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Being A Doctor In 2011: Things Have Changed

Close your eyes and think of a doctor. Do you see a Marcus Welby type? A middle-aged, smiling and friendly gentleman who makes house calls? Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you? If that is what you envision, either you haven’t been to the doctor lately or you are in a concierge practice where you pay a large upfront fee for this type of practice. Whether you live in a big city or a rural community, small practices are dissolving as fast as Alka Selzer. Hospitals and health systems are recruiting the physicians, buying their assets (unfortunately not worth much) and running the offices.

Doctors are leaving small practices and going into the protection of larger groups and corporations because of economic changes that have made it harder and harder for small practices to survive. The need for computer systems, increasing regulations, insurance consolidation, skyrocketing overhead and salaries coupled with low reimbursement has signaled the extinction of the Marcus Welby practice. Some older doctors are finishing out their years and will shutter their offices when they retire. Young to middle age physicians are selling out to large groups and new physicians would never even consider this type of practice. They are looking for an employed model from the outset.

Every doctor I know who is currently in private practice is Read more »

*This blog post was originally published at ACP Internist*

Research Investigates A Percutaneous Option For Aortic Valve Replacement

To ensure rational and responsible dissemination of this new
technology (transcatheter aortic valve replacement [TAVR]), government,
industry and medicine will need to work in harmony.”

- David R. Holmes, Jr., MD, FACC
President, American College of Cardiology

Today, Edwards Lifesciences’ will request pre-market approval of its SAPIEN Transcatheter Heart Valve from the FDA’s Circulatory Systems Devices Panel of the Medical Devices Advisory Committee. And for the first time, the groundwork for our complicated new era of health care rationing will be exposed.

To win an expensive technology on behalf of patients these days, there will have to be “harmony” between doctors and their professional organizations and government regulators. If not, patients lose.

At issue is a transformative technology – another milestone forwarding medical innovation on behalf of some of our oldest and sickest patients: those with critical aortic stenosis who are too sick to undergo open heart surgery. Aortic stenosis tends to be a disease of the elderly that carries at least a 2-year 50% mortality when accompanied by a weakened heart muscle. Yet thanks to the wonders of careful engineering and some daring researchers that paired their expertise and lessons learned from a variety of disciples (cardiothoracic and peripheral vascular surgery, cardiology, and even cardiac electrophysiology), technigues and technology have combined to offer a percutaneous option for aortic valve replacement.

Everyone involved in this research (and even those who have watched from afar) knows this therapy works. Most believe in the long run, it will prove to be a safer option than open heart surgery in these patients.

But that’s about where the harmony ends. Read more »

*This blog post was originally published at Dr. Wes*

Goodbye Marcus Welby, Hello Hospital Employee MD

Close your eyes and think of a doctor.  Do you see a Marcus Welby type? A middle aged, smiling and friendly gentleman who makes house calls?   Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you?  If that is what you envision, either you haven’t been to the doctor lately or you are in a concierge practice where you pay a large upfront fee for this type of practice.  Whether you live in a big city or a rural community, small practices are dissolving as fast as Alka Selzer.  Hospitals and health systems are recruiting the physicians, buying their assets (unfortunately not worth much) and running the offices.

Doctors are leaving small practices and going into the protection of larger groups and corporations because of economic changes that have made it harder and harder for small practices  to survive.  The need for Read more »

*This blog post was originally published at EverythingHealth*

Primary Care Wednesdays: Where Did Marcus Welby Go?

By Steve Simmons, M.D.

Photo of Steve Simmons, M.D.

Steve Simmons, M.D.

In the early 70s Marcus Welby MD, embodied the expectations of patients and the hopes of doctors seeking to emulate his bedside manner.  Sadly, when we look at medicine today, patients and doctors alike are left wondering what happened to Welby’s style of patient-focused medicine.  Much has changed in healthcare during the nearly 40 years since the show first aired.  Patients are more informed and expect to be included when clinical decisions are made.  Insurance companies and government bureaucracies have wrested control of the patients from their doctors.  Doctors must now focus on business and mind-numbing paperwork to the detriment of their medical knowledge and patients.  Runaway costs and an impersonal health care system dominate the landscape of the early 21st century.

The interests of the patient should be paramount and the doctor-patient relationship sacrosanct; however, by inviting a third party into this relationship the interests of the patient are frequently subverted.  The office meetings of the past, where difficult medical cases would be discussed, have been replaced with business meetings, insurance coding seminars, and a parade of experts reminding physicians to sit during the office visit to create the impression of more time being spent with their patient.  The inevitable frustration patients feel is directed towards their physician, who in turn has been saddled with his own frustration trying to merge ethical and business concerns.

Doctors are leaving primary care in droves, half planning to work less, become administrators, or retire.  A survey of medical students discovered hectic clinics, burdensome paperwork, and systems that do a poor job of managing patients with chronic illness as reasons for not choosing primary care medicine. Only 2% of students plan to select general internal medicine as a career. Most students are becoming specialists, where they can make more money, glean respect, and better control their schedule. If national healthcare becomes a reality, today’s critical shortage of primary care doctors will become problematic when the uninsured start looking for a doctor.

What qualities do we want in a primary care physician and what role do we need him to play in our lives?  A succession of TV doctors: Welby, Hawkeye, and now, House, share the virtues of diligence, attention to detail, and moral courage.  They can help us track the evolution of our patient’s expectations over four decades.  Dr. Welby’s patients willingly followed his guidance and instruction, while Dr. House’s patients live in the Information Age and have probably searched the internet before seeking his help.  Unfortunately, the admiration felt for Dr. House helps demonstrate that an entire generation expects an aggressive and uncaring doctor, thinking it the norm.

In 1979, Alan Alda gave the commencement address at Columbia University Medical School, titled, “On Being a Real Doctor.”  He said, “We both study the human being and we both try to offer relief–you through medicine, and I through laughter–but we both try to reduce suffering.”  Few believe today’s healthcare system is focused on suffering.  Third party payers are holding on to the money, controlling care, and this influences doctors. Patients like physicians have lost focus on what really matters: to ease suffering.

I sometimes imagine Dr. Welby practicing medicine today.  Towards the end of his day I see him sitting behind his desk, entangled in red tape, frustrated by his inability to untie the knot binding medical and financial realities.  His waiting room is full of patients, dragging the same red tape behind them. 

Fortunately, if one doctor’s argument is correct and all primary care physicians are Marcus Welby, we have reason to hope.  Our healthcare system is broken, but not irrevocably. Doctors and patients can stop wrestling against their constraints, turn away from their frustration, and find each other.  Patients will use access to information and drive health reform forward; many are speaking up today.  Doctors would do well to remember we are all patients but the onus of explaining the healthcare crisis and proposing meaningful change falls on physicians.  In our practice, doctokr Family Medicine, we try to cut red tape wherever we can, striving for an open and transparent practice, placing the doctor-patient relationship central in everything we do.  I believe you can find a doctor like Marcus Welby in your community and hope our posts will encourage you to try.

Until next week, I remain yours in primary care,

Dr. Steve Simmons, doctokr Family Medicine

Where Have All the Family Practice Doctors Gone? First Aid for Primary Care

By Alan W. Dappen, MD; Steve Simmons, MD; Valerie Tinley, FNP of Doctokr Family Medicine

We are a family doctor, an internist and a family nurse practitioner working on the front line of the American health care system. We share a moral and ethical duty to protect the health of our patients along with all our colleagues who labor daily doing the same.We as Americans are proud of what has long been considered a first-rate health care system. Sadly, this system is broken despite our best efforts. Americans spend much more per capita for care as any other country. The World Health Organization has graded our care as 37th “best” in the world. Even worse, American citizens were the least satisfied with their medical care compared to the next five leading socialized industrialized countries, including England, Germany, Canada, Australia and New Zealand. There are many things wrong. Let’s examine a few:

Primary care medicine in America is gasping for its last breath. Internists, family doctors, pediatricians (whom health experts consider essential to a robust and cost-effective delivery system) are leaving primary care in droves. The number of newly trained generalist doctors has plummeted so fast that extinction of the generalist doctor has been forecasted within 20 years by both the American Academy of Family Practice and the American College of Physicians.

Patients are angry and exasperated with long delays, poor service and confusing and redundant paperwork. To date 17% of us are uninsured and this number will quickly grow in a deepening recession.

Employers face a huge cost burden as health insurance prices go through the roof. CEOs consistently say the runaway costs in health care benefits (which double in price every seven to ten years) threaten the viability of their companies. Since 2000, the number of small businesses offering health insurance has dropped 8%.

Health insurance companies are making so much money that several states have motioned legislation compelling insurance companies to disclose the percentage of premiums spent on actual medical care. Not surprisingly, their lobbyists are resisting. It is not uncommon for insurance companies to keep 30-40% of every dollar for “administration” and profits. Many of these companies are on record reaffirming their commitment to shareholders and short-term profits.

Doctokr (“doc-talker”) Family Medicine is a medical practice that was created to respond to the conflicts and problems listed above. We have worked to resuscitate the soul of the Marcus Welby-style patient-focused physician while adding technology to deliver fast, responsive and informed care. All fees are transparent and time-based and are the responsibility of our patients to pay. All parties that interfere with the doctor patient relationship or increase our costs have been removed from the equation. The practice delivers “concierge level” services: 24/7 access, connectivity to the doctor no matter where our patients are located, same day office visits for those that need to be seen, even house calls for those unable to get to our office. By removing the hurdles and restoring transparency and trust, 75% of our clients get their entire primary care needs met for $300.00 a year.

This post is written by three medical professionals who stopped waiting for someone else to find a solution and are actively changing primary care in ways that dramatically improve quality, convenience and access, while drastically reducing costs. The US deserves excellent health care and it must be done right. To understand why we would bother to “walk the walk,” we ask your indulgence and participation while we “talk the talk.” We hope this format will educate and inform you in ways that move you to participate in your care. Health care is about you, just as much as it about us, because we are all patients. We all have a stake in shaping the inevitable need for reform.

The next upcoming topics:

  1. Where did the Marcus Welby, MD-style of primary care go and how can we get it back?
  2. How have you as a patient lost control of your body and health?
  3. Turning the primary care model upside down: What does primary care need to do to reinvent itself so that it serves its patients without other conflicting interests?
  4. Begin the exploration of the unexamined assumptions of health care….

Until next week, we remain yours in primary care.

- Alan, Steve, and Valerie

   

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When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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