Thursday, May 31, 2007

I love my doctor

A year ago, my three year old woke us up screaming in the middle of the night. Not tantrum-screaming, bloody-murder screaming. We turned on the lights, picked her up, found the favorite blanket, and tried to hold her writhing body. After about 20 minutes, without so much as a pause for air on her part, we called our pediatrician's after-hours number. This connected us to a switchboard who asked us several questions (date of birth, weight, etc) who then transferred us to a pediatric-nurse hotline, who then asked the same questions. She unhelpfully suggested we undress her to see if we saw anything on her body (hard to do with a screaming-writhing kid), then confessed she had no idea what to do and we should probably take her to the emergency room "just in case". Thinking that my pediatrician had admitting privileges at only certain hospitals or the practice might prefer the children's hospital, I asked which hospital to take her to. "The nearest one" she replied -- at which point I discovered that this nurse was in Wisconsin (we, and our pediatrician live in New Mexico). We bundled the now-naked screaming kid into the car and took off.

This isn't the first time a doctor (or their practice) has let us down in a time of need. I've waited for three hours for an appointment. I have had the temporary "doctor of the day" in a group practice override written instructions left by my midwife (who I can't see because she has to be scheduled five weeks in advance -- in fact my monthly appointments have to be "fit in"). A number of baby books have chapters on "How to select your child's pediatrician". You might as well save your breath. No matter how carefully you research your pediatrician you will see him or her only for scheduled shots. The majority of visits (head bonks, ear infections, weird rashes -- the most important visits from the patient's/parents's point of view) can't wait three weeks, so you will be seen by a rotation of nurse practitioners, none of whom will be working for the office next time you call. I've waited six weeks to see a doctor I'd hand picked to discuss surgery options, only to discover someone had changed my appointment so I'll be seeing the newly minted MD resident instead.

But it doesn't have to be like this. And right now, it isn't. Friends of ours recommended a doctor they "really liked" -- little did they tell me this was going to be a life-changing experience for our family. The first indication was her receptionist telling us that the first appointment would be for an hour, and suggesting that it would be better if we were completely well at the time of that appointment. With an hour, our new doctor had enough time to listen and take a health-history, write out ongoing prescriptions, and discuss toddler ear-infection philosophies. She takes her own call, except when someone covers for her on vacation. Standard appointments after the first are for 30 minutes and can usually be scheduled in a few days. What I call "fit in" appointments are 10-15 minutes and are usually same day or next morning. These include single issue urgent items: can you look at the baby's ear? Does she have pink eye? This family doctor understands the dynamics of infection in a family using daycare, she can check all of our throats for strep, and is gently, gradually getting us to take better care of our heath -- stress reduction here, cholesterol there. The difference continuity of care makes is enormous. Here is someone I actually trust -- she's been there for me, she knows how I think about my health and she sets me challenges -- I'm actually doing yoga and walking, rather than just thinking about it. As a single healthy 20-something, medical care played a tiny part in my life, but now as a 36 year-old with a child, this makes such a big difference in our quality of life I can't imagine moving, unless she comes with us. Oddly enough this "quality of life" effect persists outside her office. Read something scary on the web? Don't worry, we'll print it out and take it to the next visit for her opinion. Baby has a fever on a Friday afternoon? No panic. We'll treat it with ibuprofen, and if she breaks out in Dengue fever on Saturday, our doctor will be there. Someone we trust, who knows us, will answer the phone.

I've been told you can get medical treatment of this quality in large cities such as Washington DC and Los Anglos, under the name of "concierge medicine"-- you pay an annual fee $1,000-$20,000 (completely unreimbursable under your health insurance). For this you get continuity of care, same day appointments that start within 30 minutes of their scheduled time, and the pager number of your doctor. The extra money allows the doctor to see fewer patients and run a smaller practice without losing income.

But what my doctor is doing is different. She's in a solo practice; she calls it "providing a medical home for her patients". She's part of a larger group that calls their goal Ideal Micropractice. They are participating in a study by The Physicians Foundation for Health System Excellence (the preliminary and rather technical report).

I asked her what this is like from her perspective. In the old office she used to see 20-25 patients a day, then chart for 2 hours, and answer calls. Now she sees 10-12 patients each day, giving her time to care for and enjoy her relationship with patients. Unlike a group practice she does her own chores. She cleans up after herself, answers most of her own calls, call pharmacies, orders medical supplies, calls to find lost labs, and fills in forms. However, daily, it takes no more time than charting, answering calls and taking call did at the group practice. (She protests "It is still too much time!"). Her solo practice works financially because the average overhead for a family practice office is 65-70%. She's cuts this to 25-30%. So despite seeing half the number of patients, she makes (only?) 20% less than she would in a local group practice. While her solo practice is doing well, she does worry that in the long run, her practice will get squeezed to death between rising costs and malpractice, rising demands by all insurance plans for more paperwork and lower or flat insurance payments. She says she feels like she walks a thin line each day between the number of patients she can care for well, and the financial costs. (Actually her worst complaint is that she has to administer shots herself to the babies -- a chore the nurses get to do in typical group practice.)

It's not just me that appreciates the quality of care. The first visit with a newborn/new mom always includes help with breast-feeding. Teenagers don't have to explain delicate health issues to first a receptionist, then a nurse, before they get to a doctor they know and trust. She says "A lot of them call me from college with crises and news". There are about 50-70 of these doctors in the US (in addition to the small town types who have known their patients well for years).

Want one for yourself? You can get a list of them at

Do these people have anything in common? Does working solo actually imply a philosophy? In fact it they do seem to hold some common truths. They don't like medicine as it's being practiced -- they don't enjoy doing it and they don't think it's good for the health of their patients. While quality-of-care sounds like a throwback to small town family doctor days, they are pro-technology -- electronic records, evidence based medicine and surveys (in particular "How's Your Health") and determined to beat costly and debilitating disease by being proactive with patient behavior (note my walking and yoga...more than I've ever done for any other doctor).

Other article on micropractice/solo practice/ideal practice/medical homes:

And the screaming in the middle of the night, how did that end? My daughter fell fast asleep in the car on the way to the emergency room. She stayed that way through the first two hours of our wait (I wasn't upset with the wait -- I was relieved she'd quit screaming and we certainly no longer looked like any kind of emergency) and then started causing mischief in the waiting room at 4 AM. Four hours after we arrived we gave up and went home, mostly exhausted but slightly uncomfortable about the lack of medical feedback that our kiddo was going to be OK. The next day the assistant to the nurse who assists our doctor called us (evidently they keep track of who uses the rent-a-nurse line) to see if we were OK. She tentatively suggested it might have been gas(!) or a nightmare(!) but didn't know for sure, not being medically trained. She also didn't offer us an appointment or a phone call to discus it with the doctor. She had no idea that the after-hours line connected to somewhere out of state. We fired that pediatrician -- or rather her practice -- and having found a "medical home" we haven't looked back.

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