Not to beat a dead horse about the lack of primary care doctors, but I want everyone to realize this FACT...there IS a lack of primary care doctors. It has been well documented that fewer and fewer medical students are choosing
to enter primary care specialities, such as family medicine. The truth is, our friendly leaders in the White House have also been reviewing statistics on this same subject. So, one of the many ways Mr. White-House is trying to encourage more family practice docs, aside from giving them our tax money to go to medical school (oops, that is top secret information), is to expose more medical students
to family medicine, such as by requiring them to do a clinical clerkship in a
family medicine office. I guess the logic is that if they see how great and
fulfilling it is to be a family doctor, then more of them will want to go into
it as a career.
As well-intentioned as this may seem, there is no better way to turn
off medical students from going into primary care than by having them see
first-hand how frazzled, frustrated, and overworked a primary care doctor's life
really is. In fact, have them rotate through our local walk-in clinics and they will see first hand how it works...check in patient, take back to room, give pill, collect money, send out the door, go to the next room and do it all over again. Never mind that their blood pressure indicates risk for stroke or heart attack, or that their weight puts them at risk for diabetes.
But, if you really want students to go into primary care, have them rotate
through an office where there is enough time to talk with patients, where
doctors are not overworked, and where both doctors and patients are happy.
One of the worst pieces of advice I got in medical school was to guard my ‘professionalism’ – which meant, act like a talking robot. I think he worked for Mr. White-House. Hogwash! Doctors are all unique, and the better patients get to know us, the better they’ll sort themselves into good matches with their primary physician.
Will family medicine survive? Of course it will! Society is going to get the health care it wants and deserves, and medical students are going to get the medical career they want and deserve. Make no mistake: We are not helpless pawns in the current system. When given a choice, patients will go where they receive quality care.
One month ago, I embarked on a quest to serve my patients. The many who know me and the many who will get to know me, will find it refreshing that I am someone who is not simply on a mission to get in and out of the exam room and who prefers to address the actual problems instead of throwing pills at them.
So, in an effort to "guard my professionalism" and maintain my Hippocratic Oath (an oath historically taken by physicians swearing to practice medicine ethically and honestly) I have decided, with the help of some very special people, to create my solo medical practice.
I thought it appropriate to name my practice, "Center Stage Primary Care", because realistically, my hope is that you will allow me, to help you, take your health "center stage." Each patient no matter what age, will learn about overall health and wellness.
I will focus on diagnosing and treating conditions of all ages while emphasizing preventative medicine. I will refer patients, when appropriate, to specialists and/or to hospitals for tests, further treatment and therapy. Most importantly, I will focus on YOU, the patient!
My new address:1601 NW 114th St Suite 142, Clive, IA 50325. For now, you may call 515.222.3151 to schedule an appointment. When you hear the receptionist say, "Central Iowa Orthopeadics," don't hang up. You have the right number. Let Kerri, Jodi, Pam, or one of the other fabulous girls in the office welcome you and schedule your appointment. And, just between you and I, thank them for giving us a home so we can help each other take your health CENTER STAGE!
Official start date is October 15, 2012 provided no delays in my credentialling.
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Wednesday, September 26, 2012
Friday, September 21, 2012
Are You Ready for a Doctor Shortage?
I believe the projected doctor shortage caused by the Affordable Care Act will drive primary care into two opposite tracks:
- The “Apex of the Pyramid” Track
- The Concierge Medicine Track
Each is a distinct and logical response to the patient overload from the doctor shortage that is rapidly approaching. Each points out gaping holes in our medical education that must be addressed. Concierge medicine has an additional powerful force acting in its favor.
The American Medical Colleges estimates that there will be a doctor shortage of 63,000 doctors by 2015 and 130,600 by 2025 in the wake of the SCOTUS decision to let the Affordable Care Act stand. This doctor shortage is caused by a tidal wave of newly insured patients has to be served somehow and US Medical Schools and Residency Programs cannot supply anywhere near these numbers of new physicians in this short of a time frame.
How will healthcare markets respond to this doctor shortage – especially with regards to primary care? I see two likely options.
1) Volume Driven: Doctor as apex of a care pyramid
In the more traditional practice structure, the doctor shortage will force the primary care physician to become the leader of a care team supervising a number of physician extenders who provide the majority of the hands on services. The skill and experience of the physician will be saved for the more complicated and severe cases seen that day.
The majority of the doctor’s activity will be devoted to leading and coordinating the care provided by the pyramid of N.P’s and P.A.’s who are their direct reports.
The challenge to this model is the complete absence of functional leadership skills training in most medical school and residency programs. 30-50% of these physician’s time will likely be spent in leadership and management activities for which they are not prepared on graduation.
2) Service Driven: Concierge Medicine/direct care model
As the doctor shortage worsens, the typical patient will begin to notice they are only seen by a physician on rare occasion. A certain percentage will become willing to pay for that privilege. I suspect this will quickly grow to a huge new demand for concierge medicine services, where you pay a reasonable monthly fee to guarantee you are always seen by your doctor.
As the doctor shortage continues to worsens, I believe a larger and larger segment of our population will become willing to pay to continue to see their primary care doctor as they do today and their only alternative will be concierge medicine.
The huge popularity of concierge medicine will have another important driving force – the office duties of the concierge medicine physician are exactly the opposite of those in example #1 above.
In a concierge medicine practice, the physician is often seeing less than 15 patients a day, providing direct patient care and continuing to have meaningful personal relationships with their patients.
Let me know your thoughts. Which direction do you think medicine is going?
Monday, September 17, 2012
John Galt Speech
A John Galt Speech For Direct-Pay Physicians
“You demand to know what has happened to us, the physicians you thought you controlled. You have cried that our sins are destroying the world and you have cursed us for our unwillingness to practice the virtues you demanded. Since virtue, to you, consists of sacrifice, you have demanded more sacrifices at every turn. You have sacrificed all those evils which you held as the cause of your plight. You have sacrificed justice to mercy. You have sacrificed independence to unity. You have sacrificed wealth to need. You have sacrificed self-esteem to self-denial. You have sacrificed happiness to duty.
“While you were dragging us to your sacrificial altars, we physicians who value justice, independence, reason, and self-esteem – we finally came to see the nature of the game you were playing, which we had previously been too innocently generous to grasp. And we have chosen to play no longer.
“All the physicians who have vanished from your system, the doctors you hated, yet dreaded to lose, we are gone from you. Do not cry that it is our duty to serve you. We do not recognize such duty. Do not cry that you need us. We do not consider your need a claim. Do not cry that you own us. You don’t. Do not beg us to return. We are making our own way, apart from you.
“In your cynical attempt to control the healthcare system, you have coerced us – with your threats to our livelihood, threats of massive fines, threats of jail – to abandon our sacred obligation to our patients. Society must come first, you say. The needs of the collective are paramount, you insist. We must do what the experts tell us to do, you demand. And in the process you have destroyed the doctor-patient relationship which is the backbone of our profession. You have reduced physicians to ciphers, to puppets. And you have reduced our patients – the living, loving, hoping, striving people who come to us, who place their trust in us and their lives in our hands – to interchangeable members of a vast herd. You have demanded that we guard society’s interests, and abandon our sick to their own devices in your cruel and parsimonious healthcare system.
“Your process is now firmly established. Your methods have been legislated by Congress, embodied in volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the courts, and finally (and most tellingly) sanctioned as being entirely “ethical” by your allies, the leadership of our own professional organizations. You have made the healthcare system untenable for doctors who value true medical ethics.
“You have placed us into a position where we must either resign ourselves to an unethical, demeaning, health-destroying style of practice, or get out. We have gotten out.
“We have gotten out. We have left your Program. We refuse to sacrifice ourselves for you any longer. We will not sacrifice our livelihoods, our morals, our independence, our minds, or our patients for your bastardized idea of virtue.
“We will practice medicine in the only manner that still permits us to behave ethically toward our patients, in the only way that we can honor the true doctor-patient relationship, in the only way we can legitimately regain the title of professional. We have chosen to be paid directly by the people to whom we provide our services, by the people to whom we dedicate ourselves as professionals. We have chosen to cut you out.
“To argue that direct-pay practices are unethical – to argue that any innovation that would somehow restore both our professional integrity and the patient’s rightful advocate is unethical – is completely upside down. This argument only reveals your own inner corruption. We are taking the only pathway that remains to us to restore the true foundation of medical ethics, to restore our profession – to always place the patient first.
“To argue that direct-pay practices threaten the general welfare completely ignores reality. We are doing the only thing we can do to begin restoring protections that people are supposed to have when they are sick and facing a healthcare system that is utterly bent on withholding their care whenever it can be gotten away with.
“To argue that direct-pay medicine will create a two-tiered healthcare system is absurd on its face. It provides a mechanism by which at least some of your intended victims can escape the deadly obstacles you have laid before them. Saying that it amounts to a two-tiered healthcare system is as absurd as arguing that slaveholders were wrong to free their slaves before Emancipation, because doing so would create an elite subpopulation of former slaves; that until all slaves are freed, no slaves should be freed. But when a few slaves were freed and walked the earth as free men, that action was not only ethical, but it also showed others what was possible. Over time, it created a widespread expectation for freedom that eventually could no longer be ignored, and that, at huge cost, was finally fulfilled.
“You wouldn’t understand this – you who already know everything, you whose experts already have all the answers – but any innovation that can potentially spare patients from some of the harm you have in store for them will necessarily be applicable to only a few patients at first. That is how disruptive processes work. In your proposed perfect system, of course, disruptive processes are anathema – because they disrupt. But in the real world disruptive processes are creative processes, processes of growth, processes of rejuvenation, processes that create opportunity. This is why you always try to suffocate disruptive processes, with your cries of “unfair!”
“Disruptive processes always begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers. But if at their core they are offering something fundamentally useful, they will slowly demonstrate their worth – and eventually all the potential users will see the light, and demand for the product will become explosive. At this stage the means are invariably found to make the new product affordable and available to meet the demand, while preserving the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.
” We are a disruptive process, and the process we are disrupting is yours.
“We are not playing your game any longer. We will no longer be victims; we will no longer subject ourselves to your attempts to make us guilty. We will no longer walk, heads bent down, to your altar of sacrifice.
“You no longer have any hold on us. We have done our time. We are getting out. If we decided to leave medicine and open a road-side fruit stand, or become lumberjacks, or just spend our time puttering around in the basement, you would have no objection to that. So by what right do you object if we hang out our shingles, and see a few patients who voluntarily come to us, using their own resources to do so? You can have no rightful objection to such a thing. So be quiet about it, or admit to your own corruption.”
“You demand to know what has happened to us, the physicians you thought you controlled. You have cried that our sins are destroying the world and you have cursed us for our unwillingness to practice the virtues you demanded. Since virtue, to you, consists of sacrifice, you have demanded more sacrifices at every turn. You have sacrificed all those evils which you held as the cause of your plight. You have sacrificed justice to mercy. You have sacrificed independence to unity. You have sacrificed wealth to need. You have sacrificed self-esteem to self-denial. You have sacrificed happiness to duty.
“While you were dragging us to your sacrificial altars, we physicians who value justice, independence, reason, and self-esteem – we finally came to see the nature of the game you were playing, which we had previously been too innocently generous to grasp. And we have chosen to play no longer.
“All the physicians who have vanished from your system, the doctors you hated, yet dreaded to lose, we are gone from you. Do not cry that it is our duty to serve you. We do not recognize such duty. Do not cry that you need us. We do not consider your need a claim. Do not cry that you own us. You don’t. Do not beg us to return. We are making our own way, apart from you.
“In your cynical attempt to control the healthcare system, you have coerced us – with your threats to our livelihood, threats of massive fines, threats of jail – to abandon our sacred obligation to our patients. Society must come first, you say. The needs of the collective are paramount, you insist. We must do what the experts tell us to do, you demand. And in the process you have destroyed the doctor-patient relationship which is the backbone of our profession. You have reduced physicians to ciphers, to puppets. And you have reduced our patients – the living, loving, hoping, striving people who come to us, who place their trust in us and their lives in our hands – to interchangeable members of a vast herd. You have demanded that we guard society’s interests, and abandon our sick to their own devices in your cruel and parsimonious healthcare system.
“Your process is now firmly established. Your methods have been legislated by Congress, embodied in volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the courts, and finally (and most tellingly) sanctioned as being entirely “ethical” by your allies, the leadership of our own professional organizations. You have made the healthcare system untenable for doctors who value true medical ethics.
“You have placed us into a position where we must either resign ourselves to an unethical, demeaning, health-destroying style of practice, or get out. We have gotten out.
“We have gotten out. We have left your Program. We refuse to sacrifice ourselves for you any longer. We will not sacrifice our livelihoods, our morals, our independence, our minds, or our patients for your bastardized idea of virtue.
“We will practice medicine in the only manner that still permits us to behave ethically toward our patients, in the only way that we can honor the true doctor-patient relationship, in the only way we can legitimately regain the title of professional. We have chosen to be paid directly by the people to whom we provide our services, by the people to whom we dedicate ourselves as professionals. We have chosen to cut you out.
“To argue that direct-pay practices are unethical – to argue that any innovation that would somehow restore both our professional integrity and the patient’s rightful advocate is unethical – is completely upside down. This argument only reveals your own inner corruption. We are taking the only pathway that remains to us to restore the true foundation of medical ethics, to restore our profession – to always place the patient first.
“To argue that direct-pay practices threaten the general welfare completely ignores reality. We are doing the only thing we can do to begin restoring protections that people are supposed to have when they are sick and facing a healthcare system that is utterly bent on withholding their care whenever it can be gotten away with.
“To argue that direct-pay medicine will create a two-tiered healthcare system is absurd on its face. It provides a mechanism by which at least some of your intended victims can escape the deadly obstacles you have laid before them. Saying that it amounts to a two-tiered healthcare system is as absurd as arguing that slaveholders were wrong to free their slaves before Emancipation, because doing so would create an elite subpopulation of former slaves; that until all slaves are freed, no slaves should be freed. But when a few slaves were freed and walked the earth as free men, that action was not only ethical, but it also showed others what was possible. Over time, it created a widespread expectation for freedom that eventually could no longer be ignored, and that, at huge cost, was finally fulfilled.
“You wouldn’t understand this – you who already know everything, you whose experts already have all the answers – but any innovation that can potentially spare patients from some of the harm you have in store for them will necessarily be applicable to only a few patients at first. That is how disruptive processes work. In your proposed perfect system, of course, disruptive processes are anathema – because they disrupt. But in the real world disruptive processes are creative processes, processes of growth, processes of rejuvenation, processes that create opportunity. This is why you always try to suffocate disruptive processes, with your cries of “unfair!”
“Disruptive processes always begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers. But if at their core they are offering something fundamentally useful, they will slowly demonstrate their worth – and eventually all the potential users will see the light, and demand for the product will become explosive. At this stage the means are invariably found to make the new product affordable and available to meet the demand, while preserving the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.
” We are a disruptive process, and the process we are disrupting is yours.
“We are not playing your game any longer. We will no longer be victims; we will no longer subject ourselves to your attempts to make us guilty. We will no longer walk, heads bent down, to your altar of sacrifice.
“You no longer have any hold on us. We have done our time. We are getting out. If we decided to leave medicine and open a road-side fruit stand, or become lumberjacks, or just spend our time puttering around in the basement, you would have no objection to that. So by what right do you object if we hang out our shingles, and see a few patients who voluntarily come to us, using their own resources to do so? You can have no rightful objection to such a thing. So be quiet about it, or admit to your own corruption.”
Wednesday, September 05, 2012
The Butterfly Effect
The last few days I have noticed something new in my backyard garden. I kept seeing these "dragonflies" whisping past me. I thought to myself, there are a lot of dragonflies back here. I had not seen them much since my days growing up on Lake Okoboji.
As I took a closer look and watched them fly about, these were no dragonflies! They are hummingbirds! Call me silly, but I had never seen a hummingbird before. I noticed, then, that my neighbors had hummingbird feeders...those red feeders stuck on the kitchen windows to attract them. I googled on the types of plants that hummingbirds liked and found that I had some wonderful plants for them to nourish themselves.
And the butterflies....wow, so many butterflies. This year I planted two new butterfly bushes. Let me tell you...if you plant it, they will come! Butterflies are amazing. I named my first Monarch "Petie". I swear Petie came back to see me every summer when I was a kid growing up on West 9th street. He knew just where to come. He would land on my finger and I knew it was him...not changed one bit from year to year.
Are you aware that in 1963 Edward Lorenz presented a hypothesis to the NY Academy of Science stating that a butterfly could flap its wings and set molecules of air in motion, which would move other molecules of air, in turn moving more molecules of air--eventually capable of starting a hurricaine on the other side of the planet? Lorenz and his ideas of the "butterfly effect" were laughed out of the conference.
Thirty years later, it was no suprise that professors came to the conclusion that the butterfly effect was authentic. Soon after, it became law.....The Law of Sensitive Dependence Upon Initial Conditions. And it encompases more than just butterflies...it includes people as well.
You and I make moves whose effects ripple through the lives of others everywhere...just like the butterfly that flaps its wings to move molecules. You can look back as far as the eyes can see and you will find that one thing can be traced back to another, and another, and another. And how far forward would we need to go in your life to show the difference you will make. Everything you do matters and many lives will be shaped because of something you and I do today. No one is created equal. All our abilities are in no one else. And you may not know it, but you and I have had an effect on someone else. We will never know when and how, but it happens.
My Monarch friend, Petie, changed my life. A couple flaps of his wings moved molecules of air, and those molecules moved more molecules of air, and so on. There was not a hurricaine, but those movements affected me. Petie will never know how much I love monarchs or nature or those silly "dragonflies" I see in my backyard. You just never know....
As I took a closer look and watched them fly about, these were no dragonflies! They are hummingbirds! Call me silly, but I had never seen a hummingbird before. I noticed, then, that my neighbors had hummingbird feeders...those red feeders stuck on the kitchen windows to attract them. I googled on the types of plants that hummingbirds liked and found that I had some wonderful plants for them to nourish themselves.
And the butterflies....wow, so many butterflies. This year I planted two new butterfly bushes. Let me tell you...if you plant it, they will come! Butterflies are amazing. I named my first Monarch "Petie". I swear Petie came back to see me every summer when I was a kid growing up on West 9th street. He knew just where to come. He would land on my finger and I knew it was him...not changed one bit from year to year.
Are you aware that in 1963 Edward Lorenz presented a hypothesis to the NY Academy of Science stating that a butterfly could flap its wings and set molecules of air in motion, which would move other molecules of air, in turn moving more molecules of air--eventually capable of starting a hurricaine on the other side of the planet? Lorenz and his ideas of the "butterfly effect" were laughed out of the conference.
Thirty years later, it was no suprise that professors came to the conclusion that the butterfly effect was authentic. Soon after, it became law.....The Law of Sensitive Dependence Upon Initial Conditions. And it encompases more than just butterflies...it includes people as well.
You and I make moves whose effects ripple through the lives of others everywhere...just like the butterfly that flaps its wings to move molecules. You can look back as far as the eyes can see and you will find that one thing can be traced back to another, and another, and another. And how far forward would we need to go in your life to show the difference you will make. Everything you do matters and many lives will be shaped because of something you and I do today. No one is created equal. All our abilities are in no one else. And you may not know it, but you and I have had an effect on someone else. We will never know when and how, but it happens.
My Monarch friend, Petie, changed my life. A couple flaps of his wings moved molecules of air, and those molecules moved more molecules of air, and so on. There was not a hurricaine, but those movements affected me. Petie will never know how much I love monarchs or nature or those silly "dragonflies" I see in my backyard. You just never know....
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