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Wednesday, September 28, 2011

Patient Centered Outcomes Research--a good start

The affordable care act, in its 2000 plus pages, provided for many projects with the potential to improve health care delivery in the US. The most actively debated part of the bill, the mandate to insure just about everyone, may not turn out to be the most important piece. The problems the affordable care act attempted to address are the fact that American health care spending is too high and buys too little, including poor outcomes for those who do get health care and the fact that too few people who need health care actually receive it. All of these issues are addressed in some way or another in the myriad provisions of the bill.

One rarely advertised provision of the bill is the Patient Centered Outcomes Research Institute (PCORI).  This is a private institute, publicly funded, which includes a huge diversity of players, from patients to providers and sundry others, who are charged with figuring out exactly what Patient Centered Outcomes Research is, and then making it happen and disseminating the results. According to a recent article in the New England Journal of Medicine, they have been holding meetings, many of them public, just to figure out what it is that they feel they should do and how they will most effectively do that thing. At this point the groundwork is mostly done.

The PCORI has decided that its prime directive is to help patients answer these 4 questions:

  1. “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”
  2. “What are my options and what are the benefits and harms of those options?”
  3. “What can I do to improve the outcomes that are most important to me?”
  4. “How can the health care system improve my chances of achieving the outcomes I prefer?
Given the present scurrying behavior of most physicians to try to  develop systems to help them practice evidence based medicine which will theoretically pay them more for reaching certain benchmarks in treating various common diseases, these patient centered questions are very relevant and an absolute necessity. As we as physicians begin to see our paychecks depend upon whether our diabetic patients are getting statin medications to prevent heart attacks and maintaining certain blood glucose levels, we vitally need to be reminded that our job is truly to improve patients' lives. That means adjusting what we do to respond to those patients' educated preferences. Results of patient centered outcomes research may help us do that.

I have some misgivings about the PCORI. It is very large. I can't quite figure out how large, but large enough that it sounds as if decision making is slow going. That will not slow the research that they fund, since that can be done by small groups with good ideas. Still, implementing change based on new research may be slow. I also wonder how information that helps doctors and patients make individualized decisions about care will interact with the freight train of "pay for performance" based on scientific evidence which usually demands strict adherence to a protocol. 

I presently choose to have faith that the process of patient centered outcomes research will eventually meet up with pay for performance and we will actually be paid for the performance of individualized care for patients who are undeniably individuals with individual needs and preferences. It is just possible that the truth shall set us free.

Saturday, September 24, 2011

Physician non-compete clauses--another way to gut rural health care

Lately I have been dealing with the painful process of separating from my medical group. I have been part of this group since its inception, about 12 years ago. It serves two small towns in adjacent states and has about 30 employees and 12 providers, mostly located in the larger of our two clinics, in which I do not work.  We originally came together from 3 primary care practices in order to share resources and reduce overhead. Cultures and values were somewhat different, but we did all care about delivering good quality medicine, letting our physicians have autonomy in decision making, and about making sure that each one of us could have lives that were humane, valuing family time or outside interests and covering each others' patient's needs so that care would not suffer.

When we came together we wrote a contract which was longer and more formal than any I had signed before and had various elements that made me somewhat uncomfortable. One was the "buy-in". This was an amount of money that we all agreed to put in to essentially buy the practice. I balked at the size of this, since my location of practice was very inexpensive, and the physicians in the larger office were "buying in" to a large and brand new medical office building. My concerns were respected, and my buy-in was smaller, as was that of my two partners.  The other issue was a non-compete clause, which I was told was standard and non-negotiable. This clause in the contract stated that if my employment with the corporation ended, I would not practice medicine within 20 miles for 2 years.

Physician non-compete clauses are strongly disfavored by the American Medical Association and considered unethical. They restrict choice of practice and they penalize patients when a physician is at odds with his or her employer.  They are hard to enforce and void in some states, most prominently California. They have been viewed as restrictions on trade, though various interpretations of this have arisen from court cases. They remain a common component of physician contracts. They are particularly hard to enforce if it can be shown that the physician is needed in his or her community and that enforcement of the clause will harm patients.

In the case of me and my clinic partner, who are obliged to sever our connection to our parent organization because our clinic is no longer viable after loss of half of our provider staff, there are a multitude of reasons why a non-compete clause is going to be unenforceable. The most important of these involves the patients in the community. Our town of just over 20,000 people now will have 2 rather than 4 internal medicine physicians, which is inadequate for our aging population. In another practice in town which has an even more restrictive non-compete clause, physicians are unable to make changes that might be in everyone's best interest, since if they leave the practice they must also leave the community and most of them are strongly tied to it, with children in school and spouses with jobs.

If a non-compete clause is unenforceable, unethical and disfavored by our national organization, why do we even worry about it? It is very common for an organization to threaten to enforce a non-compete clause, and to have this happen would be painful or disastrous. Court cases such as these cost 10s of thousands of dollars to complete and result in frequent and unpredictable time commitments that make it difficult or impossible to concentrate on a medical practice.

I have chosen to do a 2 year sabbatical at the end of my association with my present group for many reasons, and mostly because I really want to and think that the experience and knowledge I will pick up will be positively transforming in ways that I can't predict. But I would like to be able to fill in here or there in my community if I am needed during those two years. I can do the exile thing, but it is hardly good for my patients or colleagues, including those at the corporation I am leaving. Nevertheless, sabers are rattling and threats being spoken. My colleague is experiencing the same constraints. It affects both the community and our families, who will be mightily disrupted by our departure or frequent absences.

I have learned an important lesson, which I will not have trouble remembering. I will NEVER sign another contract which contains a non-compete clause.  provides a lawyerly review of some of the issues. presents a bit more on the AMAs position. recognizes the power of the threat of enforcement.

Wednesday, September 21, 2011

Who wants me?

Today was filled with the usual stuff, which is actually never the same from day to day. My first patient of the day dropped in because she was having a stroke. She was actually my partner's patient, but I knew her pretty well from a previous visit and was happy to be able to help her out. I was also wickedly late for my first scheduled patient who just needed a preventive physical exam. Both were good interactions, understanding people with commendable patience (especially the one who waited an hour) and despite being clearly way behind for the rest of the day, it was what I love to do.

I have been more late, of late, because all of my routine appointments involve an explanation of what I'm doing when I quit my job next month, a recommendation for what to do for any health care needs, including a pretty exhaustive review of all of the doctors in the community who might be appropriate matches and some kind of heartfelt recognition of the length and depth of our doctor-patient relationship. This takes awhile, but is necessary and valuable. I have taken care of some of my patients for 17 years, and that means lots of stories told and heard, trust won and compromises hammered out. These are mini-divorces. They are not acrimonious, but they are intense. And then, of course, there is also the problem that the patient is having at the moment to be heard and maybe solved. My agenda at these appointments also involves looking at the whole set of problems and trying to make sure that we both have a clear view of the best strategies for getting them solved and that any loose ends are tied up.

The number of patient for whom a physician is responsible is difficult to glean from our medical records, due to the fact that many patients see a doctor only rarely, or see different doctors based on availability. But based on my official patient panel size when I worked for Group Health, and based on information from an internal medicine preceptor of mine many years ago, a full time physician might have 1800-3000 patients who regard them as "my doctor." The doctor patient relationship is important to most of these patients, even if they are seen infrequently, I am finding out.  Some of the people who are most unhappy to see me go are people I see at most once a year. They don't come in with every ailment, but the fact that I exist and know them is really important to their feeling safe. At least that's what it sounds like.

But I'm not just doing this important doctor patient stuff, I'm also trying to find a job.

A primary care internist who is well educated, board certified, speaks English and hasn't done anything reprehensible is in demand in the US. I will find a job. The easiest of jobs to find will be in places that are very hard to get to, in rural areas where there are desperate doctor shortages.

When I first decided to contact a locum tenens recruiter, I went to the organization which had an excellent reputation with a locum tenens surgeon who I respected. I called them and was immediately put in contact with a man who told me a little bit about the whole process. He told me which states really needed physicians, what different jobs paid, that sort of thing, and tactfully tried to ascertain what awful skeleton in my closet was leading me to look for work. I told him my story of planned adventure, and he told me that anything was possible. He failed to outright relieve me of my misapprehensions about how I could get a really short term job anywhere I wanted whenever I wanted and be home with my family lots. He did that acquiescent groveling thing that representatives of drug companies do when they try to get me to use medications of dubious utility and ridiculously high cost. I tried to be reassuring so he would treat me like a regular person and give me straight advice, but it took over a month for me to realize that unless I wanted to go somewhere and work really hard for 3 or more months straight and then consider moving there, I was going to be looking at 12 hour hospital shifts or really remote locations with really not enough doctors to handle the patient volumes.

Just two days ago I finally decided I needed to contact a larger company with more job opportunities. I was immediately put in contact with two people who seemed more than capable of making me understand how the process works. There were several jobs that sounded possible, if not perfect. And today, through the first guy, I got a call from a very jolly, clearly English as a second language family practitioner from a microscopic town in Wisconsin not far from the Canadian border, and frankly it sounds pretty sweet. We shall see what comes of all of this.

Monday, September 19, 2011

Walk, sing, practice medicine

I have worked as a primary care internal medicine doctor in a small university town for the last 17 years and have loved it more each year. I like my office, I feel at home and appreciated at the hospital across the street where I care for patients I know and for some who I eventually get to know through doctoring them. I can do intensive care medicine, take care of patients with delicate social situations and pick up the medical pieces with patients who have surgeries or injuries. It is never dull and it only rarely makes me feel sad or frustrated. I know the nurses well, count on them and am almost never disappointed. My relationships with my fellow physicians are warm and I respect them.

On October 31 of this year I am quitting my job. I am not old, so I am not retiring. It's just time to do something else. Various things happened which were the universe's way of telling me that I needed to do something different. My nurse practitioner partner with whom I shared an office, a world view and plans for future brilliant schemes, died suddenly in April, and one of 3 remaining partners in my clinic decided to take a job elsewhere as a kind of partial retirement. It is not possible to effectively hire another internal medicine doctor for a clinic such as ours in a small town such as ours with any degree of certainty, and my remaining partner and I were becoming swamped. It is possible to keep up with the level of work we were doing for a few months, but not for the rest of my work life.

My plan is to get as many experiences as possible practicing medicine as many places and settings as I can for the next two years. I want to see how other people do what I do, how other systems work, how they don't work, what they smell like, feel like, taste like. I would also like to take long walks in places I've never been, and since I'm asking for what I want, sing. I love singing with people and it is a hobby that is not hard to indulge. I especially like singing with small groups in harmony. But more about that later, perhaps. I bet I'll be able to squeeze some good music into the next year or two. I will also take lots of delicious continuing medical education courses and learn from academics how to do things that I don't know how to do.

I'm calling it a sabbatical. The term "walkabout" would also be accurate. That term, as I understand it, refers to native Australian's need to leave what they are doing and do something else, somewhere else, for a time. It's a fascinating concept, but it is not entirely clear how it's going to work. I have started to look into my options by signing up with a locums company, a group that will find me jobs in places where they desperately need a doctor to fill in for a time. Ideally, these positions would be for just long enough for me to experience a new place and get familiar with their routines, meet new people, explore my new communities. I'm finding out, though, that jobs want me for as long as possible, as full time as possible, and preferably they would like me to eventually move there and take the job full time.

I would also like to go back to Haiti, to La Gonave, and work with the communities that I have started to get to know on public health issues such as birth control, safe sex, contraception and building healthcare teams. This is expensive for me, but will be less expensive when I am not having to pay a staff and an office to run in my absence.

I also plan to work in a rather remote clinic in Alaska where a friend of mine has worked for years, intermittently, but probably not starting in the dead of winter. I will work this out myself, with the help of the hospital administrator there.

Locum tenens companies, like the one I signed up with, take care of the details of credentialing, malpractice insurance, arranging licenses, travel, housing and any money negotiations that have to happen. They also charge a lot of money for doing this, which is absorbed by the poor desperate hospital or clinic that uses their services to fill a slot. This means that, by participating in this process I will be directly contributing to high health care costs. I do like the idea of having everything arranged, but in the best of all possible worlds, I will find at least some of my own jobs and negotiate the details myself.

Other than the fact that I am leaving my patients and community in a lurch, this is a great plan. I get the idea, though, that it won't go particularly smoothly. It seems entirely possible that I won't get exactly what I want, and sometimes not vaguely what I want. I am expecting that by the process of trying various things, failing and succeeding, I will learn lots of amazing stuff, including how to do this thing that I'm going to be doing. If I do figure that out, maybe it will make this kind of thing easier for other physicians to do. The reason that it is a great idea is that medical practices are kind of like little Galapagos islands, developing procedures, tricks, solutions that they never share with other groups. Deliberately learning new stuff and sharing it just has to be something that holds hope for improving medical care and efficiency.

I will be using this blog to document my adventures, should I have them, and the perils and pitfalls of getting this stuff all arranged. I will also continue to write about the wonderful tidbits of American medical care in its glory and absurdity as I have been doing.