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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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6 Responses to “Where Have All the Family Practice Doctors Gone? First Aid for Primary Care”

  1. Katie Brewer says:

    I truly see this as an area of commonality with nurses and doctors – nurses have been moaning of the shortage of qualified nurses to deliver bedside for what, 10 years? Now we see this looming shortage of primary care doctors. I would love to see these two groups unite to solve our problems together – many of the causal issues are similar – your recent podcast with the three nurse bloggers points that out!

  2. #1 DInosaur says:

    Gee, that’s exactly how I run my solo family practice. Unfortunately I still feel too responsible to those of my patients who can’t afford my services without their insurance, so I’m still doing the HMO/referral/insurance nonsense. Concierge care at insurance payment levels; it sucks. I’ll work up my nerve to dump it all and go cash only in another year or two.

  3. Emily Downward says:

    Sounds like an interesting service. Wish they were in my area!

  4. Peter Dunn says:

    If there’s no development with health care, even policyholders of health insurance plans don’t get the assurance that they are gonna be treated in the best ways.

  5. Barbara K. says:

    Many mental health providers have gone to that model. One consequence is that their practice becomes inaccessible to the folks at lower income levels, even with a sliding fee scale. How does the practice you describe deal with this issue — especially for those whose care needs exceed $300

  6. Responding to Comment #1
    Like we mentioned in our comment below to Barbara K, over half of our patients do not have insurance or have high-deductible insurance, so we understand your struggle. If you do make the leap, we’d be interested in to hear reports of how it is going!

    Response to Comment #5
    Funding and finding high quality primary care for the poor was and will always remain a problem. Solutions will continue to require subsidies either via non-profits or the federal or state government.

    A theme that will keep appearing through our weekly content will be “no money no mission,” and trying to get people to understand, no matter where you stand on the political spectrum of health care that health care is not free. The primary mission of our practice at this time is to demonstrate a day to day solution focusing on responsive, high quality care that significantly reduces barriers to reaching a medical expert, gets people the care they need, when they need it and significantly reduces the system cost of care.

    The innovations we practice can easily by adopted by health centers throughout the country already but then you need to decide; “Do I want to spend $1 million to subsidize those who can’t afford care or adopt a new paradigm like doctokr which reports better care, happier patients, happier doctors and delivers the same, in fact better care for $500,000.00.” Almost 50% of our patients have no insurance or high deductible insurance. Without any other subsidy, we too are doing what we can. Our ideas, we think, are part of the solution for the poor but we emphasize the word “part.”

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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