if she is going to get their business, so she is ramping up very slowly.

Then there is the town.  I won't bore you with all the prosaic descriptions of small town characteristics. Suffice to say that the hospital has farm land on two sides, the stock yard is right next door to the Wendy's, and I could buy farmland there for about 20% what I would pay in Lexington.  In short....I love it.  My husband also likes it enough to consider retiring there, and meanwhile it is an easy drive for me to make each week and he can visit midweek if he wants, or not, because I'm taking a horse or two with me each week so I won't be lonesome.

When you consider that I will be making five times what my practice has been paying me, plus all the typical stuff like health insurance, actual PAID VACATION...( I haven't taken a vacation except IMP Camp since 2004)....  Well, I'd have to be pretty stupid not to give this a try.

Stay tuned for how it works out.  My first week on the job starts on May 5th...Cinco de Mayo...hmmm
Annie Skaggs MD
Lexington KY

Six Year Anniversary

Although hard to believe, tomorrow marks the six year anniversary of my practice. During that time, I have had over 15,000 visits from over 2000 patients. I watched babies from their first week of life grow to the point they are now ready for first grade. I diagnosed and treated diseases, reassured those who were healthy, and watched helplessly as some die. I became engaged in my neighborhood (where my practice is located) and have spoken at numerous schools at all levels. Articles were written about my practice in local and national journals and I even tried my own hand at writing some op-ed pieces. I had the pleasure of watching as the IMP movement grew from a few crazy iconoclasts into a real force on the cutting edge of medicine. I have spoken at state and national conventions and, through the support of my fellow IMPs, I have even won an award. Through the guidance of John Wasson and Gordon Moore, I understand more now about the doctor-patient relationship and what constitutes good medicine than I ever thought possible, and strive as hard as I can to improve the care I give to my patients. Along the way, I never missed one of my childrens' school meetings and made almost every field hockey or soccer game. I even completed two marathons (which were very painful). Though in constant motion, my personal and professional lives are in sync with each augmenting the other. I am happy.

I write this not because I am a narcissist gloating over what has transpired, but because I feel strongly if I can do it others can. Happiness and success is possible in primary care, but the practice has to be specifically set up to allow it to happen. Automony (the ability to make and implement decisions you deem best for patient care without outside interference) and Breathing Room (the time set aside each week to focus on improving you and your office) are essential. I have made many mistakes over the past six years, but having the time to assess my processes and the flexibility to change them allows me to learn from my mistakes and encourages my practice improve and evolve.

With all that said, my fear is that the future of my practice is still in doubt. I can see practicing like this for years or even decades longer, but the environment surrounding primary care is toxic and depressing and worsening every day. My practice is still running on a razor thin margin and my take home salary remains less than it was in my previous practice. Although the quality I am delivering is much better than average (and I have the data to prove it), insurance companies are rejecting more claims and are putting ever increasing administrative hurdles (prior auths, referrals, etc) in the way. These financial uncertainties and administrative insanities combine to make my practice's future look murky. I love what I do. My patients love what I do. The larger community seems to love what I do. But, I'm not certain I will still be around in another six years because an insane payment system makes it impossible to stay financially viable. That realization is a rather bitter birthday pill to swallow. 

John Brady

Mr. President - the current health reform plan without robust payment and delivery system redesign will be a political and ethical disaster

I was not at all surprised to read a piece in the Boston Globe:  ER visits, cost in Mass. climb

High performing health system achieve better outcomes, improved experience of care and at lower per person cost than the non system we have in the US.
High performing health systems have comprehensive primary care as their foundation.
Comprehensive primary care is defined by a patient population who can say:
"I can get care when and how I need it"
"I have a PCP who knows me as a person"
"My PCP cares for the bulk of my needs"
"If I need care outside my PCP office I know who to turn to, my PCP coordinates my care"

Presence of these attributes has in published studies reduced hospitalization rates, emergency room use, improved presenteeism at work and school, improved rates of preventive care and the effectiveness of chronic disease management.   Presence of these attributes results in improved experience of care and the aggregate effect on the population results in reduced per capita costs of health care.

The work of comprehensive primary care is blocked by payment policies that make primary care a repugnant career choice and punish PCPs for engaging in the full scope of work of comprehensive primary care.  The solution to the problem is health reform.

Health reform requires three elements:
1:  Everyone has access
2:  The money flow inside health care supports the desired health outcomes and the work it takes to get us there
3:  The work of health care is redesigned to support the desired health outcomes

MA provides false access and maintains a broken and dysfunctional delivery system.  MA moved on #1 without making any substantive move on 2 & 3. That the current plan results in an angry disillusioned public and increased costs with no demonstrable improvement in health outcome was a foregone conclusion.   Our nation is about to embark on the same path.  If it continues on this trajectory I predict a disappointed and angry nation paying more for bad care in 2012.  Woe to the party tagged with this disaster.

The nation need not follow the mistakes of MA.  Invest in serious payment reform and simultaneous delivery system redesign - not the tepid incremental programs that provide marginal improvement, but truly innovative solutions that give us the breakthroughs in outcomes.  Use the burning platform and your bully pulpit Mr. President and step boldly forward to embrace the true solutions you espouse.

L. Gordon Moore MD

Why won't Wyeth sell single dose Prevnar?

Jean Antonucci MD in Farmington ME is in a jam that is reflective of many solo independent practices in the States.  Because of rampant poverty in ME, many of the children who come to her are covered by a state vaccine program.  The few remaining don't make up much volume in her practice. 

Jean sees her role as a primary care clinician providing vaccine administration because it is the right thing to do. 

The problem is that Wyeth won't sell Prevnar in less than a ten pack.  With the low volume need in non-state covered kids, the ten pack goes bad and Jean has to eat the cost. 

Jean is getting past the learned helplessness of many PCPs and called Wyeth directly, eventually speaking to David Ross, A.V.P. of Wyeth Vaccines.

Here's a paraphrased quote: "Dr. Antonucci - this is the first I've ever heard of this problem.  You're obviously a unique doc and we can't change our way of business just for one doc.  If I heard from lots of docs that this was an issue, then maybe we could do something."

I found Mr. Ross' contact info on Plaxo and left him a polite voicemail. It took all of two minutes. Maybe others would consider doing the same.  [I also set up a web page for this on SavingPrimaryCare.org] 

We should not ask Jean and many other independent practices to choose between giving up on vaccines (turf to the health department) and eating the (substantial) cost of wasted vaccines.

Wyeth could package and ship individual vials.  Wyeth could partner with a distributor like Cardinal Health.  Wyeth could partner with retail pharmacies.  There are options in addition to "suck it up."

L. Gordon Moore MD

How odd - the public doesn't necessarily believe that EMRs will improve their care

NPR / Kaiser / Harvard School of Public Health published a poll that shows that, for the most part, the public is on our side.  They believe that “their doctor” is the best to take care of them, make decisions and decide what is the best treatment,  and that  insurance companies and government should stay out of the decision making process.  The poll shows that the public believes that we are trying to keep cost down and that insurance should pay for all services asked for by their doctor.

The poll also shows that the public, as us, believes that just spending money on EMR’s is not going to improve their health or bring cost down; the most important part, it seems, is their relationship with their doctor.

Personally, I think that we should make sure that the government and all powers at be, understand this plain and simple reality.  This poll validates my point that we need to bring our patients into the fray; they should populate the barricades with us.

José E. Batlle, MD
Hoboken NJ

Grateful

I met Beatrice (not her real name) a little more than 2 years ago. She had just turned 90, and her daughter brought her in because she had been feeling a little more tired and short of breath lately. As she put it, she was having problems "getting going" in the morning. She had rarely been to a regular medical doctor, preferring homeopaths, in line with her beliefs as a Christian Scientist. 

Up until a year before, she had been living for 19 years in Ojai, CA, 9 of them with her husband who passed away 10 years earlier of lung cancer. She had been active and doing yoga up until 1 year earlier when she fell and broke her arm. Ever since then, she had been living in an assisted living facility closer to her daughter. She had also been developing signs of Alzheimer's dementia over the past 4 years.

Beatrice was a pleasant and cheerful woman who acknowledged having some memory problems but kept repeating over and over again how “grateful” she was for her life so far. She proudly told how she was one of the first female bank tellers before she became a permanent homemaker. She also mentioned how throughout her life she never liked to take medicine or see doctors. 

After examining her, I discovered that she had atrial fibrillation causing mild congestive heart failure, which was also the cause of her shortness of breath and fatigue. She also scored 13 out of 30 on her Mini-Mental State Exam, consistent with moderate dementia. Beatrice went home without any medications because her daughter wanted more time to think about what to do next. This first visit took 90 minutes.

After a series of e-mail communications and a follow up visit, we agreed to start Beatrice on some medication to help her breathe better. Over the next few months, she gradually improved with medication to the point where she was breathing comfortably again. Her daughter told me that while Beatrice couldn’t remember anything about what we had talked about, she did remember me and liked me. 

I would see Beatrice several times for follow up over the next 12 months, and even though she couldn’t remember what she had for breakfast, each time she would smile and say how “grateful” she was for everything. That seemed to be the one thing she would never forget. She remained stable as far as her breathing but her dementia continued to worsen ever so slowly, and eventually she started having trouble with agitation and even remembering who her daughters were sometimes.

Unfortunately, this happens all too often with many elderly patients in this day and age. Even as you wonder if this is the kind of life they, or anyone, would want to have, it is often too hard to stop giving medications that you know are helping to keep someone alive.

In a typical busy doctor’s office, there just isn’t enough time to talk about what is really important to her or her family. It would just be assumed that we should just do our best to keep her heart from going into rapid A-fib and developing congestive heart failure, and to do otherwise would be unmerciful. And so, Beatrice would continue to take her Digoxin and Lasix, and her mind would continue to gradually wither away, losing bits and pieces of herself as time went on. 

And eventually she would get a stroke and lose her ability to walk, speak or feed herself. Or she would fall trying to get out of bed in the middle of the night and break her hip. And she would end up bedridden and develop pressure ulcers on her fragile skin. And finally, if she didn't die of something else first, she would end up in a “persistent vegetative state”, her self-awareness gone, left with only a thin, frail body curled up in a nursing home bed, kept from malfunctioning further with well-intentioned medications, waiting to die.

That is, she would have if she had received care as usual. 

Instead, I had long discussions with Beatrice’s two daughters that started 9 months ago, in person, by phone and by e-mail. We discussed the likely outcomes of continued treatment along with that of stopping treatment. We discussed adding medications to treat her agitation and anxiety and their potential side effects. We discussed what Beatrice valued in life, what her preferences would have been and what she would have chosen for herself, if she were able. We discussed their concerns that their mother not suffer. 

After 4 months of discussion and reflection, her daughters decided that a palliative approach was what their mother would have wanted and started inquiries into hospice programs. A month later, she had enrolled with a hospice program, and I stopped directing her medical care, since the hospice program already had a physician. 

Yesterday, I received an e-mail from Beatrice’s daughter saying that, after a few weeks of terminal agitation, her mother had passed away peacefully. 

I’d like to think that Beatrice was grateful to go this way. 

I'd be grateful if every primary care physician could be given the time and paid for the time to do the right thing for their elderly patients, rather than give "care as usual".

Gary Seto, MD

South Pasadena, CA

Let's hope Ezekiel Emanuel can help the White House see beyond improved coverage

I see that Ezekiel Emanuel MD is advising the White House Budget Director Peter Orszag.  This is a very good thing as Dr. Emanuel is a brilliant thinker on how we might reform the way America purchases health care.

Zeke – please tell me that there is more to the White House plan than just moving us toward universal coverage.  I’m totally in favor of universal coverage, it’s just that without changing how the money flows inside health care or changing the way we work in health care, we’re just going to add immensely to the expense of health care.

Orszag rightly identifies health care reform as a necessary step in fixing the economy in the US, but the fix has got to be based on more than “HIT” and “more focus on prevention.”  Again – I’m not against either:  good HIT (matched with changing the way we work) leads to significant benefit.

If we are ever going to have anything like a high performing health system that improves outcomes, improves the experience of care, and at a cost we can afford, we MUST reform the way health care dollars flow in the system and we MUST reform the way we deliver care.

I don't yet see any serious discussion on these points.

L. Gordon Moore MD

Stories from the front lines: unsung heroes doing the right thing

John is probably squirming over the "unsung heroes" part, but he is one to me, so I though I'd call it out.
Gordon
Here's his story:

Just a little today example of why this sort of practice is worth it to me, and why I hope it can survive.

80+ y/o lady comes in with her nurse daughter. Has been declining cognitively and physically for years. On presentation, obviously has dementia, bad edema. Still lives alone, needing more assistance from family, but denies she has much of a problem. Has only been seeing her gyn, who tried to send her 1.5 hrs away for neuropsych testing, but pt would have none of it.

If I was still in a fast-paced practice: I would have been frustrated by the slow history-taking. Would have managed a rushed MMSE (mini mental status exam). Would have given her Aricept that she would not have taken. Would have tried to send her to a consultant to confirm her diagnosis, and she would not have gone. Daughter would have been quite frustrated at not getting enough answers. Appropriate care would have been delayed, and the patient may not have been safe.

Today, I was able to spend nearly 2 hours with this patient. We didn't get to everything, but we became comfortable and respectful together. We completed a full MMSE, a fascinating clock-drawing test, and a vascular dementia score, and basically confirmed the diagnosis of AD-type dementia, although we are doing a few tests to screen for other issues. She was comfortable with a trial of medication. We discussed safety and prognosis issues at length and are getting a full home evaluation and assistance through home health. Maybe, when she's ready, we'll get a neurology consultation. We were able to meet (figuratively) where the patient and her daughter were, not where I was in my day, even though I was awfully busy.

This is why I do what I do.

Unfortunately, my ability to provide for my family would have improved if I had spent 30 minutes, ordered more tests and consultations, written a prescription, and had her return with great difficulty for a 15 minute visit next time. We saved the system a lot of money today...a shame that a portion of the savings came out of my pocket.

John Watts Haresch, MD
Kill Devil Hills, NC

How do we get past the fearing our patients? Start by putting their needs at the center to rediscover mutual respect.

I just spoke up once again last at my local medical society meeting. The subject was Reach My Doctor, which is a platform for HIPPA compliant communication between doctors and doctors, and doctors and patients. In the past month, I got one of our local GI docs on board with me on this and he is hooked.

Getting my other peers, mainly the primary care providers, "hooked" is a completely different matter. They were very concerned with adding "another layer of things to do". "How do we keep professional bloggers from taking over our email?" they cried. "Will they not drive me crazy with midnight phone calls if I remove barriers from the care of my patients?"

I had to say something, and I feel that maybe one or two individuals heard what I was saying, which went something like this:  If we, as physicians, stop building more and more barriers to accessing our physician empathy and brain power, and treat patients the way we ourselves want to be treated, we will all be a lot happier, two way respect will start to take hold again, and we as healers, will be able to better help alleviate suffering.

Pain is an unavoidable fact of life. Death is an unavoidable fact of life. What we do to alleviate the human-made suffering is where it counts. That is where our healer talents, in combination with our scientific background, can actually make a difference.

Fear is reigning right now. I could hear it in the doctors voices. Doctors are afraid of patients. Doctors in general, have been forced by the current non system of health care provision to abandon the doctor-patient relationship, and I feel this very fact has made us frightened of what we have become.

Patients are afraid, not only of what the non system is going to do to them physically as well as the loss of control over their lives, but also what it is going to do to their life savings.

Doctors can alleviate the suffering that comes with fear through kindness, explanation, offering options of what to do, what will happen if this is done, and what will happen if nothing is done. Doctors wield and understand the technology. We must wield this understanding the fear it provokes and help lessen this fear.

Our patients are not widgets, and physicians are not commodities, but we, both the patients and doctors, currently bow to a non system that requires belief that humanity and its suffering can be reduced to entities/diagnosis that fit nicely in a box.

Suffering will not fit neatly into a box, a protocol or a simple flow chart. Flow charts and protocols are meant as guides as we individualize our care. They were not meant to BE the care. We must understand our patient populations not to make every one fit into the same protocol, but to be better able to advise them in their individual situation. THIS is the art of medicine.

If we start putting our patient's needs in the center, our collective suffering will begin to decrease, not through magic, but through genuine respect for the individuals that make up our world.

They all stared at me in stunned silence, but they were smiling, so I either had spinach in my teeth or maybe they heard something in what I said.

Megan Lewis, M.D.
Durango, CO

We have sacrificed the people we serve on the altar of ‘economies of scale.’

For years health care has been caught up in the notion that we can be better business entities if we pursue the principle of “economies of scale.” 
“We can have one person answer the phones, another do the check-in….”  It all seems to make so much sense – I mean, isn’t this efficient?

We see large practices that have many staff and have large waiting rooms (more economical than several small waiting room, right?).  We have billing staff, referral staff, managers to help manage the staff.

Because of all the people, we have to hire human resource staff as well.  We purchase an EMR so that we can code better and wring every blasted penny we can out of the insurance billing craziness.

What gets lost in this?  The people we serve. We become institutions and the care becomes impersonal.  We then struggle endlessly trying to get “patients” to be “compliant” with our wonderful evidence based guidelines and protocols.  “I have this 60 year old diabetic that just won’t listen to me – I am just so tired of this non-compliance!”

We have sacrificed the people we serve on the altar of ‘economies of scale.’  When we wake up from the nightmare we have created we have to tear down the walls we have built to keep the ‘patients’ at bay.  For our recommendations to have meaning in the complex lives of those we serve we have to slow down and actually listen to people.

The benefit of knowing patients as people and treating them with dignity and respect is profound.  Economies of scale erode the very foundation of the ethical practice of medicine unless sequestered to parts of our work that do not impact the personal relationship.

L Gordon Moore