Adaptability

The slogan, "Adapt or Die" is not new and seems to refer to anything from technological innovation to becoming more accustomed to the weather.  An MSNBC articles reads, "With the world losing the battle against global warming so far, experts are warning that humans need to follow nature's example: Adapt or die."  The newspaper industry has said it of themselves; hence the proliferation of online news, letters to the editor, and blogs by famous people.  A recent catchy Gatorade jingle, "If you want a revolution, the only solution: Evolve, evolve," seems to say it all.  Evolve or Die:  Seven Steps to Rethink the Way You Do Business, reads the title of the book by Robin Crow.  It was published this past April.  With the number seven in the name, it sounds almost Biblical or lucky at very least.  I am finally convinced this is true of my own profession.  We must evolve or die.

As in most evolutionary processes, we should not "throw the baby out with the bathwater".  It doesn't mean starting from scratch.  To evolve implies building upon strengths while moving away from what works poorly or is non-functional.


The greatest strength of general internal medicine is that most of us are in it, heart and soul.  We were attracted to medicine due to its intellectual complexity, the challenge of sleuthing out the diagnosis with careful history followed by physical examination and analysis of data.  We admired our professors of medicine for knowing something about almost everything.  We form an idea and then confirm or negate our suspicion.  We care for individual conditions in individual patients who are part of a family and part of a community, who are global citizens and have a global impact.  Counseling and screening according to best research serves an important role in prevention and treatment of disease. Ultimately, this is of benefit by reducing healthcare spending, thus contributing to the health of the overall economy.

What is working poorly is the system of compensation.  Under the influence of the AMA, the Centers for Medicare Services has progressively adopted a system of compensation for physicians' services that is based on procedures (called CPT codes).  Other insurance companies use these codes as well to determine physician payment.  Procedures have become increasingly valued, whereas "Evaluation and Management" services (or the thought processes of doctors) have become devalued.  Partly for this reason, we have one of the most costly healthcare systems in the world, even though we have left 50 million people uninsured.  I am not ungrateful for procedures, having been a patient as well; however, it is a little bit unreasonable that the average gastroenterologist's salary is more than double the average internist's!  Sometimes, just pausing and thinking about a case may prevent a procedure from being done; however, there is more reward for going ahead and doing the procedure.  With the rising cost of practicing medicine, it is hard for primary care doctors to survive.  Some have simply left medicine, others have dropped insurance contracts, and still others are "going concierge."

Concierge medicine represents a maladaption.  Disgruntled colleagues of mine became distressed, looking at an ever-decreasing bottom-line.  Solicited by an attorney-run company called MDVIP, they decided to place stake in longterm relationships with patients who trusted them.  In this model, doctors charge their patients a $1500 membership fee which is inclusive of a thorough annual physical examination and associated costs, giving patients 24x7 access to their own physician, and a CD containing health history.  Additional visits are usually charged to the insurance company.  Concierge doctors agree to limit their practices to only 600 patients.  I have received several mail solicitations from MDVIP this year, alone, in addition to e-mails.  I wish they would just give up!

Concierge medicine is of ethical concern, because it disrupts the doctor-patient relationship.  The doctor-patient relationship is inherently unequal; hence, medical societies forbid doctors to date their patients.  The doctor graduated from medical school and finished medical training whereas (in most cases) the patient did not.  The doctor has knowledge the patient does not.   In the concierge model, however, there is an exchange of power.  Even though the doctor still has more medical knowledge, the patient may demand his or her will.  The most concerning case is in the over-prescription of antibiotics.  A patient with a cold may come in to the office and demand, "I want my z-pack. Now, please."  The concierge doctor, who is essentially employed by the patient, is then coerced to prescribe the antibiotic even though conventional wisdom dictates against prescribing antibiotics for a virus.  Unnecessary prescribing of an antibiotic could result in a severe or even life-threatening allergic reaction or secondary infection like C. difficile colitis.  It may also result in a resistant strain.  Over-prescription of antibiotics is largely responsible for the presence of MRSA and resistant E. coli in non-hospitalized patients.

It is not as if the concierge doctor went back to medical school or somehow became smarter.  The decrease in case load reduces the doctor's exposure to learning experiences.  My clinical acumen has increased over the past eleven years through the practice of medicine.  Caring for an economically and ethnically diverse practice full of patients has given me exposure to a wide range of conditions that a textbook could hardly teach me.  When I am unsure of the answer, I will pick up the phone and call a specialist.  Through an extensive network of colleagues and an adequate caseload, I have learned a great deal of medicine.  Taking care of the poor is especially instructive, as they often present with a host of conditions requiring close attention.  It is not only instructive to care for the needy, it is the right thing to do.   It is not only the right thing to do, it is a blessing.  Concierge doctors are missing out, in my book.  Besides, they are contributing to the primary care shortage.


Still, there was something deeply broken in the old paper chart model of practicing medicine. It was unsustainable.  In my old practice, I spent much of my best energy shuffling papers. It felt like an endless cycle:  seeing a patient, phone ringing, dictating the note, secretary at the door, phone ringing, signing the prescription, seeing a patient. I finished countless 11 or 12 hour days clearing my desk of the tornado of documents and charts, phone messages and prescription refill requests.  I began to feel as though my career was competing with future happiness.  I wasn't too happy in the present, either. Many nights, I would return phone calls on my cell while driving home.  The practice model was inefficient, with 28 staff working for 7 doctors.  My patients likened it to a factory.

In October of 2004, I attended the Pri Med Conference called "Practice Solutions" in Boston, Massachusetts.  The Red Sox had just won the World Series and there was a great big party in the streets.  It was a turning point for the Red Sox and marked a turning point in my career.  At the sessions, I learned about the many benefits of electronic medical records and practice management systems as lecturers talked about "the paperless, wireless" medical office.  I might as well have been at a tent revival meeting.  I was sold, totally convinced that this was what I had to do.

I returned to Baltimore with plans to implement this model.  I was already making plans to leave my original group when the lease was up in 2006.  Though I was approached by a couple of other medical groups, I wasn't convinced that they were wholeheartedly committed to the computerized medical office.  Soon it became clear that, in order to live out my vision, I would have to start my own practice.  Though fearful, through prayer and meditation, research, and a lot of elbow grease, the pieces came together for Green Spring Internal Medicine to open in 2006.

In many ways, Green Spring Internal Medicine hasn't been everything I expected it to be.  In some ways it has been more.  More beneficial to my lifestyle, more excellent, more fulfilling and more joyful.  Yet it has also been more emotionally and spiritually taxing, more unpredictable, more financially costly, and more unsettling than I predicted it to be.  Despite our efficiency and thriftiness, it has been hard to make it.  After some analysis, I do not believe it is because of a faulty business model nor because we need to see more patients.  Of course, there were some unpredictable personal turns.  All said, primary care doctors are simply not paid enough in the current model.  It has been hard to be starved out of our own profession!  Even with healthcare reform, and a 10% increase in compensation of primary care doctors scheduled for January of 2011, it is too little and too late.  It is time to "adapt or die."

This time, the pathway for adaptation has been laid out for us.  Medicare has given us a mandate to take electronic medical records to the point of "meaningful use" and will even pay us to do it!  Thankfully, we are already about 75% there, and our software company is working on getting us the rest of the way.  We have been working on updating the Patient Portal and hope to have the new practice website up and running soon! In addition, we are working on transitioning to become NCQA certified as a patient-centered medical home.  This will enable us to receive recognition for much of the work that we already do, in addition to providing our patients with increased access to additional services both through our practice and outside the office.  It should also pave the way for better compensation and, hopefully, the addition of another doctor to the practice.  We are excited about the prospect of becoming a patient-centered medical home, as the idea has been endorsed by the American College of Physicians and the American Association of Family Practitioners.  Besides, it is a really good idea!  Our hearts are in it.

Here's to change for the better! To life!