Dream Job

This past week brought the disappointing news that Green Spring Internal Medicine was not selected as a Maryland Health Care Commission Patient-Centered Medical Home Pilot Program site.  The news broke my heart, mainly because we so strongly desire to move forward into this new model of care; however, I have no idea how I will possibly be able to accomplish it without outside funding plus a guarantee of appropriate compensation by the health insurance companies.  The Patient-Centered Medical Home has been established as a model of healthcare delivery that improves quality of care while reducing the overall cost of healthcare.  This model has been widely adopted, with great success, in the state of New York.  South Carolina has also demonstrated positive outcomes through implementation of the Patient-Centered Medical Home, through programs designed by CareFirst.  This fall, CareFirst in Maryland sent out an invitation to practices to join their pilot program; however, to small practices, there was an added requirement.  Practices of fewer than 5 physicians were required to assemble a "panel of 5" providers from the same region to sign on to the program together and agree to compile financial data for analysis by CareFirst.  I was taken aback by this requirement,  such a taxing expectation for small practices that often run (like ours) with no office manager.  It was not feasible for us to sign on.  Now we are left with a dream that makes so much sense, but seemingly no reasonable way to achieve it.  Sad.

Even though I had anticipated this as a possible outcome, it was hard to prepare for switch of parachutes in the midst of the "free fall" that the practice of internal medicine has come to feel like.  What plan will save us now?  How will it be possible for me to bring another physician on board, in the midst of such uncertainty.  I desire to move forward and adopt a more multi-disciplinary approach and more fully implement the technology that is available; however, the current model of care that I have felt constrained to is not sustainable either with or without the efficiency and safety added by the technology we are utilizing.  I was recently annoyed when a clinic director of a local "Accountability Care Organization" run by a hospital in our area visited my practice and told me that there was no way that I could become a Patient-Centered Medical Home as a small practice all on my own, that sooner or later I would have to work for a hospital.  I was annoyed, because it felt like a veiled threat, and I really do believe he intended to make me feel insecure.  Ok, so it worked for at least an hour after I had ushered him out of my office.  I am also still annoyed, because I do not feel that every patient is best served by seeing a doctor whose prime loyalty is to a hospital system.  Isn't it our job to keep patients out of the hospital?  Non-option #1.

Another non-option for me is concierge medicine.  I have previously written my defense against this model.

So, where is the hope?  I am left wondering actually.  As an inherently joyful person, I have found myself too often complaining of late.  What is it that is sapping my joy, singeing me at the edges of burnout?  It just seems that so much stands in the way of what is right and good in the current healthcare system, and I am just not so sure that the healthcare reform that passed will really result in enough change, if it is even allowed to stand by the 1st session of the 112th Congress.

The prime reason why I left the Health Associates, PA, in 2006 was a value conflict.  According to Peter Drucker, a value conflict is one of the greatest impairments to workplace happiness.  He wrote a beautiful article called "Managing Oneself" in The Harvard Business Review (January 2005) that continues to be life-changing to me.  In analyzing my present workplace problems,  I was surprised to find out that though I officially work for myself, I have a multitude of value conflicts.  To name a few:

VALUE CONFLICT versus VALUE CONSISTENT

insurance company greed versus access to affordable healthcare for all
asking impoverished patients to pay their bills versus extending grace in certain situations
financial stress versus having enough not to think a lot about money
"Medicine as business" versus "Medicine as healing art" - do I hear an AMEN?
workaholism versus strong work ethic lived out with balance
little incentive to do good versus reward for doing what is right
inability to travel/take vacation versus flexibility of schedule
facing big business risks versus being able to grow because we are creative
faltering systems versus technology-assisted organization (which we need outside help to implement)
status quo versus the Patient-Centered Medical Home
being solo versus practicing among colleagues

I guess I am going to have to talk to the boss about how to get from value-conflicted to value-consistent practice of medicine!  Of course, I don't really just work for myself.  In part, I work for my patients and in part, I work for insurance companies.  Far and away, the driving force behind my long set of value conflicts is the insurance companies' approach to my profession.  It seems that the insurance companies are our society's chosen means of obtaining healthcare access; however, having insurance is not the only means of having access to a good doctor.  Believe me, I am considering this matter with all seriousness.  It makes me feel heavy-hearted.  It is surely better for me to be in practice than to burn out.  At least, I think so for now.  I still love internal medicine and patient care.

Thankfully, my inspiring college friends, Lynne and Hye Yong, visited me this weekend and encouraged me to dream again.  It is amazing that we have now known eachother for more than half of our lives, and it seems that those who have known us from our younger years know us the best somehow. True to Mount Holyoke women, our parting words this morning were, "Change the world!"

Just for fun, I sat down at a local coffee shop this afternoon with a blank sheet of paper and brainstormed about my dream job, putting down goals in a symbolic cloud.  "All things are possible..."