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“Let’s ask which elements of our system support this and promote and enhance those elements. If anything takes time or focus away from the main principle, let’s remove or replace it. Whether it’s the EMR, payment models, prior authorizations, or even automated phone systems, let’s rethink things so the two main people — the patient and the physician — are supported, and excellent care is allowed to be delivered with compassion, care, and time. Only then will we truly heal what ails us.”

Reeta Achari is a neurologist.

She shares her story and discusses her KevinMD article, “The physician’s real problem isn’t burnout.”

The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience.

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Reeta Achari. She’s a neurologist, and her KevinMD article is titled “The physician’s real problem isn’t burnout.” Reeta, welcome to the show.

Reeta Achari: Thank you so much for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, briefly share your story and journey to where you are today.

Reeta Achari: Sure. So I am a neurologist in solo private practice in Houston, Texas, a rare breed these days. I am a fourth-generation physician. My family’s story started in India and then traveled to England, and my parents then came to Houston. I completed my medical training here, and then I joined my father in private practice. My fellowship training is in epilepsy, and I had wanted to stay in the academic area, but I wasn’t very good with the sort of politics of academics. So I was more suited to private practice, and that’s what I did, and I’ve been in practice for a little over 25 years.

So it’s given me a chance to really see how things have changed. My father went from academics into a private setting, and so, 40 years ago, as his children (my brother is a cardiologist), we were required to work in the office, understanding accounts receivable, how to make appointments, and billing. So that was a great education, but in addition to that, I also got a flavor for how medicine was being practiced 30 or 40 years ago compared to how it is being practiced now.

So I feel very fortunate to still be doing what I’m doing, in the way that I’m doing it, as an independent practitioner. For that, I’ve had to make several changes, of course, to my practice and the way that I practice. But it has really allowed me to understand what patients need, what physicians need, how we have to be adaptable, and that we have to survive economically, and that we are no good to anybody if we can’t make our businesses thrive. So, but I think, again, I speak a little bit about this in the article.

Kevin Pho: But before we get into that article, let me just ask you, because there are a couple of things that you mentioned I want to follow up on. One of the things that you mentioned is that solo practice specialists like yourself are an increasingly rare breed, right? So what are some of the things that you’re doing to survive in this health care climate, to continue thriving as a solo private practice specialist?

Reeta Achari: So one of the things that I did several years ago, and this is a bit strange for a neurologist who takes care of older patients, is that I actually opted out of Medicare. With the continuous Medicare cuts, you can’t take care of the most complicated patients with less time. We just can’t do that. So I came out of Medicare. I offered my patients a very reasonable cash price. It’s the same as what they would have been paying, but at least it allowed me time with them.

And then the other thing that I’ve done, really in the past two years, is start what I call a subscription model. There are plenty of concierge practices and models for those with primary care physicians, but very few that offer that for specialists. I need to be able to see patients short term, so we have a quarterly membership fee. So if somebody comes in to see me with a herniated disc or carpal tunnel or something for which they need a neurologic evaluation, where I don’t need to see them chronically, there’s a way for me to engage new patients and provide myself as a resource. We don’t have a lot of neurologists. We’re inadequate in terms of physician supply anyway, but neurologists especially so.

So I’m available to see new patients, and then there are patients for whom I provide chronic care, so my epilepsy patients, my Alzheimer’s patients, my Parkinson’s patients, and my migraine patients, who can choose to be with me quarterly or choose to be with me yearly. But it allows a way to buffer the payments in the practice. We still accept two insurance plans, but it gives patients a lot more time. So I have structured it so that my follow-up appointment is 30 minutes, and my new patient visit may be an hour to an hour and a half, based on what their needs are. So the patient remains the focus, and patients have really responded well to that and like it, and it’s made me very cognizant, again, of time. Time is the most valuable commodity between a physician and a patient.

Kevin Pho: So the model that you’re describing sounds similar to a direct-pay model that we have in primary care, and you’re right, it’s not as common in specialty services. I can think of probably one other physician who’s doing this, in the rheumatology field, whom we had on the podcast last year. So when you switched over to that subscription model, did you find that a lot of patients were hesitant to pay that price? Did you have trouble building up a patient panel once you opted out of Medicare?

Reeta Achari: The surprising thing is that there were two levels here. When I opted out of Medicare, I did so slowly. I let everybody know that this is what was going to happen, and I lost very few patients. With the addition of the subscription model, originally in my mind I thought of it as a concierge kind of practice, where my existing patients were going to stay with me. What I did not predict or expect was the number of new patients who came into my practice, number one because there isn’t an eight-week wait time, and because they were able to spend more time with me.

So I have definitely lost a few patients for whom this is not economically viable, but I also have the ability to give scholarships to patients, especially those, as I say, with whom we’ve grown our gray hair together, or we’ve grown old together. For patients whose care I’ve taken as my responsibility for 25 years, most of them are exempt from the fee, and we’re able to continue that care.

Kevin Pho: All right, let’s talk about your KevinMD article. It’s titled “The physician’s real problem isn’t burnout.” How did this article come together?

Reeta Achari: So I was reading an article, I think in an online magazine, and the solution to our problem was billed so easily as, “Oh my gosh, we can take care of everything if we just do medicine as a team approach. The more people that we have involved in the care of patients, patients are going to have lots of attention, and we’re going to deliver really great care.” I thought about that for a long time, and I thought about my own patients, who actually feel very lost when they are set in the middle of the team, where they’re having to go to multiple people for one problem.

And the other thing that’s happened to me, Kevin, in the last couple of years, having come out of Medicare, is that even in my own specialty, we have subspecialty neurologists. In an academic center, sometimes you will see someone for tremor, someone for epilepsy, someone for memory disorder, and someone for peripheral neuropathy. You’ve got four subspecialty neurologists. And I was starting to see more and more people come to me who were going to my colleagues, and my colleagues are fantastic. I’m in the city of Houston; I’ve got wonderful academic colleagues. But these patients needed somebody to just be the central neurologist, and it’s true, their care was piecemeal. So when we fixed the epilepsy medicine on one side, the memory got a little bit better, because it was a medication effect, and the tremor got better, right? You just need one person who is OK seeing all of those things. And again, as a general neurologist, there are fewer of me as well.

But I thought about patients not being able to see physicians because of other people. All these other caregivers and providers have a role. I don’t like to use the word “provider” for a physician; physicians are physicians. But if we could just, instead of reacting, stop and think about the main, you know, the guiding compass, right, which should be the physician-patient relationship: How do we create a good experience and good health care? I don’t think we’ve had better health care with more people and more money. We spend a lot of money on health care in the United States, but I don’t know that patients are satisfied or healthier.

Kevin Pho: Before we talk further, tell me an example of some of these stories that you have heard where patients go to a proverbial medical team and get passed from clinician to clinician, whether it’s a nurse, dietitian, or educator. What would be an example of that, just so my listeners can get an idea in their heads?

Reeta Achari: Sure. I’ll tell you about somebody that I saw the week before Thanksgiving, actually. This is a patient of mine, a 77-year-old whom I have treated for epilepsy for 25 years. She is a remarkable lady who is a marathon walker and is quite healthy. About four months ago, she started developing a little bit of headache and a little bit of vertigo. She actually came to see me at that time. The headache was mild, and we did an MRI and made sure she was OK. The vertigo was fixed, and she went away.

Then she started to have headache again, and this time she went to her primary care physician. Well, she’s never actually seen her primary care physician; she sees people in that clinic. So the first person she saw was a nurse practitioner, who gave her some medication for headache, which didn’t really work, and then she developed joint pain. Now she goes back to the clinic, and she sees the PA, and the PA said, “Well, the non-steroidals didn’t work for your headache. Now you’ve got joint pain. Let me just give you a Medrol Dosepak.” So she’s given a Medrol Dosepak, and the joint pain gets a little bit better, but not too much better. Now she starts having headache again, so she calls the office, and now the MA tells her, “Well, there’s nothing we can do for your headache, so you need to go to the ER.” So she goes to the ER, where they say, “Oh, you’ve got to go back to your primary care physician.” So now she sees the PA again, and the PA says, “Well, I’m just going to give you steroids again,” right?

Through this time, by the way, the headache doesn’t really go away, and the PA then tells her that she has anxiety and prescribes some fluoxetine for her. And so the patient now comes to see me, saying, “If you think I need to be on fluoxetine, I’ll be on it, but I don’t think I’m anxious, and this headache is just crazy.” So on examination, she’s got temporal tenderness. If you take a history, she has jaw claudication, she has joint pain, and she’s a 77-year-old woman who’s never had headache before, now partially treated twice with steroids. When we do a sed rate, the sed rate is 41, right? She has giant cell arteritis.

And again, no physician touched her. I’m lucky that I’ve seen her for as long as I have to understand this, but this is, again, somebody who is completely lost within the system of care. Again, my nurse practitioner colleague in that practice, and the PA in that practice, probably may not have put the headache and the joint pain together. And again, giant cell arteritis is not a simple thing. It’s something you have to think about; you go to medical school, you put these things together. So the most complicated of patients are now being cared for piecemeal, when they really need a holistic approach to their care.

Kevin Pho: So what are the steps going forward? Because the situation that you described is very common. Even in my practice, I hear this all the time. There’s a lack of primary care physicians, and sometimes there is no choice but to see members within a team; it could be a PA or a nurse practitioner. But tell me, what ideas do we have to solve something like this?

Reeta Achari: Well, there is no doubt that there’s a physician shortage, right? But what are we doing with physicians’ time when there is a physician shortage? We are using a physician’s time everywhere else other than with the patient. In hospitals, physicians are spending more time, I think, with the electronic health record and physician order entry. Everything that has happened to us has taken time away from our patients. So when you say there’s a physician shortage, yes, there is, but then we should be giving physicians more time with patients, not less.

So I really feel, and again, I’m not a Luddite. I love my technology. I like my electronic health records. Forty years ago, we were trying to do a computerized record for my father. So we should use these methodologies in ways that make us more efficient and allow us more time, not just as data-collecting devices. So I think the biggest thing is to try to eliminate all of the extraneous things that eat up a physician’s time. I’m not saying that teams and other valued members of our teams should not be used. Definitely they should. But they should not be replacing physicians because physicians are doing all sorts of other work. Physicians should be with patients.

Kevin Pho: So just to get a sense, for those who aren’t familiar with a typical physician’s workflow: You mentioned electronic health records as one big time suck. For those who aren’t familiar, what other things do physicians do that prevent them from seeing patients?

Reeta Achari: Well, I think this is a big one, right, which is documenting, charting, mainly for insurance purposes, and we have to spend so much time and so much extraneous, useless effort on it. The other thing involves prior authorization and trying to get our patients the medications that they need. There’s a lot of time and effort wasted because physicians are involved, because we have to do peer-to-peer calls. Trying to get my patients their epilepsy medicines this year has been a greater struggle than I’ve ever had. So there’s that.

There is communicating with other people involved in patient care, and trying to get MRIs and imaging sorted out, and even communicating with other physicians, which I think is a good thing and something we should be doing more of, rather than sending notes to each other. There are multiple things: the amount of time spent to do continuing medical education, which I support, but then board recertification. I have to take time away from my practice for a week, now every, you see, every 10 years. Now there’s new methodology just to study for my boards and to recertify. We’re the only profession that has to do that. Other professions have good continuing medical education and testing that doesn’t take them away from patient care services. So there is a lot of burden and regulation in our profession. We’re the most regulated profession, I think, period; we were just discussing that recently. But I think all of these things are issues that take our time away from patients.

Kevin Pho: Now, for those physicians who are listening to this podcast, what can they do about this? Because these are issues that we’ve been talking about for years, if not decades, and there’s a lot of inertia, right? It takes a lot of top-down changes. But from the individual physician standpoint, what can we do to solve some of the issues that you bring up?

Reeta Achari: My approach to this has been to explain to my patients why, and the ways that I’m now going to spend time with them. So I’m saying that I’m not going to do all of this insurance stuff, so I don’t take as many plans. Like I said, I’m evolving into a direct-pay practice. But it means allowing patients to understand that in order to get time with us, they need to actually understand that we need to get paid. Now, that perhaps means coming out of the roller coaster that we’ve been on, which is that we keep having contracts with insurance companies that pay us less and demand all of these things.

So I think becoming more independent is really the answer. It’s scary. It’s frightening to think, “Oh my God, I’m not going to be signed up with an insurance plan, and I’m not going to get patients.” It was only 35 years ago that not everybody had managed care. So patients ultimately will be the ones who say, “Why am I paying my doctor and paying a huge premium? Where does that, how is that fitting?” So I think we have to demand that time, and that time unfortunately comes with more costs for patients and a little bit of risk that we take as business people. But our business is different. We’re not normal business people. We carry and protect people’s health, and to have signed that over to an insurance company. I’ve done it, and I’m thinking about it differently. I think eventually we need to be independent again.

Kevin Pho: Now, for those physicians, and it could be primary care doctors or specialists like yourself, who are inspired by you and want to take that next step and go independent, like you said, it does take some risk doing so. Sometimes you have to take away that security of a salary, for instance, in exchange for that freedom. What kind of questions should they be asking themselves in order to make that next step to go independent?

Reeta Achari: Well, the first thing that you have to ask yourself is: What is your mental makeup? Are you OK doing things for yourself, understanding that you’re going to have to learn a lot of pieces of practice? If you’re somebody who doesn’t want to deal with the business of medicine, and doesn’t want to deal with billing or understanding those things, this may not be the thing for you. But for those people who are, I think there is methodology, and hopefully I’m going to share that soon in an article, on how to go about analyzing your own practice, understanding your patient base, and understanding what your particular marketplace will bear.

I’m not a high-end concierge practice. I have very nominal fees, and they’re manageable by people who are in middle-class situations, and we allow lots of different payment patterns, because that’s where I am in Houston. But it depends on your sort of base: talking to your patients and then slowly switching over. One of the nice things about being an independent practice is that we can be quick to react, and we’re agile, as we were with COVID. So you might also want to perhaps take on a side hustle, to make sure that as you transition, you’ve got some income coming in. But you don’t have to do it wholesale. You can do it piecemeal, slowly, and allow it to evolve, which is what I have done, and I would encourage people to think about it. If I were brand-new going into practice now, I would not be involved in insurance at all. I would absolutely go with a direct payment model with my patients.

Kevin Pho: And my final question: What are some of the take-home messages that you want to leave with the KevinMD audience?

Reeta Achari: I think that association, that relationship, is really the basis on which every medical decision and good health is created. It is sacrosanct, it should be respected, and it should be the center of everything that we do. And I think, if we can try always to remember: We as physicians are precious commodities, but our patients are even more precious. So really handle that gently and keep that at the center. If anything takes us away from that, question: Why are we being taken away, and is it worthwhile?

Kevin Pho: Reeta, thank you so much for sharing your time and insight, and thanks again for being on the show.

Reeta Achari: Thank you so much for having me. I appreciate the opportunity.