Happy Doctor, Happy Patient
Ten years ago and fresh from residency I walked into my first and until this day, only, family medicine position in rural-ish Wise County, Texas. I call it rural “ish” because we have a Chili’s, a Lowe's Home Improvement store, and a FIVE floor hospital. The county bovine population still rivals that of it’s more human types and the killing of wild hog is held in very high regard. I suppose at the time these factors allowed me the flexibility of definition to call myself a ‘Country Doc’ and thus I proceeded with this image of myself, treating (and forming relationships with) literally thousands of people since that first day.
The last ten years have affected me, or more correctly, the thousands of hours spent listening to patient joys and struggles has shaped me in ways I could not have known. I have personally laid awake at night worrying endlessly about this or that patient’s condition, raged at the seemingly haphazard way in which cancer and other diseases ravaged this or that individual, cried with family members and patients who have faced pain I otherwise would not have known. I have also connected in very meaningful ways with the struggles my patient’s have faced and for some, still face. Oh, I have ‘fixed’ a lot of people also. However, these successes pale in importance and meaning to the more significant role of just being with my patients and walking with them through whatever they might be enduring.
These are the reasons we embark on a career in family medicine. A thousand books could not supplant a thousand patient struggles and the personal growth derived therein. We do not choose this profession lightly and I hold in the highest regard my colleagues with whom I have worked beside; sometimes bloodied, frustrated, and panicked, but beside nonetheless.
Today, after ten years, I have mailed a notice to terminate my employment contract and this was also a decision I did not make lightly. Family medicine has become a bad business for innumerable reasons, none of them having anything to do with the patients or doctors. This tragedy has only been exaggerated by the COVID pandemic. Many doctors, like myself, are left with the only option that they can’t ‘not’ do, and that is to leave the house of cards to fall upon itself. To paint a more precise picture, more than fifty-percent of my time is now spent doing something besides directly caring for my patients. There have been points in the recent past that I have felt that this number was closer to seventy-five percent.
These ‘patient care’ activities fall into several broad categories. It is not easy enough to say that the doctor sees the patient, decides (with the help of the patient) what is in the best interest of the patient, prescribes or performs said treatment, bills the insurance company and then gets paid. More correctly, the doctor has to prove the complexity of his decision making process to the insurance company. This is accomplished by an onerous charting and billing process that is ever changing and in itself increasingly complex. The doctor has to then defend his or her decision when the inevitable denial comes (usually in the form of paper over the fax) and is on hook for explaining to the patient why the recommended treatment course is no longer an option. If the treatment is worth the fight, an increasing amount of time is then spent by the doctor and staff countering the insurance company, over multiple interactions (with the insurance company not with the patient) for a chance at the recommended treatment. The above scenario is all too common and in my case, constitutes the majority of my time.
There was a time when the little bit of ‘sand in the crawl’ was justified for the trip to the beach. The beach has become a never ending desert and the well intended doctor a mere wanderer.
Over time, and for obvious reasons, reimbursement from insurance companies and Medicaid and Medicare have paired down the time spent interacting with patients via ever decreasing reimbursement, to an average of seven minutes per encounter. Seven minutes is the number always quoted in the literature and in my best estimation is likely close to the truth. That is if a traditional primary care practice has any hope of profitability. Simply, the insurance companies have, over time, paid less per interaction forcing the doctor to see more and more patients. Such maneuvering has had the largest impact on the doctor-patient relationship. Now when the doctor enters the room they are already figuring out how to get out of the room in a timely manner. I do not believe any patient or provider would ever consider such time constraints safe and they have served to steal meaning from the doctor-patient interaction.
In an effort to counteract this phenomenon, smaller and now unprofitable practices have sold out to larger health systems in a very real game of fish eats fish leading the way to what has become known as the ‘Value-based’ healthcare model. In this model, large healthcare systems justify the unprofitable, but owned, primary care practices because of the services that those patients utilize. For instance, it is justifiable to the ‘__Fill in the blank__’ Health System administration that the primary care ‘cost center’ is unprofitable as long as the MRI scanner, the physical therapist, or the hospital bed is profitable. It is justifiable because it's the patients within that primary care ‘cost center’ that utilize, and thus pay for, those services. This has resulted in an ever increasing pressure on the doctor to prescribe diagnostic tests and services that the larger ‘value-based’ health system offers. In many cases, the doctor then has to defend the treatment plan to the insurance company as in the scenario outlined above. Arguably, in this current model of healthcare, the doctor is but a pawn and the patient the prey.
This is an overly simplistic (yet still very complex) explanation of the existential struggle that a typical family medicine doctor faces in this age of modern medicine. Moral injury. My haphazard and late night searches of my own ‘clinician distress’ has increasingly led me to this phrase. Moral injury is distinctly different than ‘burn-out’ and I lack a better way to describe it than one 2019 paper on the subject.
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury.
-Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout [published correction appears in Fed Pract. 2019 Oct;36(10):447]. Fed Pract. 2019;36(9):400-402.
As such, I have come to evaluate my own role in the healthcare system only to consider the perspective of my patients. I have chosen, today, to be done with the whole nasty business which has placed me as a pawn in a game between the insurance companies and the health systems. The Direct Primary Care, or DPC model has been developed as a worthy consideration to allow for the re-emergence of the doctor-patient relationship and I have chosen to walk this path. My last day in my current practice will be March 15th, 2021 and in very short fashion my nurse practitioner Casey Meadows and I will open Enso Direct Care. We will limit ourselves to only the amount of patients to whom we feel that we can care for with excellence. We will not waste our patients’ valuable time dealing with insurance companies and will be aligned with no health system. Our only goal will be to best serve our patients and we will have ample opportunity to accomplish this as the average time spent in patient visits in this DPC model of primary care ranges from 30-60 minutes.
For a great many patients in my current practice, they are paying what I would consider exorbitant prices for health insurance plans with exorbitant deductibles that offer little in the way of primary care benefit. I, for one, had a period of years where I paid more in health insurance premiums than I did my mortgage; only to realize that if I needed routine treatment I only needed to phone a friend. I now pay for a catastrophic plan and have what I call my HSA (a mere bank account) to cover my $10k deductible should it ever be needed. For my non-medicare patients I would recommend a similar solution. In many, if not most cases the savings in monthly insurance premiums more than makes up for the cost of membership to a DPC practice.
I have written more tonight than I have in years and suppose that I have had a lot to air out. I know that my decision will be met with some degree of resistance by some patients and others within my network, but in the short time, I have been encouraged by the support that I have received. If anything, I have done only what I couldn’t ‘not’ do and will see it through to a better way.
God Bless,
Brad D. Faglie, MD (Doc)
