Leading With a Happy Face by Pat Conrad MD


The movie “Rocky IV” featured everyone’s plucky southpaw in an ideological proxy fight with evil communism, in the person of Drago, the USSR’s engineered perfect man. In the climactic fight, Rocky beats Drago by perfecting the little-used boxing technique of smashing his face repeatedly into the Russian’s fist, until the latter is knocked out. This tactic apparently has apparently inspired Medical Economics magazine.

Last month’s cover story from senior editor Jeffrey Bendix titled, “Fighting Back – Overcome the challenges of Independent Practice” advances a similarly curious approach. The discussion begins by noting how crappy it is to try to keep an independent practice going, what with “the growing shift towards value-based payment…need to stay abreast of new technologies…growing competition from new types of providers.” An interesting statistic herein: “independent practice owners decreased from 62% in 2008 to 35% in 2013, according to the 2014 Physicians Foundation Survey of American Physicians.” The magazine “asked physicians and practice administrators to share their strategies of overcoming the challenges” and got these:

  • “accept that electronic health records are necessary to function in today’s healthcare environment…”
  • “look for ways to differentiate your practice in the eyes of payers in … efficiency and outcomes.”
  • “make population health management part of your care …[by] tracking quality data.”

So the lead off for a strategy to survive as an independent is to do as you’re told and wear a happy face.

  • “Experts say staying independent likely requires teaming up with other independent practices through vehicles such as accountable care organizations (ACOs).” Am I the only one smelling a little irony here?

Designated medical commissar Nitin Damle, MD FACP, president-elect of the American College of Physicians can’t smell anything but puppies and sunshine: “I think once you recognize that this new direction really has value, you can jump on board and in the end you’ll feel like your life and professional satisfaction will be improved because you’ll see that you’re taking better care of your patients and that you’re able to spend more time with them.”

Independent (ahem) doctor Chris Apostol, DO looks to embrace the benefits of EHR’s in his group practice: “No matter who is seeing the patient, the encounters now look pretty much the same, because the same quality measures are going to be met and the same information is going in the same spots.” Just read THAT quote again, and try to imagine the smooth level 4’s.

  • Yul Ejnes, MD says, “EHR’s also make it possible for practices to collect and generate the data needed for population health – a requirement for many of the value-based payment models.”

At this point in “Rocky IV”, the protagonist’s face is starting to become a featureless, punished mass of red with a sideways nose, that seeks out his opponents fists and launches at them repeatedly. A surprisingly accurate version of Premier Gorbachev in the balcony begins to seem concerned, as the Soviet champion appears winded.

The article on fighting back closes by embracing “evolving practice models”, which turn out to be getting paid based on quality measurements and pay-for-performance. The featured (sigh) independent joined with a much larger group, and began cranking out the stats required by the payers. I think his definition of “independent” and mine are quite different. His means, “The likelihood of transition from paying for volume to paying for value meant that I was going to need the resources to measure statistics better…You’re not going to get far with payers if you don’t understand what value you can present.” And yes, in fairness, that approach earned that provider “better compensation rates and care coordination fees from two major commercial payers.” Call me a cynic, but in all of this I think “independent” really means that you are responsible for your own overhead, but otherwise you still have to do the same dance in a prison dress as the rest of your cellmates. In the end Drago falls, and Rocky, who has miraculously retained his powers of speech, such as it is, pleads with the crowd, “If I can change, and you can change, then everybody can change!”

It was a stupid movie, criminally stupid, and stupid as telling physicians that they can retain their independence by rushing into the embrace of Big Insurance and the government, leading with their faces, expecting a win.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “Leading With a Happy Face by Pat Conrad MD

  1. Randy
    September 12, 2015 at 9:27 am

    I had read this article a few weeks ago. It looks like according to Medical Economics the best way to fight back is not to fight back. The article promised “Physicians who are beating the odds by fighting back” but uses as its sources the ACP president-elect, a CEO of a 117-provider group, a practice administrator of a GI group of unspecified size, and a guy who joined an ACO because he couldn’t make it solo. These are our fighters.

    • Perry
      September 12, 2015 at 4:46 pm

      Yeah, I never ordered Medical Economics, but somehow I get it anyway. I thought it would be great to read about how to fight back but when I came to those recommendations to embrace the BS I just about upchucked my supper.
      We are losing, big time…

  2. Steve O'
    September 12, 2015 at 9:08 am

    Nothing seems to chill Dr. Apostol in the phrase “No matter who is seeing the patient, the encounters now look pretty much the same,” To Dr. Apostol, the seeing of the patient seems to be a “thing” that can be “encountered,” only becoming real when documented. The myth overhanging medicine for thirty years is, “not documented = not done.”
    I was taught in medical school – and that’s a while ago, folks – to ridicule the surgeon’s note of the ancient days:

    POD#3 Appy (postop day #3, appendectomy).
    Eating and walking around, ready to go home. Vitals normal, belly soft, bowel sounds normal. Discharge home.

    What is absent in that note? Nothing of meaning, really. The presumption was that the surgeon took pride in one’s work, and that based on years of experience and visiting the patient, the surgeon had nothing left to offer the patient regarding the recent appendectomy.
    Now, we race towards a world where the actual job – seeing, talking and being with the patient – is disfavored, because it takes time away from the documentation. We are pushed to document dozens of normal findings, observations and generalities, none of which has the slightest thing to do with the actual care of the patient.
    “We are the Borg. Your biological and technological distinctiveness will be added to our own. Resistance is futile.” the Borg Collective is a civilization with a group mind.
    That was a sci-fi group of being that believed in the ultimate obedience of ALL to the ONE. They appeared very indomitable. But the Borg was a creation of writers for an American television show. The people who believe in the nonsense they parrot, for the greater good of the ALL, the Hive Mind, are real – and they are hurting people.
    “Experts say staying independent likely requires teaming up with other independent practices through vehicles such as accountable care organizations (ACOs)…accept that electronic health records are necessary to function in today’s healthcare environment…”
    Resistance is futile. You will be assimilated.

    • Pat
      September 12, 2015 at 1:19 pm

      Exactly Steve. All doctor’s notes, office or OR, should be so succinct. That they aren’t demonstrates an institutionalized, permanent mistrust of the physician from the outset. And we gave it away…

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