Dittoheads of the world, unite!

I know I’m running out of things to say about practice management when I read a series of great articles in great publications – and all I can add is “ditto.” I never wanted to be a dittohead, and I don’t listen to Rush Limbaugh. But there are only so many valid points to make, and unless I want to make them again with different examples, or move on to some other subject, I’m reaching the end of my tether.

Dr. Mark Sklar, an endocrinologist and assistant professor of medicine at the hospitals of Georgetown and George Washington University, popped a good opinion piece in the June 23rd Wall Street Journal. Although he is a specialist and I am a generalist, the fact that we have both experienced academic bureaucracies and opted for private practice makes us blood brothers. Like this:

"Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs."

Like I said before, doctors are really piece workers. There are no efficiencies in numbers. Have I mentioned that I don’t have an office manager, so I don’t have to pay my share of a $50,000 salary? That goes to my kids’ college fund. True, I have to make small day-to-day decisions between patients. Also true, I don’t have to meet with the office manager to go over those decisions, and check on the implementation later. I wouldn’t remember anyway. Short attention spans have their advantage, in the right setting.

"I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored."

My town is crawling with good doctors, including primary care – we had a family practice residency here for a long time, and lots of them stayed put. Every time I call my primary hospital, I listen to an advertisement for my competitors while I’m on hold; I read their full page ads in the paper; they dominate the evening news and the Yellow Pages. How is a solo FP supposed to compete? Like Dr. Sklar says. Our patients are treated like royalty. I was recently invited to join a large “concierge” organization, but there was a major problem: How was I going to offer VIP patients better service than they’re getting now for nothing?  

"Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results…. When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them."

When I read articles lauding EMRs, I feel like I’m in a parallel universe. You need an EMR to avoid duplication of tests and services? Like Dr. Sklar says, that’s what a fax machine is for. An EMR will save paper? Every time I get a “Practice Partner” five-minute office visit from one consultant, it occupies four pages of trees. An emergency room visit runs to eight single-spaced pages. It’s damn difficult to find the important stuff in all that computer-generated, ass-covering verbiage. If everyone shared a common platform, that would be one matter. But the government refused to mandate that a decade ago, and I’m paying for the results. Some day the Betamax/VHS, Blu-Ray/DVD, 8-track/cassette issue will be settled, and that’s the day I’ll shop for an EMR.

Don’t try telling that to the Patient-Centered Medical Home folks, though.

Posted at 12:22PM Jul 02, 2009 by Doug Iliff  |  Comments[4]