Ideal Medical Practices

The future is here but unevenly distributed: thriving happy PCP versus doctor hell

Like characters in a Dickens novel health care in the US demonstrates the best of times and worst of times.  We hear real horror stories and witness spots of brilliance.  My heart is heavy as Dr E's light is extinguished but gladdened by Dr B's resurgent hope.

These anecdotes highlight both the urgent need to change and what that change might bring.

We are crushing primary care practices with payment policies that fail to account for much of the work we should do on behalf of those we serve.  We exacerbate inadequate payment with unfunded mandates calling physicians away from their patients to address administrative trivia.  We thwart effective care with denials, delays, and mind-numbing bureaucracy that sap the time and destroy the spirit of the primary care work force.

But some physicians have figured out how to work outside this toxic environment and deliver great care in vital and satisfying practices.   They enjoy their work and the finances are lined up with doing right by their patients.  They are professionally and personally satisfied and delivering care in a supportive environment.

The worst of times

I've known Dr. E for years.  His soft caring voice and gentle manner must touch a lot of his patients.  As a primary care physician with a long career he has deep relationships with the people he serves that give him great insight into the right treatment recommendations and the compassion that is core to our work.

Dr. E can't sustain his primary care practice any more.  He's crushed by the administrative burden of the paperwork, the denials, the rejections that dog his every move to care for his patients.

The toxic policy environment takes down another good PCP and leaves a large number of people to seek care from strangers.

I enjoy practicing medicine.  But I hate spending so much time and energy dealing with the barriers and controlling inequities that 3rd party payers impose on my time and energy.  I am deciding to wind down over the next year or two,  giving  patients time to find other providers (I have a lot of Medicare pts who will not be happy about the task of searching for someone who accepts Medicare).  I just this week, called our local free clinic and told them I would volunteer for an additional day each month (if I am going to provide free care to patients under the disguise of insurance companies who refuse to pay,  I might as well avoid the hassles of dealing with them and up front, give care away ).    I can do locums work  for 6-8 days/ month and earn as much as I do now working 5 long days each week.  What is wrong with this picture. Sorry to sound so discouraged. 

The best of times

But not all environments are equally toxic and some have found ways to thrive. 

I was basically inspired by Obama "to be the change" and somehow decided to risk everything on some vague notion I had on how to create a medical clinic.  It was a bit of an experiment in some ways where I wanted to show that a Jr doctor with no name recognition, zero patients, no funding, and no media coverage could incorporate design into a medical environment and harness the power of social media to build a large and successful practice.   After 13 months and starting with zero patients, we are now staffed and open 7 days a week with 4 doctors and have seen over 3,300 patient visits in a fee for service model.  We have seen around 2,400 unique individuals and are averaging 7 new patients daily. 

Here's the predominant tone of patient experience in his practice:

This is the way medicine used to be and this is a refreshing change to the managed care that medicine has become. He reminds me of my grandfather who was a physician in a small town in Kansas.

I think I just found my new primary care establishment.  Right price, great service, and best of all, they value my time as much as their own.

Another PCP bites the dust

You've probably heard that there's a primary care shortage.  Maybe you've read or heard about the Physician's Foundation study describing the overwhelming number of PCPs who want out of this toxic environment.   We have people desperately searching for a PCP and we have good caring people forced out of the profession.

These statistics miss the very real pain and anguish of people who entered primary care to help people when they find the environment for primary care toxic to the ethical practice of medicine.  These voices need to be heard.

I'm asking people to post in the comments section below personal examples of primary care practitioners leaving primary care because they just can't stand the toxic environment any longer.

L Gordon Moore MD

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