Video Archives

Do Better

Ryan Neuhofel, DO, who is a colleague and a friend of mine, wrote an incredible piece for the AAFP online site.  In a very calculated and logical way he smashes the quality and metric people and then goes on to say this:

However, does a bit more — or less — money significantly change the behavior of individual physicians on a day-to-day basis? Particularly at the primary care level?

He’s right.  And all the “incentives” that were supposedly carrots they were offering were actually sticks made up of more bureaucratic tasks. It is these sticks that are still killing us.  As Neuhofel puts it:

The list of things that hamstring PCPs from doing their best is long, but let’s start with some simple math. The average full-time PCP is now responsible for a panel of 1,200 to 3,000 patients. (There is some debate on how to calculate this number in a traditional fee-for-service clinic.) Physicians are often rushed through 15 to 30 office visits per day that last 15 to 20 minutes at most. Given the complexities of modern health care and the growing prevalence of chronic illness, this is insane.

In addition to sheer patient volume, physicians are increasingly distracted by a mountain of clerical and other nonclinical tasks. We can always strive for efficiency and delegation of tasks (teamwork) when appropriate, but there is no substitute for a doctor’s time. It’s no wonder family physicians are often inaccessible to patients’ acute needs and feeling burned out.

He is spot on.  It is a no-win situation or is it?

Rather than apply more external pressure, we must recognize that intrinsic factors are what matter most to a PCP. We need an environment that fosters a sense of autonomy, mastery and purpose to fulfill our potential. The only way to create this culture is to allow PCPs the following opportunities:

  • the opportunity to sit and truly listen to each patient to understand his or her story;
  • the opportunity to educate patients and allow them to ask questions;
  • the opportunity to develop long-term, trusting relationships with patients and staff;
  • the opportunity to utilize (not just collect) relevant and coherent patient data;
  • the opportunity to learn and grow in our knowledge and skills; and
  • the opportunity to stay sane and happy while doing all of the above.

Now, what kind of job, at least in primary care, would allow this to happen?  What kind of environment would foster “a sense of autonomy, mastery and purpose to fulfill our potential”?  Hmmmm, I wonder? I spend 30-60 minutes with my patients now.  I read between patients or at home because I am not exhausted. I email patients articles I find interesting as it relates to their issues.  My wife, and office manager, babysits some patients’ kids and hangs out with them when the Mom is in the exam room.  This is the video above and a very typical day in my practice.

I am not some great doctor.  I think after 20+ years I am pretty good.  I am, however, much better in an environment that Neuhofel describes above. Life was not always like this for me.  I was brutalized in the system for 15 years working for two different hospital systems.  I put in my time in and I got burned out.  I was ready to quit medicine altogether.  It was then I decided to make a jump and do my own thing.  Has it worked out?  Yes. Was it easy?  No, but is anything worth doing easy?

I now make more than I used to make in the system.  I have only 600 patients on my panel.  With more time and less patients, I am the doctor I dreamed of being as a kid.  This is ONLY because I opened my own direct primary care practice, which proves Neuhofel’s “environment” theory is right. Some may respond, “Well, that’s easy for you but not for me.” I would again respond that it wasn’t easy for me but because of the early adopters of DPC we are making it easier for others.  DPC is gaining more and more traction from primary care doctors daily.  The DPC Alliance is the only organization truly dedicated 100% to DPC doctors unlike some associations (AAFP) who brush us off by putting non-doctors in charge of “helping” us.

If you want the opportunity Ryan talks about above, then you need to take the jump.  If you want to Do Better then you need an environment to Do Better.   I know it may take time for you to get there but until then, I’ll leave the office light on for you (because I will be home by 5 PM).

Get Dr. Farrago’s book on how to start your own DPC practice here on Amazon

Get Your ABFM Button Eyes Here

I received this message recently from a reader of this blog:

“Just got the latest ABFM mailer. The creepy ‘get with the program’ cheerleading reminded me of the following (Coraline movie clip above)”.

I was surprised that such juicy material had skipped by me without my notice. Then I saw it.  Oh, it’s a good one. Here is the PDF from the idiots at the ABFM.  I am going to copy their first article here in full:

The ABFM PRIME Support and Alignment Network News: Supporting and aligning your professional activities with practice transformation to help bring joy back to practice!

What was Good for Farms may be Good for Practices by Robert L. Phillips, Jr., MD MSPH

For more than 100 years, the Cooperative Extension System (CES) has led the way in innovation discovery in American agriculture and farming. It is heralded as one of the most successful technology catalyst programs of all time, ensuring food production at critical times in our recent history. Thanks to its connection to land-grant universities, there are now CES agents in nearly every U.S. county who continue a legacy in rural and farming communities, but who are also enabling a new generation of farmers and the locally-sourced food movement that supplies many of your favorite restaurants. The CES also has a National Framework for Health and Wellness that aims to help create healthy and safe communities, support clinical and community preventative services, and contribute to the elimination of health disparities. The well-tested and well-developed CES recognized an important opportunity to help improve health beyond food production. More than a decade ago, Dr. Don Berwick and others recognized the potential for the Cooperative Extension model to be a boon for discovering healthcare innovations and speeding up the testing and dissemination of those innovations across physician practices. Family medicine innovators, like Dr. Art Kaufman in New Mexico, and Dr. Jim Mold in Oklahoma, built co-op-like models of practice support and change-facilitation that have operated successfully for nearly two decades. In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was launched as a component of the American Recovery and Reinvestment Act. This act created 62 Regional Extension Centers that worked with individual practices to speed up adoption of electronic health records (EHRs). Congressional staffers who drafted the HITECH Act borrowed the extension model for EHR adoption. That toe-hold for healthcare extension became the nidus for the Primary Care Extension Program (PCEP) authorization in 2010, which was written, in part, by a small group of family medicine leaders. In 2011, the Agency for Healthcare Research and Quality piloted the PCEP concept with Infrastructure for Maintaining Primary Care Transformation (IMPaCT), and then in 2015 launched the much larger EvidenceNOW, which is providing quality improvement services to 250 small- and medium-sized primary care practices across 12 states. IMPaCT influenced the Centers for Medicare and Medicaid Services to launch two related demonstrations in 2015: The Comprehensive Primary Care Initiative (now in its second generation as CPC+) and the Transforming Clinical Practice Initiative (TCPi).TCPi aims to reach 140,000 clinicians across all states, providing practice assessment, transformation, and improvement services through 29 Practice Transformation Networks. CPC+ provides multi-payer payment reform and transformation support to nearly 3,000 practices in 18 regions. These three projects will put nearly $1 billion into testing the value of local practice transformation services. The ABFM believes that extension-like services are important to helping family medicine practices survive and thrive. For that reason, we are directly participating in TCPi with the ABFM PRIME Support and Alignment Network and supporting both EvidenceNOW and CPC+. It is also one of the reasons the ABFM created the PRIME Registry and is offering three years of free registry enrollment for thousands of family physicians.

Right off the bat the title of their whole publication makes me ill:

Supporting and aligning your professional activities with practice transformation to help bring joy back to practice!

You are a damn testing organization who gouging us for money and whose biggest income producer (MOC) is a scam. You are almost obsolete.  Everyone hates you. We do not want you to transform us.  Removing the MOC would be the only thing you could do to bring us joy.

Now to the article itself.  Uhh…….WTF is that?  I couldn’t understand anything this guy said.  I lost interest by sentence two.  It’s all about confusion and persuasion to make us follow them with their stupid initiatives.  Like the reader who sent me this says, “None of which makes any sense…. EHR’s are the buttons we all must sew on….like in Coraline.  Yup. 

What are your thoughts?

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Friday Funny: Erectile Dysfunction from Family Guy

This one cracks me up. Dr. Hartman is absurd but there are some true nuggets in here. Enjoy.

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