Back in the Day

Remember the good old days? Back when you could see patients, take your time, learn about them and their families, and really understand some of the actual things that affect their health (and not only the measurable metrics of lab values, BMI, and vital signs)?

Remember when you didn't have to decide if a visit was a 99213 or a 99214, and what modifiers to use? And a diagnosis was described using words, not numbers?

Remember when there were paintings on the wall, instead of big signs that say "Copay is expected in advance of your visit" and "Referrals require 72 hours notice. NO EXCEPTIONS."?



Imagine, a life without billing codes, prior authorizations, referral paperwork. Imagine a day where all the patients were entitled to the same treatment, without having to ask permission from a third party. Then add a staff that is dedicated and comes to work expecting nothing in return, (you don't even have to ask them to make decaf, they remember that's what you drink!!). And this staff, they care what happens to the patients. They pay attention to the individual. They do what they can to help them get what they need.



Then, add the fact that the patients have no insurance and very little money. So their visits are free. And the other cool thing about this staff, they work for free.



So there's no money exchanging hands. Just good sound medical advice, lots of patient advocacy, and a whole lot of generosity of time and spirit.



That's VIM, my new job. I'm the brand new medical director of the Volunteers in Medicine Clinic in Cape May Courthouse. It's a volunteer and local donation based clinic for people without insurance who live or work in Cape May County who are unable to afford healthcare. (There's a income limit formula). It started in 2002, open just 2 half days a week, and has grown rapidly to a now 5 day a week clinic for primary care, with dedicated clinic days for eye care, psychiatry, and GI and ortho. VIM has relationships with several other area specialists as well.

I'm still learning about the many ways VIM helps the patients. The staff there works hard to make sure that patients have access to hospital care and services through Charity Care, and they have a computer program to enter every patient's demographics and financial data to apply for Prescription Assistance from the major Pharmaceutical Companies. And what meds are not covered by prescription assistance (or samples), VIM is often able to use their funding to buy patients their meds from the local Acme pharmacy. Can you imagine? Patients getting their meds, without insurance or money? Without begging for authorization, or waiting for approval.

Of course, there are always things that need to improve. Chart flow and communication between the many providers and staff are high on my list. Going between my tiny practice with me and 2 part time non-clinical staff to a practice with providers that may have never met and different volunteer staff on different days of the week presents a whole new set of challenges. It is exciting to me to get to look at all the issues I've looked at for the past 10 years from a completely different perspective. I'm thrilled to be able to challenge myself in this way. And I'm thrilled to be able to explore another system that's outside the "insurance model".

The VIM logo says "Neighbors helping Neighbors". The time I spend at VIM confirms my belief that all people deserve access to quality health care. And that at least in one place in Cape May County, other people believe it too, and are doing something to make a difference.

"Never doubt that a small group of thoughtful, committed citizens can change
the world. Indeed, it is the only thing that ever has." -Margaret Mead

Learning the hard way.

So right around Labor Day I got pneumonia. Big nasty 'right lower lobe infiltrate with temps of 104, shaking chills, and hypoxia if I walked up the steps' pneumonia. I didn't leave my bed for four days, except to go to the ER and get xrayed. My mom took me. So its clear that I was Really Sick.
Now during this illness, once I was no longer solely focused on breathing, and after i finished all four Twilight books, I had some time to think, about many things related to healthcare, my job, and my life. Examples include the fact that despite a prescription plan, antibiotics are very costly; and the fact that I opted to have some of my testing done at the outpatient lab rather than while I was in the ER, because my insurance covers it at a higher rate if it is done at an outpatient facility, even though it was a participating hospital.
But I learned something more important while I was sick, and much more unexpected. I learned that somehow, in the last 18 months, I have started to develop some balance. Five years ago, when my daughter was born, I was back in the office when she was 5 days old, and I was getting called by the office while I was in labor. When I was sick in September, I was out of the office for an unprecedented 8 consecutive days. Five years ago, it took me about a year to make up financially for my maternity leave. When I came back from being sick in September, I was able to pay my staff paychecks that day and rent when it was due the following week. I didn't pay myself much for that week, but I didn't pay any bills late. I had enough buffer spaces in my schedule to fill in the people that I had to cancel while I was out, and still to work lighter days while I was recovering.
No one died, I don't even think anyone left the practice. And many many of the phone messages I got while I was out of the office were expressions of concerns and well wishes. I even got get well cards from my patients.

Being sick is a little scary. Not just the mortal fear of lack of oxygen, but there is a significant dread from loss of business, loss of income, and overwhelming medical expenses. But to come back to work, still recovering, and have a practice that is still viable, and patients that are still loyal, and a schedule that allows for emergency, and a small financial buffer that allows the bills to get paid close to on time, is huge. If I hadn't made the changes in my practice that I made back in October of 2008, I am certain I would have still been in the mill of overbooked and underpaid, scraping by to pay bills late and cramming as many patients as possible into a day.

So, the two most important things that I learned:
1. I can take a day off without losing my livelihood.
2. It really does take four to six weeks to recover from pneumonia.


After about a month, I walked up my steps one day and didn't get short of breath. I felt like I got my life back, and even better than before, because I am now a little wiser. I went back to the gym, and since then have run in two 5k runs. I've taken a short vacation and at least one personal day a month. (not including snow days). I am in the office less than two Saturdays a month. I took a day off to go to New York City with my mom before Christmas. We didn't have to hire anyone to do our leaves this fall. We painted the outside of the house ourselves.
I'd write more, but its a school holiday, so the kids and I are going skating...

Things I love about my Job. Really

I'm getting tired of hearing myself complain, so I can only imagine what it's like for the rest of the people in my life. Because, when I complain, I am doing it so that I can figure out ways to make a great job even better. But, honestly, truly, I would not trade this job for anything.
So here are some things I love about my job, some are specific to my style and location of practice, some are just wonderful things about Family Medicine.

1. Helping people.
Al once argued (for the sake of debate) that Mother Theresa was the most selfish person in the world, his argument being that it feels so good when you are able to help someone, that all the help she was doing was in order to promote her sense of self worth. It's kind of a silly argument, but it does make a person feel good to get to help others.

2. Learning stuff:
The broad nature of Family Medicine allows me to soak up knowledge from all manner of other docs, today I learned about Alcian blue staining in Barret's esophagus, yesterday about pediatric rhematology and post mycoplasma arthritis. And learning stuff is always fun.

3. My office: I've got new office space since February, and I'm digging it. The walls are "willow tree" green, totally chillin, my office/exam room is nice and big, and comfy. And bill makes coffee quite often, sometimes its too strong to drink, but it always smells great in here. And it's handy to have 2 psychiatrists down the hall, in case i have an urgent psychiatric need, like the need for a very comfy couch.

4. Relationships
I get to meet and share in the lives of so many people every day. And I am blessed with patients who send me photo Christmas cards, share their produce overflow (tomato season is coming soon!!), and invite me to graduations, birthdays, and anniversaries. I care very deeply for my patients, and I am invested in their well being. That's my job. But they don't have to care about me, and they do. That's the bonus.

5. Time: I spend way to much time here, but the fact that I can spend an hour with new patients and complicated patients, and a half hour visit time is standard, is so incredibly relaxing. Gone is the pressure from knowing that if Mr X needs an EKG its going to make me late for the next 6 people. I have the time to do what needs to be done, and it feels good.

6. Staff:
Barbara and Mary, and those who have gone before them, have tolerated my moodiness and crankiness, and still come to work every day and and smile and make the patients feel welcome and cared for. That's so cool.

7. Amazing Charts, and other technological advances: There's lots of cool techno stuff going on these days. Technology is not the answer to our health care woes, but there are some fun things happening. AmazingCharts is a easy to use, friendly, and AFFORDABLE electronic medical record, and I'm excited to be making the transition away from paper. I've resigned myself that it's going to take a Really Long Time, but I'm young. Other cool stuff happening too, I can show people their xrays that they had done in the hospital from my laptop, I can (sometimes) send prescriptions electronically to the pharmacy, I can sign orders for the visiting nurses from my laptop to go to their palmtops that they take to the patients home, and just the other day, a patient texted me a medical question. These are good times to be alive.

Lots of people in the world have to wake up in the morning and go to a job they don't really like. I am not one of those people. All my complaining and pushing for change, its really, really, just so that I can keep doing this job that I love.

What I learned tonight: Health Insurance Reform Discussion

So tonight I had the privilege to sit on the panel for an open discussion on healthcare reform sponsored (in a nonpartisan way) by the Cape May County Federation for Democratic Women. Lots of stuff happened, many words bantered. Fun, but really aggravating. I got to speak a lot of my views in a fairly nonthreatening environment, as most of the audience was already in favor of big time health insurance reform, and not many particularly resistant to universal coverage. I also got to sit next to Steve Fenichal, one of the infamous Baucus 13 ,arrested for trying to have doctors represented as equally as insurance companies and pharmaceuticals at the Senate hearing to discuss healthcare reform. He's cool, and knows lots of good supportive facts.
Also got to hear lots of arguments, and also fears from other sides of the battlefield. Lots of people worried about rationing of care, of somehow a rise in cost (how?), somehow trying to come up with common ground that allowed for a competitive market so that people could choose their coverage. It is something to think about, but every time i look at where a competitive market has gotten us, it sucks. if there is a cheap/free plan and an expensive plan, there will never be able to be fair coverage. I was on the fence, but actually the people in favor of the "public/private mix" plan pushed me over the edge (sorry , scrab-bill).

Then, it was all over, I was chatting with the other lovely social reformers there, and, as if i was in a movie, while i was getting a brownie from the refreshments table, appeared my old nemesis, Ann Richardson. And I must take this opportunity to rescind my comment about her being lucky and not having medical problems. And for any other inappropriate remarks I made about her. Her deal was this: if there is socialized medicine, "how will i know that i or my family will be able to continue to get access to the care they get now?" my response was along the lines of "why wouldn't you be able to? I'm not saying you shouldn't, I'm saying that EVERYONE should" . Her fear is that if everyone gets it, she will lose some, or have to wait, or not have choice. And there was no telling her that choice was fundamentally built into the system, that diminishing the waste in the current system will pay for the expense, and that there are even systems in place to help deal with the job losses from the health insurance workers. (which, btw is a pretty lame argument if you ask me, kind of like worrying about if we made cigarettes illegal what would happen to wawa).
And when we went over that ad nauseum, she still came back to being afraid that if everyone had health insurance she might have to give something up.

So what I learned is this: even though I feel I've got nothing to lose, I guess some other people still feel they have something to protect in this system. Misguided, brainwashed, she truly might feel this is the way to protect her family's health. And she is Afraid.

The other thing i learned, which might just save me from going completely insane, is that some conversations aren't worth the time. Everyone wants to win an argument, have the other person finally see the light of day and come to his or her senses. Then everyone wins, right?
But once it reaches "argument" mode, no one is listening, and no one wins. I walked away from Ann furious, that she could be so stubborn and closed minded. But after a brief moment of reflection, I realized that I don't really hate Ann. (i might rescind that if she bashes me in the paper tho, let me know if you see it in the gazette). I do hate the propaganda and fear mongering that she represents to me. She says "how do you know it won't be terrible?" and my answer is "what makes you think it will be?" her fears were answered and addressed in the bill, which she wouldn't answer whether or not she had read it, she said that the single payer plan would make everything worse, but she has NO DATA to back that up. There's horror stories everywhere, but for every "socialized medicine" urban legend I can give you a name of an honest to goodness Canadian that I have met that would gladly go back to Canada to get care. And after that I can give you ten true stories of delay or denial of care by the American system. But people believe the hype. Just like the swine flu and tainted peanut butter. And some people just aren't worth the argument.

But there were lots of people there tonight without an agenda to sell or a gauntlet to throw down, but with honest questions about the difference between single payer and the public/private plan. People who have come out to try to understand the options and make an educated decision. And I almost feel guilty for being so passionate, because I'm sure I might be just as unpleasant to talk to to people who might disagree with me. (maybe). And it's those people that are important. Most people, i think, don't have an agenda, but may be open to hearing arguments on both sides. These people deserve our time and respect.

My favorite moment of the evening was when someone asked what would happen to the thousands of people that would suddenly be jobless if single payer passed and the health insurance companies went away, and someone was saying there would be income protection, and job retraining, etc, and Steve F and I realized at the same time at least they'd have health insurance!

Field Trip to DC

So we decided to have a family (family of origin as well as husb and kids) vaca to DC for mom's birthday. (She's 29, if anyone asks). We're staying with my brother Mike, and when we arrived last evening there was a small gathering of his friends. I really enjoy meeting people, seeing old faces too, and learning about what they do. And of course, leaping loudly onto my soapbox to anyone who will listen.
Since this is DC, the job options are slightly more varied than they are in Cape May County, and one of the people I met was a "Healthcare Policy Analyst". At the current phase in my life, that was about as exciting to me as it would be to meet the drummer for Van Halen or a pro baseball player. I'm embarrassed to say that I monopolized her attention for at least an hour after the other guests had left! But what a great conversation!
Here's what I learned: The Agency for Healthcare Research and Quality has a program called CAHPS: consumer assesment of healthcare providers and systems. https://www.cahps.ahrq.gov/default.asp
This group has developed patient surveys for hospitals that have been used for years in order for hospitals to get full medicare payment.
This group has also developed surveys for patients about the healthcare experience in outpatient primary and specialist settings. They are freely available, but I'd never heard of them.

There are people in this group who fear the development of the PCMH model as is stands. This particular individual who would prefer to remain anonymous (as if anyone reads this) could even remember about the time when we all embraced capitation and it didn't work out. She worried about the huge push for technology as the savior of healthcare, and realized that just having a computer and emr didn't make someone a better doctor. This sounds familiar.

So here is someone in Washington, who knows and advises people who make what amount to life changing decisions for me and my patients. (She gave me the example of Medicare D, she communicated with Senator Kennedy about the fact that it was and remains a Really Bad Idea.)

So here I've got this great opportunity, and I'm sure I looked like a total spaz! She is involved in the development of surveys for patients to evaluate healthcare quality, and hasn't heard of howsyourhealth. Correction, hadn't heard of it. I am a little lost on how to follow up on the conversation. I am again overwhelmed with information. I wonder how in this world of information overload, do people who share the same views combine their data and resources to influence policymakers. Or do we need to? Maybe it will all filter up. (Like salmon getting past the status quo of profit driven healthcare policy). And I wish I knew more about the system and how it works.

But mostly I'm just excited every time I meet someone that welcomes system-wide healthcare change.

The More Things Change

So I recently read the novel "Middlemarch" by George Eliot. (actually I listened to it, a free recording from librivox.org which is a fantastic resource for audiobooks that are in the public domain). Among many other things, there was a doctor in Middlemarch, Tertius Lydgate, that came into town with lots of new ideas about how things should be done. He felt that if doctors directly dispensed medications and charged for them, they had a conflict of interest and would, perhaps, overtreat. He volunteered in the a new "fever" hospital, designed in case the cholera spread to middlemarch. He spent time knowing his patients, analysing thier conditions, and recommending approprate pharmaceutical and non pharmaceutical interventions. Some patients liked him, some didn't. Sometimes they got better, sometimes they didn't. But one thing was universally true. The stodgy old doctors in town hated Lydgate.
*small spoiler* In the end, Lydgates wife couldn't handle his dedication to his profession, he couldn't make enough money to pay his debts, he left town and went to the city, and he died young. His spoiled brat of a wife went on to marry a rich "more traditional" old doctor.

I guess I was fairly taken by the fact that even in 1870 the economics and politics of medicine were deeply enmeshed with the "medical" part of medicine. (and of course, there was no health insurance or government funding then, the hospital for the poor was financed by rich benifactors). The citizens of Middlemarch (perhaps spurred on by the old doctors) after seeing the financial and political trouble Lydgate had, began to question his medical judgement.

So I ponder the current climate. I wonder if I should make less waves. (This is purely hypothetical, because making waves is so a part of my nature that I doubt I could stop if I tried.)
I read the descriptions of the old docs in Middlemarch and had no choice but to envision the graying, balding, slightly overweight men I see at hospital and board meetings. (If you're someone I go to meetings with and reading this, I likely don't mean you). I feel as though I jump up and down and wave my arms and scream "THERE HAS TO BE ANOTHER WAY! LOOK!! TRY SOMETHING DIFFERENT!!!" (although I don't think I actually do jump up, I'm pretty sure I raise my voice.) And they look at me and shake their heads and mutter "poor misguided Tac. She had so much promise." If they see me at all. How long before they run me out of town, and I die young, penniless, and unloved.

Then I realize that I am none of those things. I am slowly chipping away at my debt. I have good community support, and home support like none could expect. And, alas, I am no longer young. So maybe we have learned something in 139 years. Or maybe things will always be in a constant state of change...

Moving Day is a very Dangerous Day

Ok, nothing quite like moving to make you realize how much stuff you have that you really, really don't need. Unfortunately, the stuff you really do need is mixed all in with it, so you can't just dump it all. But it's been an exciting few weeks despite it all.

Packing: I had these great plans of taking the opportunity to go through all my file cabinets and folders and get rid of the outdated guidelines, and organize the useful ones into something in some sort of order, downsize, computerize, and declutter. You can go ahead and stick that one on the list right after "find cure to common cold" and "world peace". I did manage to thin out the patient chart room down from 5 cabinets to 3, and put an additional 40 boxes into my storage (attic), adding to the over 30 that were already there. Someday I'm going to have to deal with all of these, but not right now. (and we are painstakingly starting to scan the charts of transferring patients, so storage of them will be on disc, not in actual space, eventually).
I also took 380 pounds of paper to the Giant Shredding Truck. Mostly old billing paperwork that I realized it wasn't worth saving when I admitted to myself that even if I needed the EOB from my 3rd patient on June 7 2004, I wasn't going to be able to find it in the boxes. It was great to be rid of all that stuff, but shredding really gives me anxiety.
By last saturday afternoon, my packing/storage plans became more of a "sweep the entire contents of your desk into a large box and deal with it later" . That large box is now under my desk, to be rummaged through when I need something. Not exactly as I had planned, but it works.
Choosing: I was fortunate to be able to make some minor changes in the new place, including having a hole cut in the wall between the receptionist office and the waiting room, and a sink into the exam room, and paint. I was also fortunate enough to have an absolutely fantastic contractor do this work for me. Most of the choices were easy, (went to home depot, picked out the least expensive reasonable looking sink and cabinet, etc), but choosing paint was hard. I'm not the most visually perceptive person, but I've made some unusual paint choices in my life, and since I look at the office walls all day every day, I wanted to to be right. Most paint stores will sell you small "sample" jars of paint (the local one by me they are $5) to test on the wall. If I can give one bit of advice GET THE SAMPLES. Even if you need to try 10 different ones, it is worth $50 not to screw up the paint color. I picked out the one I liked, it was a sortof greenish aqua, but the lighting in the room made it look like baby blue. I would have been so annoyed with my little baby boy nursery walls all day. I ended up picking one that on the little square looked way too dark, but on the walls looks peaceful and calm and deep.
Moving: There is always, always, more than you think. Saturday morning I went to the office to make sure all of Fridays "real work" medical patient stuff, was done (friday ended up being a super busy day after a really slow week). Then came the joy of moving all that stuff that was so caringly packed (10% of the contents of the office) and the stuff that was haphazardly thrown into boxes (the other 90%). It turns out that most of what doctors do is not actually hands on medical care, we actually fabricate paper. It comes out of our machines in every shape and size and fills boxes and files and drawers and covers every flat surface until none remains. (Mind you, not much of it is the small green kind that you can exchange for goods). It is really scary.
The wonderful contractor I mentioned also was saintly enough to offer us his truck and trailer, and he and his wife spent the day with us saturday. I think I would still be sitting in the back of my old office looking around wondering how to move everything if not for them. We were able to get chart file shelves onto the truck with the charts still on them, alas, we could not get them through the new foyer without tiliting them onto their sides, so thus had to remove the charts while they were in the foyer. That was a bit of a drag, but aside from little stuff like that, it was super smooth. By saturday night, the old place was empty, and the new one overflowed.
Unpacking:
I went from four small rooms to two large rooms, deciding to minimize on unneeded space and duplication of stuff and work, so I have a room that is my office and exam room, and it's great. It has all my exam stuff (table, ekg, supplies), but also my desk, computer, bookshelf, phone etc. I really really like having a centralized work area. But unpacking my crammed office, and my cluttered exam room into a useable space was not exactly easy. Ditto for the front staff area-chart room, reception desk, copy area, and storage are all in one now. I think it would have been easy to start a new practice with this very efficient layout, but cramming my old style into this new one is going to take some work. I just keep on saying to myself "I don't need more space, I need less stuff."
The first week:
I've moved about one mile from my previous place, into an office building owned by two psychiatrists. It's been years since I've shared office space with other doctors, one forgets that not everyone does things the same way. They haven't thrown me out yet, so I think it's going to be ok tho. There's still a few kinks to work out (thermostat, door locks, and psychiatrists with overly sensitive noses who smell curry when it's not really there and try to blame you for making a smelly lunch). But all in all, I am so very glad to be in my new place. The new exam room/office is comfortable and roomy (if not yet perfectly organized and arranged). I can have 3 extra chairs now for patients and family, and there is plenty of breathing space. And breathing is good, right?