A House Divided

If you put ten physicians in a room, you will get nine different opinions.  It doesn't matter if you are discussing policy, diagnostics, or politics.  Indeed, medical training develops deep independent thinking. We often feel alone in the care of our patients, we picture ourselves the sole barrier between illness and well being.   We battle our fellow physicians, administrators, and insurers.  You can argue the pros and cons of siloed thinking, but there is no denying the reality of the barriers that we have built around ourselves.  One wonders if a house divided against itself can continue to stand.

There is no doubt that the external threats to the stability of this profession are growing by the minute.  Politicians wrangle to define quality and best practices.  Allied health professions push to expand scope. Lawyers fight to police a group that is reluctant to police itself.  The alphabet soup grows in scary and threatening ways: ACA, ACO, MU, MU2, HCAPS, etc, etc, etc.  As our heads spin in dizzying circles, the physician voice fades into the background.  Nay, it is absent.

We criticize ourselves, we disagree, we reproach our own louder than all those silly little voices that encroach on our freedoms by and by.  This is who we are.  We rarely agree.  In some ways, I believe this is our greatest strength.  We are not afraid of infighting.  

Our own disorderliness, while internally nourishing, proves impotent when faced with external threat.  We are lousy mobilizers.  As much as we fight for our patients, we are poor defenders of ourselves.  

The battle lines have been set, and I believe time grows short.  The window to effect policy will only be open for so long. The practicing clinician, those wading through the mud of actual care, can and must have their voice be heard.  We cannot do this, however, if our words continue to be so glaringly disparate.

A common ground must be illuminated to the masses.  I suspect our failing point in the past was biting off far more than we could chew.  We picked the largest most contentious issues.  It's time we chose a more narrow focus point:

Meaningful use
Maintenance of Certification
Face to Face visits for home health
SGR

I am fairly certain that ninety percent of practicing clinicians (not administrators, health care policy wonks, or non practicing MDs) can agree on these issues.  

They need to be abolished.

Can we find a way to work together on this?

You Create The Cage That Imprisons Your Mind (My response to the comments on my KevinMD post)

I am only going to say this once (my response to the comments on my KevinMD post).

You are far more powerful than you think.

Your hard edges are chiseled in flesh from the molten steel of apprenticeship and add depth, character, and knowledge.  The fibrous scar tissue is experience layered upon experience learned from each searing blow.  Your brow furrows, locked in place by years of leaning over texts, squinting to decipher the tiny letters.

Your stamina is unique.  Tested by years of restless nights, interrupted sleep, and sequential emergencies, your brain reacts with clarity even in the midst of the deepest fog.  Your mind grasps complexities, multifaceted systems, and can bend with riddles and paradox.

You have witnessed both the foibles and strength of the human character.  You are a watcher, a listener,  a confidant.  You walk the tapering line between friend and advisor.  You know more of the spirit than many so called men of God.

You are dexterous.  Your hands glide over the epidermis.  Catheters are inserted, fluid is withdrawn, and diseased organs are extirpated.  Your extremities are just as nimble as your mind.

You may be haunted and broken, but your emotional depths are vast.  You have withstood lifetimes of pain.  Yet you help others find joy in the banal.  You bring hope when the light fades, clarity when there is indecision, and a soothing word to break the silence.

You are no Luddite.  Technology is neither friend nor foe but constant companion.  You adapt.  You learn.

So when I write a blog post declaring "It is time for American physicians to rise up" and you reply that you "hang your head" and that I need to "embrace the despair" I start to believe that you have created the cage that imprisons your own mind.

You are far more powerful than you think.  Do something!

Create a direct pay or concierge practice.
Retire early.
Work for an acute care facility instead of doing primary care.
Become a hospitalist.
Become a consultant and practice on the side.
Talk to each and every patient who will listen to you.
Write a blog, join twitter, yell from the roof of your hospital.
Lobby congress, lobby your fellow docs, lobby your family.

You have more skill, education, and knowledge than you ever will need.

Just flippin do something.  I did.

And then,

then you can complain.

Is Primary Care Sustainable For Physicians, My Conclusion After A Decade Of Research

I have a confession to make.  The purpose of my last blog post was to set up this one.  What I questioned, at that time, is whether the future of primary care will come from outside change (business, politics, or even specialist physicians and administrators) or internally, hence creative destruction vs internal combustion.

When I entered my first primary care practice in 2002, I had great doubts that the traditional model was sustainable.  So I spent the next 12 years studying.  My field research included stints as a hospitalist, Corp Med doc, private practitioner, and concierge physician.  In the meantime, I became a legal expert, medical director of multiple nursing facilities, took on a job as assistant medical director of hospice and started a palliative care program, and consulted with home health care companies.  Meanwhile I read every white paper, medical economics article, and op ed that I could get my hands on.

Although I have learned many details, I can distill my research into one overwhelming and primary concept.  This secret sauce, I believe, is what will separate the men from the boys, women from the girls.  It is the most basic question that each primary care practice has to ask itself if it wants to survive the slaughter that is surely coming.  But first, a few principles that the reader may or may not agree with.

1)Whether we like it or not, healthcare's pound of flesh is coming from physicians and patients.  That's right, at the end of the day, pharmaceutical companies, insurers, politicians, and administrators will all come out of this catastrophe with healthy bank accounts and bulging pockets.  If you don't believe this, I can't help you.  The Medicare data dump and Obamacare's large out of pocket deductibles are just a  few glaring examples.  I won't go into depth about this subject because it would require a series of blog posts at minimum.

2)The government and insurers primary goal is to cut costs, not improve care.  Said another way, payors may give extra money for innovative models that reduce healthcare costs and produce more healthy patients for short term.  But eventually they will stop.  They want their cake and eat it too.  I don't care if your model creates fifteen percent savings in the future, if it costs the insurers fifteen percent extra up front, it is a zero sum game.  Don't expect their support in the future.

That being said, the litmus test for any current practice model thus has become overhead.

Let me say this again.

If you want to survive today in primary care medicine you must have an extraordinary low practice overhead.

The government will not pay you more.  Insurers will not pay you more (i.e. pound of flesh we talked about previously.)  Patients can afford some concierge and direct pay fees, but don't expect to be able to leverage them either (Because they are getting squeezed by healthcare too).  And the cost of business and compliance will do nothing but go up in the next decade (inflation, meaningful use, technology, rental fees, etc.)

Primary care doctors who have been drowning for years understand this.  They have one of two options.  They either throw their hands up in the air, and join Corp Med for stability (the majority) or they begin an alternative low overhead practice (concierge or direct pay).  And mind you, those PCPs who opt for a new model are generally working very lean.

Non primary care doctors trying to enter this space, I believe, have not benefited from the years of being caught under the wheel.  They opt for high overhead, personnel intensive, high flair practices that truly deliver an awesome product.  But my prediction is that they will die an unfortunate and costly death.  Because, in the end, there is no one to pay for it.  Medicare won't.  The insurers will for a period of time, but not in the end (they want their cake and eat it to).  Patients won't.  Venture capitalists and tech visionaries may in the short term, but eventually they don't like losing money either.

That's why I blended home based practice and nursing home work as the two arms of my new business.  The common thread, of course, is an almost zero overhead.  That is where my experience has led me.

Will change come from outside or from within?

Do you want to know if your practice has there right stuff to survive the turbulent future that primary care faces?  Ask yourself this one question:

How much of every dollar that you make are you paying out to someone else?

Creative Destruction Or Internal Combustion?

Everyone seems to have a solution for the primary care crisis.  Businessman and venture capitalist Vinod Khosla thinks technology and big data will replace the imperfect physician.  Tony Hsieh and Zubin Damania (x-hospitalist and comedian/rapper) are banking on the direct practice model created by Iora Health.  Politicians, economists, and technologists all chime in with their perspectives.

Below the surface bubbles a provocative and troubling question.  Many of these entrepreneurial "experts" have little previous experience actually running a primary care practice or taking care of the average outpatient.  Although no one has directly said it (except Khosla), the underlying assumption is that change is too big or too important to come from within.  They argue that those immersed in the bubble of inefficient and expensive day to day care must be blinded by their own involvement.  These "leaders" espouse creative destruction and spurn internal combustion.

But I wonder if "good" primary care is something that can be totally grasped from the outside.  My understanding is radically different from what it was before medical school or even in residency.  With experience, my viewpoints have changed, my techniques have evolved, and my awareness has grown.  I couldn't imagine approaching disruptive change without the knowledge I now hold.

So I looked with great enthusiasm to plot the path of Iora Health and internist Rushika Fernandopulle.  What I found, however, was an unsustainable model (Iora health I believe has still never made a profit) heavily dependent on venture capital.  The Atul Gawande New Yorker article talks of a team of two physicians, two nurse practitioners, one social worker, and eight health care coaches taking care of 1200 patients.  Certainly this model is not cost efficient.  In my previous practice, I was overseeing 2000 patients on my own (and yes, my average hospital census was not much higher than theirs).  It seems there was a lot of hype and Internet buzz, but many questions still remain.  Is Iora health still running the Atlantic City clinic?  I couldn't seem to find any information about that on the web.  I would like to know more.

I am an internal medicine physician.  I have been practicing primary care, hospital medicine, and palliative care since 2002.  In January of this year, I started a new and innovative practice in which I visit patients in their homes and in the nursing home.  I schedule a full hour for each outpatient visit and answer my phone personally.

And by the way, so far I can pay my own bills and my admission rate is low.

No venture capital investors, no yoga classes, no health care coaches, no fancy videos or selection of expensive teas in my waiting room.

Instead, I do something much more simple.

I spend a lot of time with each patient.

Destiny

It was a sunny spring day as the bus turned the corner.  It was a yellow school bus filled with young children jumping up and down in their seats.  It was an average day in an average school year.  Nothing about it stood out.  Let’s take a closer look.

The boy sitting in the front of the bus holding tightly to his lunch box is named William.  His clothes are tattered and his jeans have patches.  The lunch box is empty, but no one around him knows that.  His is quiet and withdrawn.  He doesn’t play with the other children.  He is much too thin.  He will grow up to be a successful businessman, and buy his mother a house.  His children will not have to live like he has. 

The girls sitting across the aisle from William are Suzette and Lisa.  They like to sit in the front so they can rush off the bus when they get to school.  Suzette is known as the school gossip.  If something is going on, she already knows about it.  She will grow up to be an advice columnist for a local newspaper.  Lisa’s path is a little bit different.   She will succumb to the allure of drugs and get pregnant at an early age.  After the birth of  her child, she will change her life.  She will never go to college or see herself as a success.  But she will bring up a confident young daughter.

Behind the two girls are Terence and his best friend (who he currently is wrestling to the ground) Paul.  Terence will grow up the class bully.  He eventually will be arrested for armed robbery and during prison will find religion.  After serving his sentence, he will work to help released inmates reintegrate into society.  He will change many lives.  Paul will be known as the boy who never took any chances or risks, afraid of his own shadow.  Until the day, at the age of thirty five, he rushes into a burning building and saves three children before he collapses and dies.

Sarah screams across the aisle at Terence, and tells him to stop bullying Paul.  She knows in her heart that one day she will find Mr. Right, and settle down and have five children.  Seems a bit premature for an eight year old, but that is exactly what she does.

So many faces you could see if you were riding on that bus.  Each with a unique story and future.  But the point here is not the children, but to take a closer look at the man sitting up front driving.  He is a beautiful and courageous man, and he is dead.

***

The call from the cardiologist surprised me.  She was in the ICU visiting a mutual patient after a routine bypass surgery.  The surgery had gone well without complications.  I could hear the concern in her voice as she asked me what to do.  She had been talking to our patient when he suddenly had a seizure.  I told her to give him five milligrams of diazepam, start a dilantin drip, and get a stat head CT.  After calling neurology, we both waited with trepidation.

“By the way, is his wife there?”

I remembered that he had come to my office at the urging of his spouse.  Like so many males in their fifties, he started the visit by telling me he didn’t like doctors.  Being healthy, he didn’t feel the need.  But he recently started having twinges of chest pain while on the school bus.  After a month of suffering he finally was persuaded to be evaluated.

His testing showed coronary artery disease and he was sent to a cardiologist.  She recommended the cardiac catheterization that showed extensive blockages in multiple coronary arteries.  He was scheduled for a bypass surgery.

***

The call from the radiologist confirmed our fears.  There was a large tumor in the anterior portion of his brain that had bled during bypass surgery.  It was a benign tumor and could be removed.  None of us had known it was there.  The telltale symptoms were absent: no headache, no visual problems, no signs on physical exam.  It was just bad luck.

The neurosurgeons were antsy about taking him to surgery right away.  It was Saturday morning and the blood thinner used in the bypass was still present.  Furthermore, this would be a complex procedure and they felt it would be better to schedule for Monday.  So he rested in the ICU and waited.

On Sunday night he started to feel mildly nauseous.  He sat up to call the nurse and said quietly,

”Something is wrong”.  

He then collapsed back on the bed and died.  Likely the bleeding in his brain had restarted.  The increased pressure and swelling  then caused the brain to herniate.  CPR was performed for thirty minutes to no avail.  His wife and daughter were called at home and notified.

***

The next two years were a blur.  There had been multiple visits with his wife.  We had met with the cardiac surgeon to discuss what had happened.  There were tears and more tears.  I felt a pang in my chest with every visit.  I watched as depression took hold.  We discussed medications which she decided against.  We discussed therapy which she attended.  The birth of her daughter’s baby, her first grandchild, was bitter sweet.

When she strolled into my office today, however, I knew immediately that something had changed.  I could see it in the way she walked, her facial expressions, the way she talked.  She had stepped away from the sadness and started to live again.  We exchanged polite conversation for a few minutes and then I gently asked her what had changed. 

Since her husband’s death she had been focusing on loss, focusing on tragedy.  She was morning a life that was taken away far too early. After the birth of her daughter’s child her perspective changed.  Her husband, she explained, was a bus driver for a local school district.  Everyday he drove countless  young children.  He loved his job and he loved the kids. 

She figured that he had two ticking time bombs: one in his brain and one in his heart.  Each of them could have instantly caused death while he was driving the bus, not only taking his life, but the lives of all those children. 

She told me that now instead of morning his death, she celebrates all the beautiful lives that were saved the day he died quietly in the ICU.  When she feels sad, she calls her daughter and they make up stories of what would become of those precious children.  

You see...

The boy sitting in the front of the bus holding tightly to his lunch box is named William.  His clothes are tattered and his jeans have patches on them.  The lunch box is empty but no one around him knows that.