Monday, February 6, 2017
All is well in direct primary care
Let me update you on what's going on in my practice. We are getting very close to our four-year anniversary/birthday/Kwanza. We opened in February 2013 and are doing remarkably well despite having a dopey doctor at the helm of the business. I think that's testimony to the business model, actually, in that I was so afraid of the intricacies of business that I dumbed it down enough for it to be “so easy, even a doctor could do it.” And I am still doing it!
We are up to about 670 patients and are still steadily growing. For those who think this number should be higher, I was previously estimating our numbers based on my homemade EMR software, which, it turns out, was a braggart. Now the numbers are more accurate, based on the actual billing subscriptions each month. But still, that's a healthy number, and we continue to grow significantly year over year.
Jamie and Jenn are still working with me, and we are trying to improve the overall quality of the care we are giving. Lately we've been concerned that we are getting a little complacent about things, that we know we are good and don't feel the urgent need to prove it, so we are now trying to find ways to tighten the ship, improve our quality, fix areas where we are inefficient, and make the experience better for our patients. There still are very few complaints, and the busiest day we've ever had in the office is 13 patients (although there were many patients we took care of outside of the office), but we don't want to wait for complaints before working on improvement.
I reluctantly abandoned my homemade EMR product and now am using Elation EMR. I switched mainly because I didn't see myself being able to keep up with where I felt the practice needed to go in the future (mainly in the area of direct engagement with patients through their records). My EMR worked just fine, but I was basically having to do two jobs at once, which was overall too much to do in the long run. We are six months into using Elation and are happy with it.
My interactions with the rest of the health care system increasingly show me the madness that I left is only increasing. Specialists have less time and inclination to communicate with me, as do hospitals. Primary care docs I speak to are all sad and/or tired. Anyone who is trying to get insurance through anything besides a large employer finds the process difficult and incredibly expensive. While the Affordable Care Act never struck me as a solution to our problems (not addressing the man issue: the high cost of care), the tearing down of this program offers no better prospects for our future. Few people have good insurance, and many have none. It's a sorry system we have, and the prospects of improvement are not good.
But in our practice we live on this little island of sanity in a world where that is scarce. We work in a place where “You're welcome” is said far more than “I'm sorry.” Patient wait times only go up when people have the nerve to show up early.Otherwise, we still have an average of around 30 seconds. I still spend an hour with new patients, for them to get to know me and me to get to know them; and they still generally walk away with an amazed expression on their face, having never experienced a good experience at a doctor's office. We still have a steady stream of new patients without doing much at all in the way of marketing. So all's well in Robsville.
And the movement of direct primary care is booming. There are many more physicians across the country either converting to this model, or starting out of residency in this model. Just yesterday I spoke to a doctor in Augusta who plans on converting his practice “by May.” I told him I'd do whatever I can to help him. He sounded like a man who is about to get out of jail. So maybe there is some hope. We will see.
Let me close by proposing a toast. Here's to 2017. May it be full of blog posts, devoid of mutant slugs, may it surprise us and somehow give us hope for the future of our health care system, may our facts always be factual, may our news sources always be reliable, may any squirrels we encounter not be angry enough to bite us, and may we smile far more than we scowl … even with what's-his-name in the White House.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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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, 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.
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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, 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
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).
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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.
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.
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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.
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.
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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.
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