American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, April 11, 2016

Patient-centered care, part 1

Three (and a half) years ago, when I left my old practice, I was near burnout. I was exhausted, not because of the amount of time I was spending—it was actually about the same, if not less than I had worked before—but because of an ever-increasing gulf between me and my patients. I have always tried to give care that focused on the person with me in the exam room, but did so against a growing current constantly pushing me away from my patients, a current emanating from the system that was built to serve them.

My early adoption of computerized records (1997) was not because of my fondness for technology, but because I felt it was the quickest and most efficient way to organize and retrieve the information necessary for good care. I was obsessed with improving work-flow in the office, as any efficiency would buy me a little more time to focus on clinical care. As this obsession grew, the gulf between me and the other physicians in the practice, who didn't share my focus on patients, grew inextricably and irrevocably wide. The end result was a “divorce” from my partners. I was ushered out with a nice plaque, some cake, a buy-out check, and a firm “pat” on the back as I walked out the door.

Three years does a lot to crystallize one's view of the past and why things really happened. I didn't really understand the cause of the divorce while it was happening; how it could happen that within a very short time I went from a sure future as senior partner to an outsider. I went from architect of medical records and caretaker of my patients to having no access to those records of my care.

Now, as my journey has taken me and my old practice down very different roads, I see clearly the dividing point between us: patient-centerdness. Over the three years since opening my doors as a direct primary care doctor, my obsession with patient-centerdness has, if anything, grown. The same certainly cannot be said about my old practice, as it has followed the rest of the healthcare system's lemming march away from patients and toward the cliff of ICD-10, meaningful use, and whatever other requirements the payors demand.

Rather than dwelling on the malfunction of the system, however, I want to turn my eyes toward what most people don't see: what real patient-centered care could and should be. It's not that I am suddenly wiser than my colleagues in the sick-care system. Despite 18 years in practice, I was not able to see what true patient-centered care looked like until I left the system.

Why? What I've explained in the past bears repeating. A successful primary care business is fueled by 3 things: having as many sick patients as possible, doing as many procedures on those sick patients as possible, and spending as little time with each of them as possible. These 3 things are not only the antithesis of what my patients wanted, but they stand directly in the way of any attempt I made to center my focus on their needs. The only way to be a patient-centered doc in the current system in our country is to be lousy at the business of medicine. The soil on which my old self tried to grow good patient-centered care was clearly too hostile to produce anything that promoted health over sickness, reduced cost, or encouraged time spent with people. A good idea of what truly patient-centered care looks like simply cannot grow within of such a system. It dies under the intense heat of ICD, CPT, ACOs, and EMRs. I had to leave that world to understand that.

Now I am in an entirely different world. To catch those up who don't know, my current practice is entirely different than my old one. I don't accept any payments from insurance or other third-party payors. Patients pay a low monthly fee, between $30 and $60 per month with no copays for office visits. Other treatments, procedures, or diagnostic tests are given at the lowest possible cost.

I am now nearly up to 700 patients, and (despite having a doctor running the business) am seeing steady growth of the business in numbers and in the care we are able to give people. We are able to accomplish 4 things that the current system cannot touch:
1. My patients are much happier.
2. My nurses and I are much happier.
3. The care we give is much better.
4. We are saving the system (and our patients) a lot of money.

Nobody who comes to my practice would argue any of these points. The only downside at this point, and the reason this kind of practice has yet to catch on, is that my income is still about half of what I earned in my old practice. That needs to change for this model to truly disrupt our system, and if I want to retire before I am 80.

The lessons I have learned about patient-centered care are in the following areas:
• Patient-centered service
• Patient-centered communication
• Patient-centered medical care
• Patient-centered medical records
• Cost-conscious and responsible care

I've used up my words for this post (shocking as that may sound), so I'll go after each of these in upcoming articles. My goal is to give people a vision of what truly good care can look like. A number of years ago I came up with a pithy summary of the state of the health care system: People don't clamor for better care nearly enough because they don't know how bad the quality of their care is; and the reason they don't know how bad their care is in quality is because they don't know how good it could be.

I feel it is the responsibility of all folks innovating in healthcare to raise the expectations of people for whom the care the should be designed. To quote C.S. Lewis (out of context): ”[We are] like an ignorant child who wants to go on making mud pies in a slum because he cannot imagine what is meant by the offer of a holiday at the sea.” We need to expect more from our system, but the only way we can expect more is to see what the holiday at the sea would look like.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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