Tuesday, January 29, 2013

A Swan Song

"I did it," I mumbled to myself.  The numbness overwhelmed my immediate sense of dread throughout my body.  I was trembling inside, full of anguish and at the same time, unable to contain my seething anger over an uncontrollable destiny.  Just a few minutes ago, I turned off her life support system.  The series of beeps had slowed down, pace by pace, like the ritardando in a finale movement of a concerto.  It was the end of a life journey for her.

I had given birth to her 9 years before.  The birth of an idea that started with a promise to myself that I could do better as a doctor.  The idea blossomed into a wonderful, unforseen miracle.  Through her, I was able to find happiness in my work and my craft again.  Through her, I caught a glimpse of the true art of healing.  Through her, I was able to connect to my patients in a meaningful way and in return, most of my patients were deeply grateful for my aid to them and their families.  Through her, I saw my patients as complete human beings, full of promise and capability, but also acknowledging their deepest fears...their demons and imperfections.   Through her, I was able to motivate my patients to strive for good health and a balanced lifestyle.  To watch a 60-year-old beam with accomplishment for finally quitting smoking after 45 years was equally amazing as a 12 month old first learning to walk unassisted.  It was slow and incremental for sure, but it really stuck once their new habits became integrated with their old ones.  Through her, I learned to not pass judgement on others and I learned to forgive.

She was born into a world at a time when others no longer valued her ideals and thus, no longer valued her existence.  Unable to thrive in such a cold, hostile, unforgiving environment, she began to slowly wither.  A once vibrant soul now smothered by a system that valued production over quality.  A system failing to understand that human beings are not robots and widgets and that one cannot thrive merely if you meet a certain numerical threshold.  A system unable to respect human individuality and life experiences. A system that values quick fixes instead of meaningful, long-lasting healing.

In many ways, I hated myself for not being able to protect her.  For I had felt that I had brought her up in this world and I had somehow committed her to suffering and decay by coexisting with a sick system.  For many years, I thought I could save her from the system, but I could not change her world, no matter how hard I hoped.  It was not mine to control. 

As time went on, she became sicker...infected by the same illness the system had brought on to her.  Through her, I began to lose the feeling of happiness in my work, my craft.  Through her, I became angry at the world. Through her, I began to lose hope. 6 months prior to that fateful day, I watched her as she was suffering in agony. All the misery had consumed her soul... and what was left of it, she knew that it could not last. And through her, I was beginning to learn the painful lesson of being able to let love go, to let it be. She reminded me that the idea of her never dies and like the phoenix riding from the ashes, ideas can always be reborn. Perhaps it wasn't the right time, yet, but in the short time she was alive, life was truly a miracle.

In the last six months, I prepared for her death. Grief struck as my patients became saddened by the news. I mourned at the promise and the idea that was soon to be a swan song forever etched in my memories of what it once was. Nothing could prepare me for what was about to happen next, as the end came near. For it was like the hands of God...I had created, but I could destroy. I was frightful of what I was capable of. The vessel of fury and madness of what was incomprehensible...the good now gone...now filled with uncertainty. The last gasps of her soul struggling one last time to survive. The repetitive beeps now no longer deafening to my ears, the beeps coalesce into a singular, iridescent hum fading into black. The promise of tomorrow, the torch of her once vibrant flame peeks through the window curtains beside me as her soul drifts away. Even as she goes, she continues to amaze me with her little miracles. She was real. She was my medical practice.

Friday, August 17, 2012

Recent Testimony to the US House Committee on Small Business

Check this page out.  Nothing new if you've been reading this blog, but it's good to hear that a few  important people are listening.  But, (sighhh...), too little too late.   I was a victim in this continued demise of solo practice physicians.

Friday, July 27, 2012

So sad...

Take a look at this (scroll to the bottom of the page to read the article).
It's a failure of our health care system in the US and how it affects everyday lives; imagine...this happens many times, everyday, to everyone.  When will someone take a stand and do something about it?

On a positive note, there's this...where we could be and one young mother's account of health care in Canada.  But why can't that be the same here in the US??

Friday, July 13, 2012

Electronic Medical Records, Workflows, and Meaningful Use

As I've been trolling the blogs on KevinMD, and this one by Margalit Gur Arie, there are questions about whether electronic health records are the "panacea" to the problems with health care and whether they improve the quality of care of patients in the real world.

Although my own experince is just an n=1 of this question, here is my two-cents worth.

From the very beginning of my medical career, I had no illusions that electronic medical records could fix all the problems with our health care system.  But just like I envisioned the computer as the next tool that could spark further advancements in communication, the electronic medical record was an extension of that future.  Nothing more, nothing less.

I also was not going to wait for definitive studies to prove that electronic medical records could improve patient care or improve medical decision making.  For me, electronic medical records were a tool to simplify my tasks as a doctor, to automate certain tasks that humans are more prone to produce errors.  Also, all these studies are predicated on the assumption that all EMRs are equal...which are not.  It's also assumed that these EMRs are easy to use...which universally, are not.  So these studies, in my mind, are moot.

I mean, look at all the world around you...Google, Yahoo, Facebook, Macbooks, laptops, iPhones.  We are now in an electronic world.  The electronic world took off nearly 50 years ago.  There were no studies convincing people that using the iPhone could be beneficial for you.  People can see the potential without these studies.  The reason why iPhones, iPads, and Android phones are so successful is because the user interface is intuitive and the device is able to combine several tasks and simplify what were separate tasks on separate devices into one.

It pains me to see the medical world falling so behind on this.  It pains me to see doctors office still using paper charts while in the very same room, medical staff were using computers to check their e-mail, buy something from Amazon, and update their Facebook accounts.

Financial entities, insurance companies, computer software companies, internet companies, high technology companies, shipping companies, even libraries and restaurants use computers to document and track their work efficiently and without significant redundancy.  Even WalMart has this supercomputer that minutely keeps track of all their purchases and goods and it even can predict buyer trends, to help their bottom line...because they all realize that there are certain things that computers can be really, really good at doing better than humans.  And there are certain things that humans are much, much better at doing than computers.

And if they did not use the computers to their advantage, they'll be left in the dust.

It's just that the physician's office and hospitals are still at the starting gate and stalled in the first leg of the race, running around in circles about what these contraptions called electronic health records can do for them.  The insurance companies all know they have the upper hand in this because they use computers day in and day out in their industry and now they are trying to dictate to the doctors what kind of data they need, even if it doesn't neccesarily improve patient care or respect patient autonomy.

This kind of dictation to the doctors is what all this meaningful use jargon is all about.  On paper, it seems like a good idea; to set a series of guidelines and features that an EMR must have so that it is certified as a good product.

I'm a car guy, so I'm going to use this analogy for people.

Let's say you are a "certifier" and you are trying to make a list of cars that you want to "certify" that have a certain list of specifications.  The specifications include a car that makes at least 300 horsepower, has a navigation system, 2 cup holders, 4 wheels, a steering wheel, front disc brakes, and a fold down rear seat.  You compile a list of cars, but because you're looking for a car that needs more than 300 hp, you're really picking maybe 10 cars that can qualify.  And they all cost a lot!  But none of these 10 cars are easy to drive because with all that horsepower, the car has a tendency to swerve to the right or left when you press the accelerator pedal and you have to hold on to that steering wheel tight to keep from getting into an accident.  But you left out a pretty big list of cars that actually drives well and safely and still gets the job done...just not with 300 horsepower.

This is what has happend with meaningful use and EMR certification.  Some "certifier" has deemed a list of specifications that doesn't necessarily define real "meaningful use".  And this "certifier" has said that for EMR companies to be certified, they have to pony up $30,000 a year just to get a stamp of approval.  Back to the car analogy, Ford would have to go to their "certifier" to prove that their car makes at least 300 horsepower just to be on this list and Ford then passes on the cost to the buyer of the car.  Why would anyone in their right mind do that in the real world?  I certainly wouldn't want to buy a car like that, and certainly not for that amount of money!

Even worse, this list of EMRs is the only one that the government will recognize so that the buyer of the EMR may get some reimbursement of their purchase.

What is the alternate view of EMR use?

For me, I needed to have an EMR that would fit my work flow, how a doctor thinks and how we document encounters intuitively so that we don't need to spend a lot of time figuring out how to use it.  I only managed to pick a few EMRs, and most I nixed because I could not afford it as a small, solo doctor.  The one I picked initially worked "OK" but the there were things I needed to automate but could not use without adding a whole bunch of "macros" that I programmed for myself to interface with the EMR so I can order labs, send bills, send faxes, and scan documents.  It worked for a while but with any macro, any change to the system "broke" the macro and I had to start over from scratch.  Every EMR I continued to look for, was constructed in a way that looked like the billing was the central part of the system and documenting encounters took a back seat.  I understand we have to make money through billing, but it should not be how a doctor sees a patient during an appointment.  It made no sense to me and I did not see how it would help my workflow to be efficient with that kind of framework for an EMR, which was the norm; not the exception.  In an act of desparation, I gave up looking for one and I decided to make my own since I spent a lot of time making macros anyways.  Crazy, I know.  I was that desparate!

And how I made it was all based on what made sense for a doctor's work flow when I see a patient.  I was a doctor, I know my own workflows and it was based on how I was taught in medical school.  I want ready access to all patient parameters, not through multiple clicks, screens, or special terminologies that only exist in IT world.  I want automated tasks and scheduling features, reminders of important alerts, and not have these clinical decision making tools that impede my ability to document my encounter.  I created this system all on my own and I used it for myself and with my patients for the past 1 1/2 years.  And it worked really well for me and I was much more efficient that I could ever be with my practice.  Ironically, the landscape of medicine had changed so much by the time I was using it (see my previous posts) that it didn't matter how efficient I was.  The odds were against me.  That is where the limitations of EMRs can go, at least in primary care.  But I still believe that a good, user-friendly EMR is what doctors need, not to fix health care or even prevent a patient from dying, but that good communication and efficiency from using an EMR allows a doctor to focus and do what computers can never replicate...practice the art of medicine.

And that was what I did with my practice; spending quality time with my patients and the computers were way, way in the background (even though the computers were doing lots of things for me...but out of the way of the patient).  That is what improves patient care; that is what reduces health care costs.

Here's the link to my new project...NOSH EMR, coming soon for public consumption!

Tuesday, June 26, 2012

Intermission time...

These last few posts were, to shamefully reveal my Southern roots (as my wife constantly reminds me of), a "doozy!"  I'd like to take a quick moment to speak candidly about my choice to stop my practice, based on questions I hear a lot from my patients over the past few months.

Decisions, decisions....I could have gone on to join a group practice and seeing my patients as I still have many years left in my profession, but as you can see, I left that kind of system to do my "dream" practice.  I have no intention on going back as it would antithetical to my core beliefs as a physician.

I could have changed my practice to a cash-only or concierge (or boutique) practice.  I seriously considered this option.  However, I've prided myself in taking care of my patients and families of ALL socioeconomic groups, not based on their ability to pay or whether they have insurance.  Nearly 40% of my practice is a mix of Medicare, Medicaid, and uninsured patients.  With the economic disaster over the past 5 years, that number has increased.  Changing my practice would also be antithetical to my core beliefs as a physician and a human being.  Don't get me wrong...I'm not saying that those who are doing those types of practices are less of a physician or a human being...I am giving kudos to all that are in the health care field for doing what they are doing, however they are doing it.  All I'm saying is that I'm choosing to jump off of a moving train that I see will be going off of a steep cliff into a ravine.  Life is too short for me to regret not taking the high road.

Doing both of these options, in my opinion, would only affirm the inequality and the inefficient US health care system and perpetuate the ills of the system.

I've taken my practice as far as it can go without abandoning these core beliefs.  I guess I'm pretty passionate about these beliefs, and I will not sacrifice them just so I can give myself the illusion that everything is just fine.

I also know that there are people and doctors out there that share the same values but their voices are not heard (I'm pretty sure most are not speaking out or being heard, otherwise, I wouldn't be complaining!).  I suppose that's what this blog was about, to share my story to others, for those who are willing to listen.

Friday, June 15, 2012

A Perfect Storm - the third ingredient

The third ingredient is the lack of universal health care coverage for all Americans.  Again, I've harped about this in my blog.  Although the direct effect on me is less obvious, the effect on my patients is tremendous.  I've lost patients, not because they did not value my care or feel that I was an incompetent physician, but because they lost a job, can't find a job to pay for insurance, don't have money to pay for their deductibles, or their employer is struggling to pay for health care coverage and have to switch to new insurances every year.  Sometimes they switch to an insurance that puts my patient on a different network so I can't see my patient anymore.

Why does my relationship with my patient need to depend on whether they have a job, have money, or what kind of insurance they have?

Some advocates of this current system and those that say no to universal health care or "socialized medicine" say that patients have unlimited choices as to which doctor they want to have a relationship with, so why rock the boat?  My response is that all of my patients, at some time or another, unlucky or otherwise, do not and may not have a choice.  It's an illusion of choice because that choice can be taken away by circumstances beyond their control, no matter how prepared, rich, successful, or educated you are.

I know, because, I too have been a victim of this system.  Being a business owner, you're on your own regarding health insurance for yourself and your family.  Thankfully, I made enough to pay for insurance, but only the kind that is catastrophic (high-deductible).  When my wife was pregnant with my son, we consistently paid our dues on time and then on the day that my son was born, we found out after we came home from the hospital that our insurance company dropped us from the plan for not paying the previous month's dues.  We found out later, that even though we sent our payment on time, our insurance company already decided to send us a letter warning us that they would drop our insurance for failure to pay (while my wife was in labor, mind you), even though the due date hasn't even happened yet.  Subsequently, we were given a nasty surprise by the hospital that we weren't covered even though we thought we were.  Although the insurance company acknowledged later that they sent the letter in error, we had to undo the damage in reconciling the immense hospital bills that were sent to us because of that error.  And although we knew how to get ourselves out and knew the system and the games that insurances play, we were able to minimize the damage.  But mentally and psychologically, the damage was draining for our family...adding more stress where we could have spent quality time with our children.  I can imagine that our example happens quite often and how many people fall victim to the system and can't get their way out.  Obviously, being a doctor did not keep me from being immune to the system.  It was very humbling for me to experience what some of my patients had to deal with.

All the more that this system has to change.  Simply, for me, health care coverage is a right for all of us; whether you have a job or not, whether you are a child or retired, whether you are male or female, whether you've been ill before or not.  Everybody in, nobody out.

From a solo physician perspective, there are benefits to a single payer system; it would be much easier to work with one payer than hundreds, one set of rules versus a hundred set of different rules, etc.  With Medicare going to Medicare Advantage Plans several years ago, it went from one payer to many payers and it got so crazy for me that I had to drop Medicare altogether.  Not only did the change made it crazy for me, my patients had to re-apply every year and they couldn't tell heads or tails which plan was best for them (actually, none of them, in my opinion).  I think we all have better things to do than deal with our insurance.  No wonder most of our young adults don't even bother getting insurance.  Until something happens to them...

A Perfect Storm - the second ingredient

And that would be The Games Health Insurance Companies Play.  Again, my previous blogposts have covered this landscape with examples and details.  However, and this is just anectodal to me, the ways these games have been played have gotten worse recently...maybe because they see the writing on the wall with healthcare reform not necessarily going their way (yet...).

First, to preface, I have no problem with what insurance companies are.  If they are for-profit entities and they are beholden to their stockholders, their mission and their existence is clear.  What is NOT clear is the ROLE that they play in the HEALTHCARE SYSTEM IN ITS ENTIRETY.  What is clear to me is they have wedged themselves been the doctor and the patient and holding the money that is the transfer of payment for services rendered by the physician.  Aside from the payment formula disparities and lack of prioritization (See Ingredient #1), the doctors are beholden to what an insurance company will pay them for any services rendered to a patient.  These are what I refer to as the Games Health Insurance Companies Play.  There are several games I'd like to highlight that us physicians, whether we know it or not, are unwilling participants and ultimately the perennial losers in these games.

1.  The "We won't pay you because we don't know if your patient is on our insurance or not, and oh...we don't have that information yet..and we won't pay you anyways" game.  There's always a disclaimer when you hear the voice messaging system when you call the health insurance companies that they cannot guarantee payment of services based on the information they're going to tell you about eligibility for a patient.  Ever wonder why?  Because at any moment's notice, something may inexplicably change, without knowledge of the patient or to the physician or to the employer (if it's employer based) and we're at the mercy of whether the insurance company ACKNOWLEDGES that a patient is eligible.  This is even worse when it comes to secondary insurance; then it's another game of....

2.  The "The OTHER insurance company is paying it first" game.  And it goes back and forth, back and forth.  Payment, anyone?

3.  The "I want my money back" game.  Because of the first game, or the second game, or for some other lame reasons because they didn't know their own rules.  It's a total time waster, and a waste of resources.

And for the patient's point of view...the following are games that I'm very upset about.

4.  The "We're gonna make your doctor's life hell so the doctor will never want to order another test again" game.  I understand that some procedures and tests are very expensive and will need a review.  But by making the whole process to get authorization a total time waster for the doctor only so that the doctor will never want to deal with them and think twice about ordering an MRI (for instance) for where there are already standards and guidelines that we're taught over and over again.  I do not find it useful for an insurance company to have me wait 30-60 minutes on a phone to get a human person to tell me that I followed the guidelines and they're going to grant it anyways, and to also personally denigrate you on the phone after you've already met the guidelines and then tell you that your an incompetent doctor because I care about my patients and actually listen to them (by the way, that truly and shocking did happen to me).  I keep doing it anyways, but knowing that I lost 30-60 minutes of my time doing this.  When you start adding it up, it starts becoming a reality that they don't care about my time.  They only care about their profits (which I guess they are entitled to) but this is exactly where the SYSTEM is all wrong.  Take the profit motive out of it and we'll already be in a much better place.

While on this note, I will say that I understand that the government (and rightly so) wants to crack down on fraud and unnecessary testing.  Of course, the government is beholden to the people.  The motives of insurance companies are not so clear cut, and at its worst, greed and maliciousness are part of it.  But I can say that if we fixed ingredient #1 and made it less of an incentive to commit fraud for expensive procedures, hospitalizations, etc; we wouldn't necessarily be in this mess to begin with.

5.  The "You have to pay more for health care services and we keep more of it anyways" game.  Not too long ago, people only had to pay a small copay for their visits.  Now we're dealing with hundreds and thousands of dollars of yearly deductibles before an insurance company is paying a penny for services.  What's the point of having insurance if you can't pay for these deductibles anyway and you're still paying the insurance company money to have "health" insurance.  So many of my patients can barely afford to pay the deductible amounts.  And then to lose your job, you're really stuck, even with COBRA coverage.

All these games, to me, are an insult to what should have been a simple, common sense transaction for services between the patient and the physician.  What is a viable alternative?  A single-payer system where everybody's in and nobody's out coupled with priority of services to preventative care and fair pay for primary care providers.  None of these games are played in other countries with single payer program or universal health insurance.  When I tell some of my peers in other countries about my experience, they laugh, take pity on me and they think we're a bunch of suckers.

Alas, that is where this second ingredient did me in...I saw no hope in the next decade that this was ever going to change given the political climate we're in.  Worse yet for me is this simple fact...THE HEALTH OF OUR PEOPLE IS NOT A GAME.

Wednesday, June 06, 2012

A brief interlude - my story

I will give a *brief* history of how I started in this profession and what has influenced me over the years...just so you know a little about me.

My first memory from my childhood that made a lasting impression, of all things, was listening to the music of the Beatles. Their music was special and enchanting. I also remembered the assassination of John Lennon when I was in Kindergarten - I got to know much about John Lennon and what his music meant to many people as I was a young kid in elementary school; "Imagine" was the song that epitomizes what I think John really felt about humanity and the world. As a child and adolescent, it made a whole lot of sense to me...even now.

As I was learning about the Beatles and their influences, I recalled their discovery period when they visited India and that was where I became aware of Mahatma Gandhi. Also, the movie starring Ben Kingsley got me interested in this mysterious figure who happened to promote change through non-violence. Then I read about Martin Luther King, Jr who practiced Gandhi's concepts. Again, I thought that was such a cool idea; the concept of change and non-violence was my guidepost to what I did in life.
It was too bad that all the individuals I admired so far, they were all assassinated at their prime. In some ways, I was unusually fascinated with the concept of martyrdom as a child.

I grew up in a family that worshiped Buddhism. I also attended Sunday School at the local church and they all seemed like good ideas with the exception of the idea of organized religion (for both) - I also began to have an inkling of what group mentality was and that it wasn't such a great idea when it went too far. I was influenced by a book I read in junior high, The Wave, by Todd Strasser which talked about how powerful group pressure can be. There was a time I was agnostic and not committed to any type of religion.

I was enamoured by Albert Einstiein, both as a scientist and as a person. Not only could he think of great physics concepts to explain the ways of the world, he was a great violinist too! I got into computers very early on. Commodore 64, Apple II, Atari 2600, IBM...I knew the ins and outs of 1's and 0's. I created a video game out of machine language.  I also played the violin (I started playing before I knew that Mr. Einstein did himself) and played in a variety of string orchestras and jazz ensembles (Jazz with the violin??  See the Turtle Island String Quartet).

High school was in some ways challenging for me. I couldn't get hired by the local grocery store as a bagger. I couldn't get hired by McDonald's...pretty pathetic for looking at a part time job. Then I got hired on by a local bakery/cafe in St. Louis called the St. Louis Bread Company and I sold bakery goods and made soups and sandwiches which at the time was a fledgling anti-fast-food phenomenon. Just when I was graduating from high school and offered my resignation, the company was bought out by a California group of investors. People will know this local company by it's now corporate name, Panera Bread. But back then, I realized the importance of a local economy and how important I was, even as the lowest member of the totem pole, in this local company. I even saw how computerization of certain repetitive tasks (touch screen cash registers that was called the Micros system) made operations efficient, less error-prone, and made statistical analysis of items that sold well versus others that didn't...it was cool, even back then.

As this was going on, I was following the footsteps of my father as an engineer. And then...

A near-life-threatening scooter accident right after high school graduation in Taiwan started me truly thinking about what was important to me in my life. It makes you take stock of who you are as a person, what you can contribute to society, and how you can make a positive difference in even on person's life...all from this pivotal event.

I realized I only had one chance in this life to do what I really want to do; I had the choice to make and only I could make it once. I could no longer imagine myself sitting in a cubicle looking at diagrams all day long. I needed more to fill my urge to help the people around me. It had to be personal for me. But yet, I still had the scientific side that I appeared to excelled at. Thus, I chose my path to be in medicine.

I was influenced by a family doctor (too bad I didn't know his name) that spoke at one of the seminars for pre-med students at the University of Illinois where I went to college. I remembered how passionate he was about taking care of the whole person, not just the specific body part or medicines they prescribe to "fix" people. I read into this concept and put it into my letter to admissions when I was applying to medical school. And then I got in to the University of Missouri.

Medical school was like going through military training. I was poor. I lived in a cockroach infested apartment with a broken air conditioner in the sweltering heat. I ate at McDonald's nearly all the time and I felt icky all day long (see Super Size Me and you'll know what I mean). During this period of turmoil, I read a book that happened to be lying on the table at the school library called "Small Is Beautiful - Economics as if People Mattered" by E.F. Schumacher. First of all, I wasn't even remotely interested in the theory of economics (didn't take it college, any financial topic was gibberish to me, didn't know the meaning of debit and credit...), but somehow the title grabbed me.  It talked about how the theory of modern economics is irrational in that there was not an infinite amount of consumption and that humans have to know what is "enough" - the concept of "enoughness" and NOT "bigger is better" and "greed is good". The concept of Buddhism Economics was from this book and it propelled me to read more about Buddhism (specifically Zen Buddhism) as more as a philosophy and a way of life, rather than organized religion. During medical school, I also managed to fulfill a dream of mine to be in a rock band.  I got to play a whole bunch of songs from the Cure, U2, Eric Clapton, Kiss, The Eagles, and The Police (but sadly, never the Beatles).  Through that outlet, I got to let out the steam and frustration of being in school.

I also felt like I took a time space warp when I entered medical school. Everything was still documented by pen and paper. Charts upon charts - "can't find the chart" - and the obligatory hand cramps. It's crazy that this still existed when I saw how the St. Louis Bread Company could use a touch screen ordering system 8 years before?! Being a self-professed computer nerd, I was totally flabbergasted and perplexed that this was the new reality.

Looking at residency programs after medical school, I got to visit Seattle for the first time after living in the Midwest all my life. I happened to be staying at a local youth hostel (no hotel rooms were available because of the WTO conference that year). This youth hostel also was Ground Zero for social activists who were protesting at the WTO conference that ended up in violence with sound grenades, curfew, tanks and smashed windows at the Bon Marche department store. I was getting all kinds of education about fair trade not being free trade, the pros and cons of the North American Free Trade Agreement, local and sustainable practices for the economy, ecology, and the environment.  It opened my eyes to a whole new way of thinking about society, people, and the impacts we have from small to large.

After all that traveling, I ended up doing my residency in family practice in Minneapolis, Minnesota. I thrived there, taking care of the indigent population that consisted primarily of immigrant and Hispanic/Latino families. I also delivered quite a few babies during that time. I also learned more about complementary and alternative medicine. I also helped the hospital acquire an new electronic medical record system (finally!). It was everything I considered family practice to be. I also became quite aware of the problem of economic and political forces that steered students into specialty practices rather than primary care. I recognized then that family practice clinics and physicians were slowly being steamrolled into this larger byzantine system that encouraged increased procedures, increased overhead, increased patient numbers, but less time with patients, less quality of care, less connectedness to the people we serve. Everything was getting bigger and the family doctors were becoming cornered into a wall. It was as if we had no choice but to follow the status quo. Talk about peer pressure (ie The Wave).

And when I finished residency; I made a choice to take the road less traveled. I took the approach of what was small was beautiful. I centered my practice after the whole concept of whole person/whole family care. After a false start and a broken promise after 8 months, and then making a decision to fully go it alone, I have finally made my dream come true...a micro-practice that I built along with my wife. I was fully utilizing computer systems to help me streamline my operations so I can still do all of the things that computers cannot do - like diagnosing an illness, healing hands, the art of medicine, making agreements with my patients; it was recognizing the limits and ultimately creating a unique but natural balance with the way things work. Granted, it was still hard work and I didn't get paid much, but in my own way, it was the most gratifying type of work I can imagine for myself.

Now...back to the the perfect storm...

A Perfect Storm - the first ingredient

So where to begin...what caused the demise of my practice was essentially various factors and elements that led to a perfect storm.  I'll blog about each one of these elements from one posting at a time.  Some of this, if you've been reading this blog already, may be old news but I'll figure it may be good to revisit them.

The first and important factor is physician pay for primary care physicians like me.  As you can see in this graph, this is the layout of average salaries for physicians in different specialties.  This was discussed to some degree in this blog post on KevinMD.

We must redesign our health care payment systems to value primary care

Now you're saying, "That doesn't seem so bad...", but keep in mind this is an average.  And most family physicians are in group practices and are subsidized by their parent organization (hospital, multi-specialty groups) to cover the budget loss due to insufficient reimbursement for primary care physicians.  The other part that is also not seen in this graph is that for most family physicians, to keep up their end of the deal to be a part of these larger organizations, is that they have to see more to get more.  It's still not enough, but it's better than nothing.  What happens when you see more in a finite amount of time?  Less time with patients.  I learned about this perverse system more than 10 years ago in residency and all I can say is that this has not changed at all.  In fact, it's getting worse.

Stepping back, and looking at that graph, wouldn't you agree that if we were to truly talk about preventative care and prioritizing the health of our children and young adults, shouldn't this graph be a mirror image?  In my opinion, our health care priorities are not in line of what we know to be true.  I understand that doctors who do very risky and complicated procedures should be compensated duly for their education and the work that they do, but at the very least, shouldn't we be prioritizing the work of primary care physicians who try to keep patients from being in a hospital, keeping them from major procedures to prolong their life due to easily preventable lifestyle changes and other less costly interventions?  Is there not an investment in keeping people healthy rather than spending billions of dollars on futile measures?  Wouldn't we be saving money as a society rather than paying more for things that do not provide an investment in the wellness of the society starting with children?

Think about it...