Daily Fitbit stats

My fitbit #fitstats for 6/29/2012: 4,744 steps and 2.1 miles traveled. http://www.fitbit.com/user/22K3T6

My thoughts on ObamaCare- insurance exchanges

If you are anything like me, your Facebook page, twitter feed and everyone you meet have some opinion on the Supreme Court’s decision on the Affordable Care Act, otherwise known as ObamaCare.  And it is either the best plan ever or the worst decision and Justice Roberts is a traitor to his country, and blah, blah, blah.  Well that was Thursday.

Friday, it was well if we don’t overturn this mess, I am moving to Canada, Australia, Costa Rica, or other English speaking, industrialized nations all with some form of Universal Healthcare or Socialized medicine.  Also countries with a tougher immigration policy than we have, so I am not sure that unless you are super wealthy that is actually an option.

And then there is the stand by the Republican governors to not enact an exchange because they will fight this to the bitter end.  You all know that the exchange was originally a republican idea don’t you?  And probably my favorite part of the bill.  Why?  Well because I own a small business, I have 8 employees, when I started I had two employees, my husband and I, which accounted for a pool of 4 people.  Why does that matter, because when I went to purchase insurance in 2005, I was 7 months pregnant, covered under a policy which I COBRAed through the hospital that I did my residency in.  At $750 a month.  Now I was just out of residency and started my practice on my own, and well $150,000 in debt from medical school, with a new baby on the way.  So I looked for something, and the best I could find that would cover that baby was $1500 a month.  They could not deny me pregnancy coverage as pre-existing at the time, because I live in a states that if I had insurance that previously covered a condition within the last 6 months, there was no pre-existing condition.  However, do NOT ever shop for insurance when 7 months pregnant.

I called 4 insurance agents, and several companies on my own, the best that I could do was to COBRA my current policy ($750 a month) until the baby was born and then start the following month with the new insurance.  Though I actually COBRA for one additional month, because there was some question as to coverage of the brand new baby.  Anyway, this policy I could afford was roughly $400 a month per person in pool, oh and it didn’t cover pregnancy.  And I had an employee who would like to have a baby, so we changed our pool to three, and I covered her on an individual policy, that would cover pregnancy a year after it started.  (Which didn’t work because as it happens, she stopped trying to get pregnant and she had a baby 11 months after the policy started, and ended up on Medicaid for the pregnancy anyway)

Now being as I had insurance for all but my 3rd year of medical school (I had gotten married and could not stay on the plan, and well we couldn’t afford it until my husband started his internship year and it was covered) I could not believe the difference in rates.  I saw what had been taken out of my check at the hospital while I was employed, and it was not that much.  I talked to others as to what they paid working for bigger companies, and the talked the agent, and what the answer was the size of the pool.  My pool was three, and one was diabetic, I was a bigger risk, than those with thousands of employees, who could afford better coverage for less.  But if I got to 5 in the pool, or 10 the rates drop significantly, and then if I have 50 employees, well that is an even better drop.

But with an insurance exchange, here is the deal.  Let’s say your exchange becomes the state for instance.  Larger states might decide to have multiple pools, or smaller states might decide to join into a regional pool, doesn’t matter.  The pool becomes big enough that smaller businesses or the individual could choose a plan that actually works for them within their budget.  If you want to cover pregnancy care, great, here is the plan for you.  I don’t cover it for my employees because it would increase my costs $200 a month per employee, and that includes the two males, who if they become pregnant, I think I would sell their story, me who has had a tubal, and another employee or two that are menopausal.  There was only two of my current employees that would even desire pregnancy, and well at $1600 a month, well it is not even affordable for me to do so.  And as it stood before, they could not even add the coverage as an option because my pool is too small.

While I would have preferred for the market to develop something like an insurance exchange on its own, it is highly unlikely under today’s highly politicized system, it ever would have.  An insurance exchange would allow for those healthier to choose coverage to benefit them better, would allow for people to choose coverage for preventative care.  At least it would ideally, but it would also allow for those with diabetes and other chronic conditions to find a plan that would cover them.  I didn’t say that they all had to cost the same in my world, but prior to ObamaCare finding a plan with a pre-existing condition was impossible without high deductibles, and being astronomically expensive.  And then there was a year of paying for the plan before it would cover any pre-existing condition, so you can understand the frustration for those that tried, and for those that decided against buying insurance.

Like I said, I look at it from a small business who while not required thought that it was right to cover my employees.  I am in healthcare after all.  I actually like this part of the ACA, there is much of the plan that I don’t.  But the opposition to this part, is something that does not make sense, yes the free market should have produced it, but it didn’t.  But this is a natural progression of medicine since the development of Medicare and Medicaid, a natural progression from EMTALA.  I find myself frustrated at both sides on this issue, the surprise that the bill stood, the gloating that this bill is the best thing ever (it is not).  In the last 6 months it was obvious it was going to stand, and if not most of the major components were going to be put in a new bill.  Besides an estimated 60% of the costs in the infrastructure to support the system had already been put into place.  Repealing it would have been of little use.

That is just my two cents worth.  But what do I know, I merely own a small business and see patients everyday.  Do I agree with the plan in whole, no.  But I don’t see the alternative offered by the other side as much different.

And where is the compassion?

I went to a meeting this week.  And in the three days since, I have been debating whether I should write about it at all, or I should just let it go, but it has really bothered me.  Not the presenter or the people putting on the meeting, but some of the attendees of the meeting.  Now this meeting was with the local physicians who are utilizing a care measures program with the Oklahoma Medicaid and try to improve patient outcomes and to decrease costs.  Nice thought, does it work, well the program claims to be saving $40 million on the physician side of direct costs since its inception in 2008.  Don’t ask me where the numbers come from, but some of it includes savings that have been realized by less utilization of the Emergency Room.  In all honesty, I like the program because it helps to remind me of the things I need to do, and should do for my diabetic and hypertensive patients.  (There are more patient diagnosis, but we have not added them yet)  Plus, they pay me an incentive for meeting goals that are established, and they are not super strict.

Anyway that is not where the concern came from.  The concern came from the resident table when one misunderstood the comment of one of the programs nurses, and took it to mean that it is the physician’s fault if they don’t understand their directions.  And it was his fault, if they didn’t understand directions from the educator, the hospital, the nurse, and the physician.  Well if they don’t understand the physician, I would like to point out, that it is the physician’s fault, but regardless, he became so angry and everyone started to jump on the band wagon.  And then everyone started yelling about how if they smoke or drink their checks should be taken away.  This is where the difficulty truly begins.

I am not arguing whether I agree or disagree with the Medicaid and welfare programs, however, benefits cannot be tied to smoking or alcohol usage, as they are both LEGAL.  Is there an entitlement feeling in some of this population- yes.  Should we work to change that?  Yes, but as healthcare providers, we should also realize that cutting off all of their benefits will not decrease costs, it will increase them.  How?  Well because ER utilization will increase, because they cannot afford to see their physician.  And with EMTALA when the get to the ER they will all be evaluated, and probably treated because the paperwork to not treat is a lot more arduous than that to treat, and the physician would have already evaluated them anyway.

Or you can look at those without insurance or other care that try to make ends meet, when they end up in the ER they are sicker and more costly than they would have been had they shown up when symptoms started.

My problem is that the anger directed toward the Medicaid population for being noncompliant, I wonder if these same physicians are as angry at their insurance population who are noncompliant?  If their answer is no, maybe the problem with educating is the physician.  Maybe it is the better than thou attitude that is causing the problem.  If as a resident, you are already angry, and you have yet to get out of residency yet, you are in the wrong field.  Primary care, especially family practice requires compassion and the ability to empathize with your patients.  Over the last 7 years in private practice, I have seen patients that I thought were merely not listening one day actually understand what they couldn’t grasp for 3 years.  And I have been able to get patients to lose 50 pounds over the last 7 months, because of educating them repeatedly.

It has required me to understand why they don’t always get their medication filled maybe they ran out of punches and instead of letting them pay cash for the meds on the $4 plan, Wal-Mart put that medication on their card and tried to charge them cash for the more expensive med (True story), or they didn’t follow their diet because when their check came in on the 3rd, they stocked up on food that would not spoil, which generally mean more sugar and less healthy.

I left the meeting scared for the future.  If in your training you are already that cynical, where does that leave the healthcare situation in this country?  Medicine is not 9 to 5, and while many could ask me how I can talk, since I have my schedule structured so that I don’t take call (my husband takes mine), I at the very least try to find ways to better serve my patients.

There is a need for the practice to find out why the patient is noncompliant, and that doesn’t just apply to the medicaid population, but to those with insurance.  And if we believe that people with insurance are doing a better job at taking care of themselves, than you need to only look at the rate of obesity and diabetes in this country to know that is not true.

We need to find a way to help them meet the challenges of their day to day.  To find out what resources that will allow for them to have better health.  We have to help them become better partners in their health.  And we have to be able to listen.  The 15 minute office visit doesn’t allow for this, and based on the comment from another resident who said, “Well it is really only 8.” well I can see where an even more concerning problem for the future is.  Those that are focused on the clock cannot be meeting the needs of their patient.  I understand people don’t like to wait, but they are even less happy to do so, when you rush them in and out like cattle, cutting them off at 8 minutes in.  Is there even time to delve into their diabetes, their depression, or routine maintenance by 8 minutes?

Some visits will be simple, ear infections, strep, but for complete care you have to understand where the patient lives, what their culture is, the challenges they face.  Am I perfect at this?  No, but I don’t dwell on the clock, I don’t say at 7 minutes in, Well that is all the time we have, here is your prescription.  We need to actively listen to our patients, and if we don’t want to do that, well than we should go do something else.

Medicine can be taught, but compassion and empathy cannot be.  And if you don’t possess either, than primary care is not where you belong.  If you went into medicine for the money, well you are an idiot, there are easier careers that require less training and risk for the money, and in primary care, while you will be living better than most of the population, you will not be living like a rock star.

Everyday there is some report about a shortage being faced in medicine- nurses, primary care physicians, specialists, etc. But if we just fill those positions with bodies instead of compassionate, skilled individuals are we actually better off?

Medicine is challenging.  You have to be willing to fight for your patient, regardless of their income, and they have to believe that you will care whether they get better.  Sometimes it will be the happiest day of their life- when they have a baby, or sometimes it is the day when you diagnose their cancer, or tell them that they aren’t going to get better.  It is the willingness to have the hard conversations with the patient, the fight to make them more accountable for their own health.

What family medicine is not, is a blame game.  You cannot take care of a patient, if you cannot take the time to make sure that they understand your directions.  Sometimes it is frustrating, and sometimes patients will make you crazy, but it is a trust you undertook when you took that oath.

Daily Fitbit stats

My fitbit #fitstats for 6/24/2012: 8,424 steps and 3.8 miles traveled. http://www.fitbit.com/user/22K3T6

Daily Fitbit stats

My fitbit #fitstats for 6/19/2012: 12,866 steps and 5.8 miles traveled. http://www.fitbit.com/user/22K3T6

Daily Fitbit stats

My fitbit #fitstats for 6/18/2012: 15,560 steps and 8 miles traveled. http://www.fitbit.com/user/22K3T6

Daily Fitbit stats

My fitbit #fitstats for 6/17/2012: 27,377 steps and 13.5 miles traveled. http://www.fitbit.com/user/22K3T6

Daily Fitbit stats

My fitbit #fitstats for 6/16/2012: 12,541 steps and 7.5 miles traveled. http://www.fitbit.com/user/22K3T6

Daily Fitbit stats

My fitbit #fitstats for 6/15/2012: 7,311 steps and 3.3 miles traveled. http://www.fitbit.com/user/22K3T6

To all those graduating residency this month (or close to anyway)

OR What I wished someone told me when I was about to graduate.

Congratulations, welcome to the world of medicine.  Does it seem a little belated?  After all you have been licensed anywhere for 2 to 5 years depending on your specialty, you graduated from medical school and have been officially a doctor for 3 to 6 years, not to mention the 4 years of medical school before that.  So while I grant you it seems a little belated, it is not.  You are now officially on your own.  There is no back up.

For the last 6 months or so you have been counting down the days, the nights on call, weekends on call, or some variation until you were done.  You have taken board exams, presented research and have either had a graduation or are about to have a graduation that is not quite like the ones from medical school and college, but they are still nice, and they are still a big deal.  (I seemed to have forgotten that, and didn’t think to invite my parents to mine.  Whoops)  But you have been counting down the days until your time in now your time and you don’t have to answer to anyone else.

And a funny thing happens, the moment you graduate, you instantly become one of us.  In a way you weren’t before.  Those that are staying close to the program that they graduated from will find it a little more amazing the change from resident to the next morning ATTENDING.  And for the easy stuff it is amazing.  Ear infections, I got that.  Hypertension, well I will use my favorite ACE or beta blocker.  You have bronchitis, and you will be super doctor until “What the heck is that?”  Well that is what you will be thinking, and you will have to stop yourself from saying “I am going to grab my attending to come in here and look at that.”  Because you no longer have an attending you are the attending.  So you will pull out your books or go online to your favorite site and you will figure out to your best opinion what it is.  And if you are right, you will be a hero, and if you are wrong well they will either return and you will try something else, or they will go somewhere else.  You are now the EXPERT.

But don’t think that you are alone.  I made that mistake.  The profession is quite willing to help its fellow physicians, you only have to ask.  Which EMR is best, ask.  Most are more than willing to let you look at their systems and try them out.  You need help with a case in the hospital, you can either officially or unofficially consult one of your colleagues, we love being asked for advice from fellow physicians.  Just don’t ask investment advice, some are really good at it, and some are really bad, best to find a financial advisor on your own.

Make sure you have a good accountant, a good lawyer and a good relationship with a bank.  Seems silly, but those will save you time and again especially if you are starting out on your own.  Rare now a days.  I did it 7 years ago, and it is probably due to the accountant and bank that I am still standing.  You didn’t go to business school, you went to medical school, but school and residency failed to teach you about the business of medicine.  And it is a business.  You want to get an MBA, great idea in a few years.  The first couple you need to work on getting your feet wet in the medical field.  So surround yourself with a great support staff.

Your spouse/significant other who went through all of this with you, was not trained in billing and coding for the most part.  So if they are going to run your business, they need to get trained.  While the motivation is their (It’s their money too) the knowledge may be lacking and you are probably not qualified enough to teach them.  They need to either get some training or hire someone who is trained.

Take time off.  No not the first month, but you cannot go constantly.  It does not serve you and it does not improve the care you provide to your patient.  And all of  your patients are going to get sick and they are all going to be mad that you left them when they were the sickest ever, but that first day back your lobby will be filled because that guy down the street that was covering you, just doesn’t know what they are doing.

And if you are at the program you trained at DO NOT ever in that first year use the line. “When I was a resident…”  Most of the program was just a resident with you, and it loses its meaning when they can come back and say, “You were a resident just last month.”  My fourth year in medical school, I witnessed that from one of the new attending, who went around saying that.  You can say it after everyone who was ever in residency with you has graduated, but until then, they knew you in residency.

And if you use that line don’t follow it with something ridiculous like “I would have liked to get up at 2 am and do an H&P if my attending would have asked me to.”

No you wouldn’t have, and you didn’t like it.  You complained to your fellow resident the next day.  There are crappy things that residents have to do because they are learning and are residents don’t insult them by pretending they aren’t.  And remember you were once a resident, don’t just abuse them because you can.  It doesn’t make you a better doctor among your colleagues.  It just makes you an ass.

This list is far from exhaustive, and I am sure if I had time I could keep going, but I don’t and this blog is getting a little long.  So congratulations on your achievements and hard work.  And welcome to the club.  You membership fees are now due.  (This is only half a joke, you have no idea how expensive it becomes to keep all these groups fees paid)