Skip to main content

Remembrance of Docs Past

It was 10 AM and the unmarked glass door was locked. A woman in a brightly colored dress with a big smile on her face waved from inside, disappeared for a brief moment and returned with a key, unlocked the door and welcomed us to Dr. Elliott’s brand new solo practice. The small rooms were brightly lit, sparsely furnished and smelled of fresh paint. There were two elderly patients in the waiting room and one empty chair. In the next room there was a desk with a big monitor, a new printer and lots of framed pictures of happy people holding little children in their arms. Unpacked boxes and crates were stacked up in one corner and across from it the exam room door was closed. Dr. Elliott was with a patient. Mrs. Elliott, the lady with the brightly colored dress, produced a couple of extra chairs from thin air and told us all about the happy people and the little children in the framed photos, while answering phones, making appointments, checking authorizations, printing all sorts of papers, preparing charts and arranging for referrals, all at once. It was 10:30 AM and the exam room door was still closed. I was beginning to understand why Dr. Elliott’s finances were less than stellar. The door finally opened a few minutes later and a tall and gaunt gentleman with a thin colorless ponytail sticking out the back of his green baseball cap walked out of the exam room holding some papers in his hands. Dr. Elliott walked right behind him finishing an unfinished conversation with his patient and starting a brand new one with us. The patient decided to hang around and participate and somehow this looked and felt just right.

Dr. Elliott is a bubbly fidgety man in his mid-forties, and this little practice was his desperately brave response to rejection after rejection from organized medicine. Dr. Elliott was either invited to leave, or quit on his own, several health systems due to his inability to meet productivity quotas. Somehow I was not surprised, and the patient with the thinning ponytail had a toothless grin on his face. Turns out Doc wants to know everything, even what he had for breakfast today and maybe Doc should pay him for doing most of the talking. He slowly pulled a $10 bill from his stiff jeans pocket and handed it to Mrs. Elliott who thanked him and handed him a receipt which he stuffed back in the same pocket, shook hands with everybody in the room and left escorted by Mrs. Elliott who unlocked the door for him and locked it behind him. I just had to ask…

“I take insurance, but if they don’t have insurance, they still need a doctor, so they pay what they can”. My partner mumbled something about chickens. Dr. Elliott walked back into the exam room and closed the door behind him. Mrs. Elliott, still doing five things at once, told us about the new EMR they just bought and how they are working on becoming a medical home, and maybe soon she’ll be able to get a good phone system so she doesn’t have to forward calls to her personal cell phone. There was someone knocking at the door. Two teenage girls came in and one wasn’t feeling well. Can she see the doctor? Sure. The girl who wasn’t feeling well had no insurance either. Another half hour went by and Dr. Elliott walked out from the exam room behind a perky little old lady with huge glasses and cropped white hair. Miss. Sally also decided to stay and chat with us for a bit.

Miss. Sally was suffering from congestive heart failure and was in and out of hospitals for most of last year. She was pretty sure her time has come until she found Dr. Elliott, and he found a cardiologist for Miss. Sally and together they worked things out for her. She is as good as new, or so she tells us. No more hospitals for her. Instead she visits with Doc once a month and sometimes he sends her to see the cardiologist. Miss. Sally was having a grand time being the center of attention. Doc saved her life.

The teenage girl who wasn’t feeling well looked up from her cell phone for a brief moment and agreed to wait a few more minutes so Dr. Elliott can complete his oration on evidence based medicine, the importance of primary care and his great expectations from his soon to be installed state of the art EMR system. He gave Miss. Sally some education materials she will never read, and walked us to the locked door. This time I didn’t have to ask. There were some “incidents” close by and “once they walk through that door, they are my patients, and I am responsible for their safety”, said Dr. Elliott as he unlocked the glass door. As we said our goodbyes I caught a glimpse of the office hours painted on the glass in a soft gray font. The last line read Saturday 9 am – 7 pm.

The rain stopped and a hot Alabama sun was baking the dusty row of little storefronts. A distraught woman walked by looking for a bathroom. We drove back to the city passing by a cinderblock hospital with fat pipes sticking out in every direction, and I wondered how many little old ladies with congestive heart failure are in the process of dying there now. It was getting dark outside.

Note: In order to protect their privacy, the names of all people mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.

Comments

Post a Comment

Popular posts from this blog

Transforming Health Care: Values and Cultural Preferences

On his campaign trails, Harry Truman used to call on citizens to go out and vote for themselves, in their own selfish interests. It may sound shallow and divisive, but Harry Truman believed that the individual interests of the people should trump the special interests of the powerful few, and that’s how Democracy should work. Those were simpler times, but the logic still applies today, although it’s becoming increasingly difficult for people to figure out where their selfish interests lie, not because interests have changed, but because the art of spinning messages and the sheer amounts of cash thrown at it have grown beyond what Harry Truman could have imagined. Take for example the controversy around the Patient Protection and Affordable Care Act of 2010, a.k.a. Obamacare, which was spun into one little question: do we want the government to give more poor people health insurance, while forcing everybody else to pay for it? If yes, vote Democrat. If no, vote Republican. But Obamacare...
Post a Comment
Read more

De Novo EMR Design Part II: The Quest for Information

The Edwin Smith papyrus ca. 1500 BCE In Part I of this series, we engaged in a design exercise for an imaginary software product that has no stated (or hidden) purpose other than to improve patient care. Following our initial definition of patient care, we formulated three general requirements and several constraints, none of which were specific enough to start building software tools from. The next step in our journey will break down each requirement into more specific tasks. What follows below will seem like an unnecessary and laborious statement of the obvious to some. However, I would submit that the careless bypassing of fundamental analysis is precisely what led us to where we are today, and even if we are forced to cut corners eventually, it is imperative that we define all corners prior to cutting them, instead of feigning shock and surprise after the fact. So without further ado, let’s start where we left off. System shall assist with gathering information from various sourc...
Post a Comment
Read more

In Memoriam FFS

On April 16, 2015, President Obama signed into law H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), effectively sentencing Fee for Service (FFS) to death. The best explanation for how FFS is destroying the nation comes from Charles Munger , vice-chairman of Berkshire Hathaway and ad-hoc health luminary, who is equating what American doctors do, to raising rattlesnakes so they can collect the bounty for dead rattlers offered by the government in an effort to combat a growing snake problem. Based on this, and other equally compelling insights, FFS was found responsible for willful destruction of our great nation. A few months before Congress delivered its coup de grâce to the FFS system, the Secretary of Health and Human Services, explained to the elite group of NEJM paying customers, how “30% of Medicare payments should be tied to quality or value through alternative payment models by 2016 (50% by 2018)”. Other than transforming traditional Medicare into a vi...
Post a Comment
Read more