Mourning the death of my medical practice

“I did it,” I mumbled to myself.

The numbness overwhelmed my immediate sense of dread throughout my body.  I was trembling inside, full of anguish and at the same time, unable to contain my seething anger over an uncontrollable destiny.  Just a few minutes ago, I turned off her life support system.  The series of beeps had slowed down, pace by pace, like the ritardando in a finale movement of a concerto.  It was the end of a life journey for her. I had given birth to her 9 years before.  The birth of an idea that started with a promise to myself that I could do better as a doctor.

The idea blossomed into a wonderful, unforseen miracle.  Through her, I was able to find happiness in my work and my craft again.  Through her, I caught a glimpse of the true art of healing.  Through her, I was able to connect to my patients in a meaningful way and in return, most of my patients were deeply grateful for my aid to them and their families.  Through her, I saw my patients as complete human beings, full of promise and capability, but also acknowledging their deepest fears … their demons and imperfections.   Through her, I was able to motivate my patients to strive for good health and a balanced lifestyle.

To watch a 60-year-old beam with accomplishment for finally quitting smoking after 45 years was equally amazing as a 12-month old first learning to walk unassisted.  It was slow and incremental for sure, but it really stuck once their new habits became integrated with their old ones.  Through her, I learned to not pass judgement on others and I learned to forgive.

She was born into a world at a time when others no longer valued her ideals and thus, no longer valued her existence.  Unable to thrive in such a cold, hostile, unforgiving environment, she began to slowly wither.  A once vibrant soul now smothered by a system that valued production over quality.  A system failing to understand that human beings are not robots and widgets and that one cannot thrive merely if you meet a certain numerical threshold.  A system unable to respect human individuality and life experiences. A system that values quick fixes instead of meaningful, long-lasting healing.

In many ways, I hated myself for not being able to protect her.  For I had felt that I had brought her up in this world and I had somehow committed her to suffering and decay by coexisting with a sick system.  For many years, I thought I could save her from the system, but I could not change her world, no matter how hard I hoped.  It was not mine to control.

As time went on, she became sicker … infected by the same illness the system had brought on to her.  Through her, I began to lose the feeling of happiness in my work, my craft.  Through her, I became angry at the world. Through her, I began to lose hope. 6 months prior to that fateful day, I watched her as she was suffering in agony. All the misery had consumed her soul … and what was left of it, she knew that it could not last. And through her, I was beginning to learn the painful lesson of being able to let love go, to let it be. She reminded me that the idea of her never dies and like the phoenix riding from the ashes, ideas can always be reborn. Perhaps it wasn’t the right time, yet, but in the short time she was alive, life was truly a miracle.

In the last six months, I prepared for her death. Grief struck as my patients became saddened by the news. I mourned at the promise and the idea that was soon to be a swan song forever etched in my memories of what it once was. Nothing could prepare me for what was about to happen next, as the end came near. For it was like the hands of God … I had created, but I could destroy. I was frightful of what I was capable of. The vessel of fury and madness of what was incomprehensible … the good now gone … now filled with uncertainty.

The last gasps of her soul struggling one last time to survive. The repetitive beeps now no longer deafening to my ears, the beeps coalesce into a singular, iridescent hum fading into black. The promise of tomorrow, the torch of her once vibrant flame peeks through the window curtains beside me as her soul drifts away. Even as she goes, she continues to amaze me with her little miracles. She was real. She was my medical practice.

Michael Chen is a family physician who blogs at About Family Health.

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  • southerndoc1

    The AAFP has the blood of your and many other practices on its hands.

    • http://twitter.com/shihjay2 Michael Chen

      Although the AAFP is one of many organizations involved in our health care system that may have contributed or allowed small, independent practices like mine to struggle to their demise, perhaps going forward the questions we as physicians should ask ourselves is what are our priorities for our patients, both individually and also for the community. With those priorities as our guiding point, are we being mindful about the approach to getting to our goals? I think, this is where our health care system falls short. I see tremendous value in the relationships between the patient and physician but through all of the changes going on in our health care system today, I believe our health care system pays lip service to the patient-physician relationship and ultimately to its detriment. Other like-minded physicians see this eroding as we are trying to get to the goal of providing cost-effective care and increasing health care coverage and access. I believe the ideals of a micropractice do address both without the sacrifice of the patient-physician relationship. There just has not been an effective voice and leadership to push forward these concepts that have proven to be effective, not just locally, but also in other countries where primary care is highly regarded and supported through fair reimbursement rates and a healthy primary care workforce (both of which are in significant danger in the US).

      • southerndoc1

        What you’re describing is exactly what one would expect the AAFP to do in a sane world. Instead, they have chosen to align themselves with Big Corporate Medicine, against the interests of physicians and patients.

    • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

      I hate to say it, but the AAFP suffers from the same problem as the AMA. They are attended and run mainly by academic physicians who know NOTHING about the finances of practice and what it takes to sustain their salaries. I dare say that most academics know very little about “facility fees”, “RUC”, or how medicare billing even works.

      The Physician “Leaders” of this country are merely puppets with their strings being pulled by large academic institutions that benefit from the system as is.

      • http://twitter.com/shihjay2 Michael Chen

        I recall sometime last year AAFP was thinking of butting heads and revealing RUC but they backed down at the last minute. Not sure what that was about, but I suspect some political stuff was going on with that. Either way, I was dismayed about the outcome and that was when I knew (amongst other issues) that my practice was doomed.

        • drg

          This is so very sad. Very well written and heartfelt!! If I may ask, are practicing medicine now at all? I read your blog on your site. Very thoughtful articles. Your article written here has obviously touched a lot of us that feel similarly. I wish we all could do more about this.

  • http://prenatal-cradle.com/ Prenatal Cradle

    Amazingly well written article, saddening as it was to read it.

  • doublj01

    why is this happening? why is it that family practices are no longer viable?

    • http://twitter.com/shihjay2 Michael Chen

      The 2 big factors:
      1) Perpetually unfair reimbursement rates for primary care visits, especially for chronic care
      2) Increasing non-reimbursed activities for physicians and their support staff for the same level of care. This includes insurance reimbursement hassles, prior authorizations for referrals, treatments, and tests.
      Put those 2 together and you get a situation where medical students are no longer interested in pursuing primary care as student debt rises and increasing burnout amongst the currently primary care workforce. There are other smaller factors (like Health IT stressors such as Meaningful Use), but these are the important ones.

      • ninguem

        And the fact that the big box mega-clinic or hospital-run facility can get paid twice as much for the same service by billing “facility fees”. Faced with a rigged game, the independent doc goes down the street to the mega-clinic. Enough docs do that, independent medical practices soon go extinct, and the cost of outpatient care will double.

        • http://warmsocks.wordpress.com/ WarmSocks

          That “facility fee” comes out of my pocket, since it’s applied to the deductible. Who in their right mind would go somewhere that charges a facility fee if private practice doctors provide better care without the facility fee?

          Independent docs can go together and form their own large group, with the understanding that they all continue to run as private practices. They buy bargaining power yet retain independence.

          • Suzi Q 38

            If you are like me, and wanted a certain surgeon at a certain rather large teaching hospital that had an off-site office closer to my home.
            I learned. I got charged to off-site facility fee only once.
            The teaching hospital site did not have a facility fee.
            I just try to go to the teaching hospital to see my surgeon.
            I know if I want the convenience of going to the local building, I have to pay the facility fee.
            I think the fee was $100.00, not sure.
            I paid it, but thought that was kind of excessive, since I have PPO.

          • http://warmsocks.wordpress.com/ WarmSocks

            We certainly learn, and ask beforehand. Children’s Hospital has started charging a $275 facility fee for routine follow-ups in the clinic. Since there are no other pediatric rheumatologists in the state, patients don’t really have much choice. It seems criminal. It shouldn’t cost them more in overhead to run that office than any other doctor’s office, and it’s understandable that private practice doctors are upset about not being able to charge that fee if others can. With any luck it’s temporary.

            Private practice doctors who can hold on will find themselves highly desired by people who dont’ want to be sucked into the big hospital systems.

          • http://twitter.com/shihjay2 Michael Chen

            I agree, WarmSocks. One of the reasons I feel the message and therefore lack of action to change our health care system is not enough awareness by the public at large regarding the plight of primary care physicians. My patients were in shock that this was even an issue when I announced my pending closure. I admit, as a doctor, I didn’t advertise or even raise a voice about it except on my blogs because as a profession, there is an unwritten expectation to suffer silently. Perhaps no change will ever come when we (doctors and patients) keep silent.

          • Suzi Q 38

            I will admit that I had a bad attitude about this before until I saw what the PCP gets paid for each visit. The AMA has a campaign going on right now to help medical students with their med school costs. I had to email a pre written letter.
            I think that I accessed it on one of the articles on this blog.

            It is time that the AMA works for your specialty, too.

          • http://www.facebook.com/virginia.scanlan Virginia Scanlan

            Dr. Chen: Private practice specialists are going down the drain as well. Some specilalties have seen 50% cuts in Medicare reimbursements and can barely pay their bills. They, too, were sold out by their specialty colleges, led by people more interested in power and getting government jobs than the needs of their members.Unfortunately, doctors will suffer such abuse that in the end, they will be forced to unionize to protect their patients.Many hospital administrators know nothing about managing a medical practice or what patients need. Doctors have become shift workers and will have to organize. Payment for quality has been pushed by the the big clinics who have been advocating to be designated as ‘centers of excellence’ for years and to be paid more and to protect their sources of referrals.They will join with insurance companies and the government to prohibit tertiary care outside their systems..As for facilities fees, they are the result of more powerful and focused lobbying than any of the specilaty colleges delivered. The hospitals knew that their very existence was on the line and their lobbyists fought tooth and nail to protect them. By contrast the academicians and big clinic leaadership in the specialty colleges have always disdained private practioners and were only too happy to collude in their demise. My sincerest sympathy for losing the practice you loved.

          • http://twitter.com/shihjay2 Michael Chen

            Thank you, Virginia, for your comments. I have noticed this effect too for the specialists who are in private practice or in solo, independent practices. I know most have be survive by adapting to a concerige type model of practice, but whehter that will change the face of our health care system and those who have the power to influence health care remains to be seen. I think there is something to be said about having innovative, smaller, personalized practices but they are all going by the wayside, like you mentioned with the triple onslaught by hospitals, big clinics, and insurance companies.

          • ninguem

            Glad to see you recognize this WarmSocks. In my private office, I can’t get $275 for any office visit of any kind. And that’s just the facility fee. There’s the regular billing on top of that. The ripoff is absolutely reprehensible. Where does the money go? Administrative bloat. That’s how the administrators get millions…….and I wish I were exaggerating, I’m not……in compensation.

            But as long as “facility fees” are allowed, expect to see more and more medical practices disappear.

            How do you compete with that?

          • http://warmsocks.wordpress.com/ WarmSocks

            Children’s can’t get that $275 out of me. I don’t have other options on places to take my child, but did find a way to avoid the fee. I was happy to pay my bill before, but that pushed us over the edge to where we applied for patient assistance. I guess that means they get to write off more on their taxes, but doesn’t give them more income.
            As for competing, I don’t understand why doctors would join the hospital: lose autonomy, forced to see more patients per day, forced to refer in-system instead of to whomever you believe to be best, generate more income for your employer but not for yourself. It seems the freedom to work for yourself would be worth fighting for, but I obviously don’t know all that’s involved. My family physician joined together with a few other private practices, the idea being that if they band together, they don’t have to sell out to the hospitals. I noticed that right after they did that, his $ from my insurance company increased about $13 per office visit so the group must’ve had more bargaining power. I hope he’s able to stay independent. I hate to see people railroaded.

          • sungazer4

            Doctors join because this whole systematic change contributes to their referral base slowly disappearing. That along with the cost of maintaining the cost of a practice – and keeping the lights on becoming untenable.

          • ninguem

            If you’re an independent surgeon, you get patients referred to you from primary care doctors.

            If all the primary care doctors are “owned” by a Big Box entity, they are “persuaded” at the point of a gun to refer to the surgeon “owned” by that same Big Box.

          • http://warmsocks.wordpress.com/ WarmSocks

            I understand that specialists get referrals from others within the same system. Through a horrible experience, I understand all too well that they aren’t allowed to refer to a competing hospital system even if that is in the patient’s best interest.

            HOWEVER, It doesn’t seem like there are that many subspecialists referring people to primary care. Primary care doesn’t get that many referrals; they write them. Are you saying that doctors within one hospital system will refuse referrals from private practice doctors in an attempt to force the private primary care doctors into the system?

          • Suzi Q 38

            This happened to me.
            My neurologist wanted me to have my surgery at the cancer teaching hospital, even though I had no tumor or cancer. I wanted to get another opinion from a local teaching hospital that specialized in neuro, and the neurologist refused to refer me to the neuro teaching hospital. I instead had to get my PCP in my city to request the referral. This caused me to lose even more time.

          • drg

            why do you think your neuro would not refer you out?

          • Suzi Q 38

            The neurologist was adamant about my having it at his cancer teaching hospital. Even though they were primarily really good with cancers, they maintained throughout my care that they could handle neuro and endocrinology.

            I thought that their surgeon was very good for cancer tumors, but not sure about the neurology department as a whole, since they only had one neurologist and 3 neurosurgeons…no M.S. specialists, which was part of my questionable diagnosis at the time.

            Another thought was that they were concerned that since my spinal blockage and symtoms occurred two years prior after a hysterectomy at their facility, that another surgeon may discover a problem. The PA for the neurosurgeon at the cancer hospital said that someone could have dropped me on my head, and I wouldn’t have known it because I was asleep. I couldn’t believe he said that, as I never though anything of the sort.

            I was annoyed that they would not do this for me, and I will probably explain myself to advocacy later, but I felt that that was the least they should have done.
            I just felt that it was time to move on, as I had been there to correct my symptoms for almost two years, and they had their chance. Once I found out that it was serious, I realized I needed to move on to a hospital that specialized in neurology.

            You have to realize that medical care has become somewhat competitive. An anterior discectomy costs approximately $60K-$80K with the surgeon, anesthesiologist, OR, and all additional staff, hospital room, and medical supplies for my 30 hour stay.

            Also, if I like the hospital and doctors, there is a chance that I may stay.

          • drg

            you have been through an awful lot! I hope you feel better. When was your surgery?

          • Suzi Q 38

            Yes, I am feeling a little better, thank you.

            I have been spending some time on these medical threads as they have helped me see the “other side.”
            I would not be able to do so, had I not been home for the last month.

            Two days ago, I did not feel well. Yesterday and today, I feel great. I feel that I al least have more stamina, even though I am still weak and walking a bit too deliberately and slowly.

            My surgery was 1/18/13. I checked in at 6:00 AM and then left at 12:00 noon the next day.

            The hospital probably loved it that I went home so early and lived to tell about it, LOL. DRG’s (diagnostic related goods) and all.
            I think that I was allowed to stay there up to 4 or 5 days.
            After having had TWO visiting nurses two days in a row, I knew that my family could do better.

            The night nurse was fantastic, but she kept me up every hour and a half a night.

            I also was concerned with MRSA and other hospital acquired infections.

          • drg

            glad you are beginning to feel a bit better.

          • southerndoc1

            Write letters: to your Senators, your Rep, hospital administrators, your insurer, and your employer, if they provide your insurance. Write to your state insurance commissioner. Write letters to the editor of all local papers. Call the local TV stations.Get other patients at this hopital to do the same. Complain bitterly to your doctors: don’t let them off the hook. Voice your displeasure loudly and clearly at check-in and check-out every visit.

          • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

            This is really interesting. Im in private practice and I dont think i’ve heard this “facility fee” thing before. is this very wide spread? is this being charged to medicare pt’s too? or just private insurance pts?

            just not clear on how they are getting away with this….

          • Suzi Q 38

            I am not sure how they are getting away with this, either.
            Here I decided I wanted a consult with a certain surgeon.
            I was told that on Thursdays, he sees patients in XXX facility. Okay.
            When I get there, I see a brand new, fancy building.
            They charge $6.00 for parking and serve coffee and snacks.
            The staff all wear color coordinated uniforms.
            When I am filling out the paperwork, I notice a form for me to sign notifying me about the “facility fee.”
            I signed it, and i had to pay $100.00 extra, above and beyond what my PPO insurance paid (my co-pay is $15.00).
            I don’t get charged the facility fee if I go to see the same doctor at the teaching hospital.

          • http://twitter.com/shihjay2 Michael Chen

            Brian,
            The facility fee in it of itself is not new. However, as hospital systems are trying to acquire primary care practices in anticipation for the changes related to Accountable Care Organizations, they realize they could reduce the income loss because of the paltry reimbursements of PCPs by insurance by tacking on the facility fee. But as Suzi Q indicates, the cost goes to the patient if the patient is responsible for the deductible. The facility fee is being used everywhere because they legally can under current Medicare rules. The rationale is that these large organizations have to incur a cost for unused labor and supplies. Not sure if this is the right solution for cost effective care, however. A lean but patient focused practice is still the way to go in my opinion.

          • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

            wow… not sure how I missed that.
            So BIG corps can charge patients to help offset dismal PCP reimbursement, but the little guy gets threatened with Jail time and fraud if he considers anything to help offset losses from Medicare. wow… and I thought I knew just how ugly it was. It just got a whole lot uglier.

            so… as stated earlier in this comment section. How come this “facility fee” is not driving a whole bunch of people to go out and find independent physicians?

          • southerndoc1

            Eliminating the facility fee is lowest-hanging fruit, the easiest way to quickly save big bucks. That neither CMS, the large insurers, or the medical societies are proposing this indicates that none of them have any real interest in lowering costs.

            The well-paid whores running the AAFP refuse to comment on this issue, just more proof that they’re committed to the destruction of private practice.

          • ninguem

            ^^^ what southerndoc said ^^^

            …..I find myself saying that a lot…..

          • Suzi Q 38

            I am.
            Once I get stabilized and am finished with my surgeon, you can bet that I am NOT going back to that facility that charges the $100.00 (or more).
            Also, after my experience with some very good and some very bad specialists, I am hanging on for dear “life” to my PCP of 10 + years. As good and bad as my experience in the last two years was, I couldn’t have done it without him.
            I am realizing though, that he is about 6-7 years older than me….sadly this means that he is about 62 or 63.

            When do doctors retire?

          • Suzi Q 38

            I have decided that I am not paying it if possible my not going to that new, state of the art, fancy clinic that the surgeon sees patients in.
            To my knowledge, the clinic located at the teaching hospital itself does not charge this fee.
            If it is hidden, I do not know where.
            I am going to pay closer attention to the bills, now that you say so.

            I agree that a lean but focused practice is still the way to go, but my condition was so complex that even my PCP (my favorite doctor of all time of 10+ years) told me to go ahead with the consults. It was beyond his knowledge and expertise. He had no referrals for me. He was stumped and worried about me.

            He was funny though. He didn’t want to fill out a ton of paperwork for my referrals. I told him that I would write a letter to the referral doctors and that he could sign it.
            He agreed. I wrote the letter, and stopped by his office to send to the specialists and teaching hospital that I wanted to go to. He looked at the letter, and laughed. He said that he could not have written it better….LOL.
            He was surprised that I had a little knowledge of my condition and why I needed to see a specialist. I wrote it as if I were the doctor. He just signed it.

            I realize now that this was a big deal to him because he could not be paid for the service. I offered to allow him to bill my insurance company for the visit, but he declined to do so. In retrospect, I should have just paid him $50.00 the time it took to process the paperwork and fax it in.

            It is still not to late to do so.
            i will see him this month. I can see that he is taking more and more medicare and medical patients. They fill his office. I don’t really care, as he was always my doctor since I moved here and I am fairly loyal since he is a good doctor.

          • http://warmsocks.wordpress.com/ WarmSocks

            I think hospital stays always have a facility fee buried somewhere in the bill. My insurance company told me that hospitals can charge it, but clinics can’t. I agree, I don’t understand how clinics associated with hospitals can get away with it.

            One of my doctors is associated with a hospital, but that system does not (yet) charge a facility fee for office visits. If they do, I will have to search for someone equally competent who doesn’t charge extra for the use of the office. I will certainly take this subject up with our insurer, since our policy is up for renewal.

          • drg

            Hey Remember when the book 1984 was JUST a sci fi novel???
            Are there any actions being done to correct this? This –meaning corporate America taking over the world.

            I wonder why this is not making the news? All you read about is there is a shortage of PCP’s and rising healthcare costs.
            Well NO WONDER!! There is no mystery in that! But to the newspapers and public it is a well kept secret with no solutions. The obvious solution of paying PCP’s !! is not addressed!!!!
            I was discouraged by reading the Klepper article RUC survives and now our healthcare system is worse off. It sounded like there were only a few PCP’s fighting and the AAFP is not backing them?? I enjoyed life better when 1984 was just a novel…..

        • EmilyAnon

          I pay a facility fee everytime I get a routine blood test at my hospital. Here’s a breakdown of the bill:

          phlebotomist fee $62
          CA 125 (blood test) $135
          facility fee (lab) $153

          • http://warmsocks.wordpress.com/ WarmSocks

            You can ask your doctor for a lab slip that you can take to an outside lab. I’m pretty sure that, legally, they can’t require you to use the hospital’s lab.

          • southerndoc1

            So why don’t you go to a free-standing lab?

          • ninguem

            Medicare pays me three dollars for phlebotomy.

            The facility fee of $153 is more than the whole fee for my office visit.

          • EmilyAnon

            I should have said I get charged a facility fee which my insurance, so far, pays. So because I don’t directly pay, I haven’t been motivated to make any change. But in case coverage is denied in the future, I did find out you can purchase a voucher for any blood test through an online company (MyMedLab) and get the test done at any participating lab. No prescription needed. My test would cost $65.

          • Suzi Q 38

            I would just find the local lab in your area. Get some forms, and have your PCP use them to order your blood work.
            They can send the results to your PCP directly.
            That is just nuts.

      • Suzi Q 38

        Dr. Chen,
        Thank you for your story.
        I am so sorry about your practice.
        Until I stumbled on to this site, I had no idea what my PCP doctor was going through. I am embarrassed to say that only paid the $15.00 copay all of these years (10-12). I have realized that I need to pay more. I maybe need to write an article or two about this, so that other patients like myself can better understand.

        I have decided to pay $50.00 a visit co pay if it will help, but I am only one person.
        A practice like yours in California would be unheard of.
        It was a forward thinking dream, a great thought and a good deed.

        Thank you for trying. Not everything works out the first time around. It sounds like you are driven, intelligent, and good.
        I am glad that you are still working in medicine, albeit in a different way.

      • buzzkillerjsmith

        It’s da money. Money is easily transformed into a better practice, such as more helpers to fool with the EHR, prior auths, etc. It’s da money.

      • doublj01

        I maybe one of the few medical students still interested in primary care. How do you see things changing? for the worse as I see from these comments. What would you say to a young medical student who would like to do primary care? dont do it? then do what? specialize against my will?

        • http://twitter.com/shihjay2 Michael Chen

          As you see in some of the articles on KevinMD, primary care is at a crossroads. And many indications are that unless there is strong advocacy for saving and enahncing primary care, our health care system will struggle for years to come to undo the damage that has been wrought.with the decisions that are being made (intentionally or unintentionally) decimating primary care as we know it. If you are certainly passionate about primary care, I would go for it! Know that it will be a great struggle. Try to take care of yourself. And know when to quit before it consumes you. (Obviously, it happened to me). The medical field right now is certainly very hostile to the very idea of primary care but the more we have primary care advocates like you as well as increasing public knowledge about the benefits of primary care in the whole scope of spiraling health care costs and increased fragmentation of care threatening unified and patient-focused care, we wouldn’t have much health in health care any more.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    Yes, it is very sad to see the death of many solo practices. Such a small scale of practice does not seem viable anymore. About the only ones that seem to be surviving are concierge practices or prepaid (subscription) care.

  • Carol Collins

    I too was in private practice. I had to close my practice almost 3 years ago. I know how you feel and I wish I could go back. I work for a large hospital system and it isn’t the same . By the way I am a Gi physician and it was still hard to stay a float. Hope things go well for you in the future

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    Painfully Beautiful Dr Chen. Poetic.

  • turtlezero@webtv.net

    ok dr chen…we have a problem that is important to most persons interested in health…we need to start a new group today…here on kevinmd…i am a depressed physician who has seen these terrible things…will you start with me today on a mission to change the way
    things are done…we will include anyone interested in professional change…not just doctors but everyone….send me an e-mail…
    harry

  • Soontobeextinct

    We are currently watching an exodus of our primary care colleagues out of the profession. The current Federally mandated approach to medicine is via large, bureaucratic top-down directed organizations that aim to both control and eliminate choice on the part of the physician. The physician is no longer trusted to determine and provide the appropriate care to a patient. Now large systems create protocols of care that are pushed down to the physicians involved with their pay held hostage to following these pre-determined protocols. So, we’re watching what was once a profession simply become a group of craftspeople working to an agenda set by others in control. Maybe this can theoretically improve quality (although I doubt it and have to see improvement in the real world) but it certainly is destroying an entire profession. I am saddened by the current state of medicine and the great people being destroyed along with it.

  • drg

    Any thoughts why AAFP is working against itself?

    • southerndoc1

      That is an excellent question.
      I find it impossible to believe that any group of living, breathing human beings could be as completely brain-dead as their leadership appears to be. I take the more charitable opinion that they’re 100% corrupt.

    • buzzkillerjsmith

      They’re out of their depth, babes in the wood, dazed and confused.

      Plus they get to lunches with powerful politicians, which is a heck of a lot more pleasant than slogging through the clinic.

      Nice work if you can get it. A office job. No blood, no tears, no pus, no vomitus. How could I get a job like that?

      • drg

        LOL! You’re not kidding. i’d love to have that gig!
        Well I don’t know if you saw, but Dr. Chen was thinking about a group of us writing a letter more written to the public to inform them of our concern and explaining the underpinnings of the demise of primary care in perhaps a letter to new york times. The idea is not yet well formulated but what do you think and would you be willing? Please anyone on this blog let us know if you are interested. Everyone here both patients and docs have been very bright and articulate and certainly passionate about this problem.

  • drg

    Anyone know if there are any political or legal actions taken to expose this?
    This–meaning corporate america taking over the world.
    Hey Remember when the book 1984 was JUST a sci fi novel???

    I wonder why this is not making the news? All I hear about is there is a shortage of PCP’s.
    Well NO WONDER!! There is no mystery in that! But to the newspapers and public it is a well kept secret with no solutions. The obvious solution of paying them!! is not addressed!!!!
    I was discouraged by reading the Klepper article RUC survives and now our healthcare system is worse off. It sounded like there were only a few PCP fighting and the AAFP is not backing them?? I enjoyed life better when 1984 was just a novel…..

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Very sad article

  • http://twitter.com/shihjay2 Michael Chen

    @ninguem,
    That is so true about what hospitals would do if the facility fee went away. But like @southerndoc stated; it is low hanging fruit and on the scale of the enormous money pit called the US health care system, it will not fix the inequities regarding fair payment for primary care physicians. The hospitals and insurance companies have the money and leverage to make the system work to their advantage whereas the PCPs are scrounging for scraps left over.

    • ninguem

      I suppose. It’s the low-hanging fruit in that it would actually be easy to do, and the only entity hurt are hospital administrations. “Low-hanging fruit” means it’s one of the first things that needs to be done.

      The affected docs would just get spun off back to independent practice. It would take a lot of pressure off me, in that I would not have hospital big box clinics nipping at my heels, competing with me, and trying to take over my practice.

      I hear what you’re saying, but I would not discount it either. If facilities fees were eliminated tomorrow, I would consider it very good news, VERY good news.

      One step at a time.

      • http://twitter.com/shihjay2 Michael Chen

        I agree with your approach. Just wanted to make a point that we shouldn’t forget to look at the bigger picture (RUC influence being one of them) as there are many stressors that are squeezing PCPs to the brink.

        • ninguem

          Agreed

  • http://twitter.com/shihjay2 Michael Chen

    Thanks @ninguem, it looks like you have done a lot of research and data regarding these organizations and their background. It certainly is helpful to see where the money is and like the old adage “follow the money”, the answers to our questions become very apparent .

    • drg

      One last thought, has anyone thought of writing a group letter–say to NY Times to expose this. i don’t think the public is aware of the big picture about primary care being dismantled.

      • http://twitter.com/shihjay2 Michael Chen

        I would be willing to contribute to a group letter. I think if we have a group of patients as well as physicians from all specialties who are concerned about this, it would be even more powerful and perhaps bring awareness to the larger public. That’s where true advocacy starts. Something that AAFP has failed to engage…the public to support its cause.

        • Suzi Q 38

          I would be willing to contribute to writing or signing a group letter, and there are other patients, I am sure.
          Let us know what to do.

        • drg

          That is wonderful. Well I’ve never done anything like this. How do we start? I can give you my email address if that’s easier. So far we have suziQ and above harry at turtlezero@webtvnet:disqus and i would guess that so far 66 posts here all are passionate and I bet willing.
          I have no clue how to actually organize a group on a blog but i am willing to help. How do we write a group letter? Do you want to start? Do you want me to start? I don’t mind either way.
          You got 66 posts so you must be doing something right– is all I can say. There is another patient kristy on another blog that wants to help. I bet docbart, buzzerkillerjsmith,ninguem, brian stephens, warmsocks and southerndoc would all be willing. And there are i’m sure plenty of patients that would sign. What are your thoughts? I’m at lucky273467@hushmail.com

          • http://warmsocks.wordpress.com/ WarmSocks

            Yes, I’d be willing to sign a letter. My email is warmsocksblogquestions@gmail.com

          • drg

            thanks.

          • http://twitter.com/shihjay2 Michael Chen

            Anyone have any ideas about setting up a petition/support online so that we can gather as many individuals to help support the cause? DRG, it sounds like you have many of the e-mail addresses or contacts, so there is one avenue there.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I am about to pass out…. :-)

            Here are my thoughts: There are several petitions sites, one is Care2, which is private but requires email There is always the White House site but that too requires email. I would make two observations:

            1) This needs to be way more than just a one time petition or letter

            2) Many docs wish to remain completely anonymous

            I would suggest that we set up a website dedicated to this, with content (nothing fancy initially) and collect supporters (anonymous is fine and email is not absolutely required). To get the biggest bang initially, a medium size statement explaining what this is and the purpose of it, and a call to action (sign the support form) at the end.

            I am sure Kevin will be kind enough to post it here, and all like minded others that have their own blogs, should publish it on the same day (like Engage with Grace). Then everybody uses Facebook, twitter, G+, Linkedin and any listserv you are on, to create a buzz and direct people to the website to express support.

            If it goes well, it will be picked up by the media and we can take it from there… to the NYT or whatever, and the website can be used to organize and grow the movement.

            My 2 cents, and obviously I’m in…. :-)

          • Suzi Q 38

            Good ideas. Keep it going…

          • drg

            it looks like there already is an RUC website. but what do you think we could do differently? this is a tough one. brian discouraged a letter like you.
            http://www.replacetheruc.org

          • http://twitter.com/shihjay2 Michael Chen

            Thanks, Margalit for the wonderful ideas. I totally agree with the points you made and yes, DRG, we should not re-invent the wheel so to speak. Our primary focus should be to educate the public about the RUC and its substantial impact on endangered primary care and independent practices in the US, leading to the higher cost of healthcare for everyone.
            I also agree that this will take teamwork and a coordinated social media attack to get the message out to as many individuals as possible.

          • http://twitter.com/shihjay2 Michael Chen

            I’d be willing to look into creating a separate blog site set up to accept supporters (anonymous or otherwise).

          • drg

            I like margalit’s idea. I agree one letter will not do too much. I was on Brian Klepper’s site and a lot has been done already that has not been particularly effective according to Brian. So here is what he wrote me if anyone is interested. first there is a whole site on RUC below…
            http://www.replacetheruc.org

            Gregory Warner at Marketplace did a fine radio article on the probleml (http://www.marketplace.org/topics/life/health-care/world-health-care-pricing). Joe Eaton from the Center for Public Integrity did a great piece in 2010 (http://www.kaiserhealthnews.org/stories/2010/october/27/ama-center-public-integrity.aspx). And you saw the excellent pieces by Anna Mathews and Tom McGinty at the WSJ.
            But in the main, reporters have viewed the RUC as too technical and “inside baseball” to focus on for the mainstream. That’s been part of the problem.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            They say that if you can’t beat them, you should join them, which is what the associations are doing. I would offer another approach and if you can’t beat them at their style of war, invent a new kind of war.
            The RUC war is about money. It resonates poorly with a nation in a recession and a government busy blaming doctors for everything that’s wrong in health care. The fight should be about the ability of doctors to care and advocate for their patients, which is being taken away by regulations and special interests.
            If you want millions of supporters, you need to describe the problem from their perspective in a way they can understand. At this point in time, you guys (still) have the trust of your patients. In a few more years, after medicine has been co-opted by corporations and government, with doctors as their employed agents, and diluted by changing its definition to retail and computer-based care, that trust may be significantly diminished.
            If you want to preserve the right to serve your patients in an ethical, compassionate and professional manner, and the rights of the people to receive such care, the time to speak is now. If your cause is honest, properly presented, understood and adopted, the money issue will resolve itself.

          • drg

            I agree. It can only help. I admit i feel a bit lost as to where to start but I love your ideas of how to do this on the internet. I only mentioned those things because a lot has been done already but your ideas are very innovative.

          • Suzi Q 38

            my email is suziq38@gmail.com

          • http://twitter.com/shihjay2 Michael Chen
          • drg

            Did not realize the cardiologist have sued the government over this as well in 2009..Dr. Wes blog

  • drg

    OMG! How ludicrous that it’s easier to work at an urgent care! So we can drive the cost up further. Yet newspapers mention skyrocketing costs in ER’s like it’s a mystery as to why. Any thoughts why this is not getting accurately reported in the news? Anyone?
    I have a good friend who gave up his psychiatric practice for somewhat similar reasons I think as you. He is now following the money which for mental health is in prisons. There was no funding for mental health in private practice but because there was legislature passed about prisoners not getting adequate medical treatment he is now working there. Don’t know how he can stand it. But he makes a ton of money. more than I ever will.
    I am glad you are working on EMR’s that are efficient and actually help the doctor. I really appreciate your writing this as I think we all feel this. I have learned so much from this blog and the comments made here. Unfortunately, it seems like the powers in charge are very destructive and their values–just like RUC’s are extremely distorted.

    • ninguem

      Notice, time and again, it’s not that these different models of delivery are more efficient, just that they found ways to extract higher payment.

  • buzzkillerjsmith

    To Dr Chen and all,

    Have you consider a physician-owned HMO like Kaiser? I worked there from 1989 to 1995 and absolutely hated it, but I’ve heard indirectly that it’s better than it used to be. Anyone with thoughts on this?

    At least the overlords there are doctors, or at any rate they used to be. Any port in a storm.

    • http://twitter.com/shihjay2 Michael Chen

      I currently work for a physician owned multi-specialty group (it’s not an HMO). I figured it was better than working for administrators and bureaucrats. At least whoever is running the ship had some idea of medicine and not from a purely economical or productivity standpoint. I didn’t realize Kaiser was physician owned, but I know that some of my colleagues like the fact that Kaiser does build a strong network of other multi-specialty doctors and through that solidarity, there is trust that they all count on PCPs to truly manage their patients. I heard it’s better too, but I’m still skeptical. Time will tell, bad wounds apparently take a lot of time to heal.

      • Suzi Q 38

        My best friend’s husband is a physician at Kaiser.
        He has worked there for 30 years. He has a difficult job, I am sure, but she is proud to say that he comes home M-F at about 6:30-7:00 to eat dinner with the family almost every night.
        I have teased her and said, “How does that happen?? People don’t always get sick from 9-5.” She admits that after dinner he returns patient’s phone calls for an hour some nights.
        They also offer benefits that are good.

  • http://twitter.com/shihjay2 Michael Chen

    I agree, the solutions presented are not very inspired or realistic. The sad part is that there are many other ex PCPs that would be willing to return if the environment changes. An easy way to restore the workforce right away is to eliminate the RUC and replace it with a more just process of determining health service fees. There was no mention of the premature loss of the existing, talented, PCPs that have burnt out from the system. Imagine the complete waste of resources and talent that has already occurred as this steady destruction of primary care continues. Sad.

    • drg

      Agreed.I could not have said it any better. It is almost worse than ignorance because they have some awareness of the problem but no willingness to address it. This is where it gets sticky.

  • rosiethenurse

    I am an emergency room nurse and feel so badly for the doctors. One doctor keeps getting reprimanded for being too slow. He is not slow , he is thorough. Everything is about numbers and time. A friend of mine. a brilliant neprhrologist has ” retired” pretty much quit at medicine at 58 years old, it was too expensive too run a practice and all. He took a class and works as a poker dealer. I know he misses medicine. He would n
    ot let his daughters go to medical school, they became nurses, instead.

    • Suzi Q 38

      Incredible.

      This reminds me of a post from the wife of a pediatrician, who had a rough time with some sad cases of patients and administration.

      After I don’t know how many years of it, he just quit. She said he sits in his room and plays video games all day, everyday.
      Good thing they they live on some investments that they had made pior.