A small but growing group of physicians is starting ‘’ideal medical practices” that put the individual patient at the heart of health care.
John Grossmann | September/October 2012 Issue
John, a slight 60-year-old with severe arthritis and high blood pressure, sits in the hallway outside his doctor’s office in Eugene, Oregon, reading a thick book on wellness he’s brought from home. Home is 100 miles away in Newport. John thinks nothing of traveling so far for his annual physical because he has something most people only dream of: a doctor-patient relationship so personal, so unhurried, so valuable to him that even when he’s with strangers John often boasts about what a terrific doctor he has.
He’s waiting to see her now not because she’s running behind schedule (he’s 20 minutes early), but because of the very way she practices medicine, Dr. Pamela Wible rarely keeps patients waiting. On the rare occasion that she does make patients wait more than 10 minutes, Wible holds out a gift basket and lets them select an item, a book perhaps, or handmade soap or jewelry, often things she has taken in trade from those otherwise unable to pay her. That’s after she greets them, as she does all patients, by name and with a smile and a big hug.
Health care in the United States is badly broken. Tens of millions are uninsured. Many seek medical care only when unattended chronic conditions like diabetes or heart disease send them to hospital emergency rooms. Runaway costs batter the nation’s economy. The Obama Administration’s controversial health-care reform legislation, at 2,700 pages, embodies the complexity of the task.
And ask about the very foundation of health care, visits to primary care physicians, and most have plenty to say, and very little of it positive: I’m kept waiting and waiting … My doctor barges into the examining room with barely a hello and rushes through the exam … He’s always looking down at my folder on his lap; he never looks me in the eye … She doesn’t know me and I’ve been coming to her for years … Is there a doctor in this office who is happy? Mine surely doesn’t seem to be …
Little wonder. For an average appointment, patients spend 50 minutes in the office of their primary care physician, but only 10 minutes with their doctor. Two dozen patient visits, even three dozen or more, is a typical day’s work for most American primary care physicians. Not because they want to see that many patients, but because their group practices demand it, because there’s so much office overhead to cover before anybody makes any money. “You wonder why doctors are tired?” asks Wible when she speaks publicly about her clinic, part of a growing trend known as “idealized medical practice.” “Because they’re inefficiently churning people through a disease billing system.”
Even the head of the American Academy of Family Physicians (AAFP) essentially agrees. “Doctors feel like they’re on a productivity treadmill,” says AAFP president-elect Jeffrey Cain, “because they’re rewarded for the number of patient visits per day, and that grinding style of practice has a lot of overhead, a lot of nurses and support background. That’s where the frustration comes in for both patients and physicians.” Indeed, the terms “healer burnout” and “physician burnout” appear frequently in the titles of medical journal articles. One study of 3,000 physicians found the most distress among doctors under time pressure and with little control of their work environment. A fix has come for some: Doctors who cater to the well-to-do offer what’s known as concierge, or boutique, care in smaller, more intimate practices. In return for increased access to doctors and unlimited visits, patients pay an annual up-front fee, often $1,500 but climbing at some concierge practices as high as $25,000.
To get herself off the productivity treadmill, Wible created a stripped-down solo practice, a sort of slow medicine. At 280 square feet, her office epitomizes the micro-clinic version of an idealized medical practice for the 99 percent. There is no waiting room. Patients arriving early for an appointment can sit (or nap, as some do) on a couch in the quiet hallway of her building, a former school in a peaceful residential neighborhood in Eugene that’s now home to a wellness center with a wheelchair-accessible saltwater swimming pool and yoga studio and a few carefully chosen doctor’s offices.
To drown out conversations on the other side of the door, she runs a white-noise machine in the hallway. Images of a brunette woman cut from a magazine adorn a reversible sign that hangs on her office door that says either: shhhh … quiet please doctor in session or the doctor is out please call again and displays her phone number. Wible jokingly refers to this as her “laminated secretary”. She cleans the office herself and takes turns cleaning the bathroom she shares with the doctor and midwife in the office next door. By keeping operating expenses to about $10,000 a year, she can run a profitable clinic (in fact, she personally earns more than at her last group practice), even typically seeing fewer patients in a week than she formerly did in a single day.The office has two rooms separated by a six-foot-high pony wall. She greets patients in the outer room, which is furnished with a futon couch bearing overstuffed pillows. She sits across from them in a wicker chair. A laptop computer rests close at hand atop a three-basket wicker side table. She can quickly call up a patient’s history on her screen and typically takes a few notes while chatting with a patient. The space is intended to evoke a comfortable living room. The back room has a scale and an examining table and a side table topped with a Zenlike design she made herself: a mosaic tile inlay of a spiral path.
“Most people don’t even make it into the exam room,” she says. “There is something kind of odd about always putting patients on an exam table and the doctor is either standing over them or sitting under them. You’re never at eye level.” When patients do go to the back room, they find the exam table covered by cloth, not the latest yank on a thin paper roll, and they’re offered cloth gowns, not paper gowns, to change into. Wible washes the used items at home.
Her office hours are Mondays, Wednesdays and Fridays from 1 p.m. to 6 p.m., but she also sees patients at other times and in other places. Occasionally she makes a house call. She once examined a patient’s finger at a Department of Motor Vehicles office to make sure a wound was healing properly. He called; she was headed to renew her driver’s license and knew the patient lived near the DMV, so she suggested they meet there. He needed to transfer his car title, so he was thrilled by her suggestion. When Wible finished the exam, he reached into his wallet and paid her $50, telling everyone in earshot: “This is a great doctor.”
Pamela Wible is a practicing family doctor today only because she created her own desperately needed cure. In the fall of 2004, Wible slept through her 37th birthday. She’d become so depressed that she didn’t really care if her eyes reopened to see the next sunrise. Born into a family of physicians, Wible had dreamed of becoming a doctor since she was a little girl.
Her self-diagnosis wasn’t difficult. The irony only increased her depression. For it was her very profession, Wible knew, that sapped her spirit and left her so disconsolate after 10 years of working in one assembly-line, big-box clinic after another. In the best of those jobs, Wible was responsible for 2,000 patients. She generally had 15 minutes per patient, including paperwork. “This,” she says, “is like having 35 children and trying to remember who goes to what school and which one has the red toothbrush.”
What finally got her out of bed after six weeks was an inchoate vision of a more satisfying way to practice family medicine. What if ordinary people across America joined together to dream up an ideal health-care system, not designed by experts, lobbyists or politicians? And what if she brought a portion of that dream to life? All revolutions, she realized, start with a dream.
The first thing Wible did was call the local paper and announce her intention of holding town meetings, inviting residents of Eugene to help her create her new practice around their needs. She held nine meetings over six weeks in downtown cafés, private homes and the community rooms of local organizations and paid close attention to what people said and wrote on the questionnaires she passed out. People wanted comfortable furniture. No counters separating people from people. They didn’t want to have to wait days for an appointment. They wanted their doctor to be open to alternative therapies. The nearly 100 pages of written “testimony,” which included floor-plan suggestions, also expressed this yearning: “The doctor knows everyone by their first name and knows the patients in a social context.”
Though she didn’t know it at the time she first threw open her office door in spring 2005, Wible was in the vanguard of a movement pioneered in 2001 in Rochester, New York, by Dr. L. Gordon Moore with some grant funding and the assistance of the former head of practice redesign at the Institute for Healthcare Improvement, Dartmouth Medical School Professor John Wasson, M.D. Wasson believes the established model, which aggregates doctors in group practices, transforms physicians into factory workers and patients into assembly-line goods. To rehumanize the doctor-patient relationship, he points paradoxically to cold, hard business metrics, citing the national average for overhead at traditional group practices at 60 percent of revenues and blaming that for untenable patient loads. “If you reduce it to 30 percent,” he says, “you can spend more time with patients. And good things happen.”
With the emphasis on unhurried, personalized care and same-day appointments, there’s a Marcus Welby, M.D. feel to idealized medical practices. But there’s nothing old-fashioned about computerized billing, online scheduling of consultations or visits by email and Skype. Some doctors shrink their costs by going absolutely solo, like Wible. Others prefer to practice with a like-minded partner. About a year into his pioneering practice, Moore added a nurse. “I wanted to start doing group visits for diabetes,” he says. “And it morphed into her coming on almost full time with me as a health coach supporting people in the management of lifestyle and behavioral change.”
How many family doctors are breaking ranks by shifting to new kinds of practices? The nonprofit Idealized Medical Practice (IMP) group, which grew out of the groundbreaking work that doctors Moore and Wasson did for the Institute for Healthcare Improvement, claims 500 members on its website. Moore believes as many as 1,000 American family doctors may be practicing medicine in smaller, slower-paced and far less institutional offices and spending much more time with far fewer patients. If that’s the number, it represents only about 1.5 percent of the 66,000 practicing family doctors in the American Academy of Family Physicians. But it’s a start.
Who are these doctors? No one really knows, not even the IMP, which hasn’t yet surveyed its members to learn their genders and ages and prior years working in group practices. But Dr. Amy Solomon, who runs a small practice in a town of 5,000 in the mountains above Santa Cruz, exemplifies one recurring theme: doctors switching to totally different practices after having work experience elsewhere rather than opening such a practice from scratch.
Before she hung her shingle at Balance Health of Ben Lomond, in a Silicon Valley bedroom community of 5,000, Solomon spent a few days standing outside a busy supermarket, chatting with locals and handing out questionnaires that asked, What’s important to you? What would you like to see in a clinic designed for you? What services would you pay for? What little things might improve the clinic for all?
The feedback, plus her own vision, produced a doctor’s office that is anything but institutional. The receptionist offers coffee and chats with patients. There’s an office dog. “New patients walk in and are blown away by how relaxed and beautiful the office is,” says Solomon. “It’s not fancy, but people feel comfortable. It’s serene. Some patients like to eat their lunch here.”
Those who expressed a desire to barter for their medical services on the questionnaires have been pleased. “Today, I got paid in homemade jewelry,” Solomon says. “My son’s bar mitzvah cake was made on trade. The handyman for our home and the office has no insurance. This helps him out. Without the questionnaires, I don’t know if I would have appreciated the need for barter being as great as it is. At my former practice, I was insulated from the people who weren’t getting care.”
Her former practice had 30 physicians and she typically saw 13 or 14 patients a day, fewer than her colleagues because she refused to “hit the productivity goals.” At her new practice, she actually sees more patients a day, sometimes as many as 20, a rarity for doctors creating idealized medical practices. But that’s because everything runs much more efficiently. Because she doesn’t like doing the “grunt work,” Solomon operates with more staff than most idealized medical practitioners. She employs a medical assistant, a nurse practitioner with a medical assistant, two front-office workers, and even a teenager who works part-time “because I think teenagers are innovative. They look at things differently than I do.”
“My patients will tell you how much better I look and how much happier I am,” she says. “I’ve taken more vacations in the three years I’ve been gone than in the previous 12 years where I used to work.”
Dr. Sunil Pai heads a very different kind of clinic, in Albuquerque, New Mexico. He employs two receptionists, a lifestyle director and an aesthetician. The 3,600-square-foot facility has a clinic side and a lifestyle side, which includes a yoga room, which recently filled for a showing of the diet and disease movie Forks Over Knives. Pai, who studied alternative medicine in India after his medical training in the U.S., makes many of the nutritional products and supplements and skin-care products he recommends and prescribes. In August, he’ll move to a 10,000-square-foot facility that will include an organic vegan restaurant, juice bar and coffee shop. They’re potential profit centers but also entrepreneurial headaches he says he’d prefer not have to deal with, but he considers them necessary in a location currently lacking healthy alternatives for his patients.
Although he’s got 2,500 people on his rolls, many come solely for dietary consultations. Pai is currently the primary care physician for about 1,000 patients. He works 9 a.m. to 5 p.m., six days a week. “I know of family practices here where the doctors see as many as 30 to 40 patients a day,” says Pai. “I see a maximum of four or five.” An initial visit lasts about two hours and costs $300. Follow-up visits cost $62 for 15 minutes and $125 for a half hour, the typical length of most visits. “I provide a lot of information,” he says. “Many patients bring tape recorders.”
“It’s kind of odd when a cardiologist is telling someone to quit smoking and lose weight and they’re eating a cheeseburger and smoking during their lunch break,” he says. “You really have to practice what you preach. Over time I’ve become healthier and healthier. I share my lifestyle changes with my patients. Tell them what I struggle with. Tell them they have to invest in their health every day. Insurance doesn’t do that. It just means that some of your bill will be paid. We want to ensure that people really take control of their health care.” To help embed his advice on healthy eating, Pai sometimes accompanies patients to the supermarket to help them optimally fill their cart.
Wible has six patients scheduled on a recent afternoon. Instead of a white coat with her name stitched on the pocket, she is wearing a long-sleeved brown top and blue jeans. No stethoscope loops around the nape of her neck. Her strawberry blonde hair descends to her shoulders in untamed curls. Patients consider her a friend who is also their doctor. Her questions deliberately go way beyond aches and pains.
So notes one of today’s patients, a middle-aged occupational nurse named Sheri, who’s come for a blood-pressure and weight check. Sheri wears no makeup, her brown hair in bangs, and speaks frankly. “Does your doctor want to know anything more than just your physical body?” she says. “Pamela will ask, ‘What do you think is standing in the way of getting where you want to be?’ She wants to know about your aspirations.” Small details matter. Patients who precede Wible into the examining room to disrobe often find a wrapped chocolate awaiting them on the exam table. Today, on one of her periodic patient appreciation days, Wible has brought in a batch of helium balloons to hand out.
Arun, a 61-year-old publisher who first met Wible at one of her practice-defining community meetings, walks in carrying a bicycle helmet. Asked if he has gotten what he and others wanted, Arun replies, “Yes, definitely. As you can see, we’ve become friends, which is what a doctor needs to be. It shouldn’t be like I’m the boss and you’re the patient. If you don’t trust them, you’re not going to follow their advice. Pamela rewards good living style. When you bicycle to see her, she gives you a little gift.” Today, he selects a book from the basket.
The most loquacious patient of the day is the one who’s come all the way from Newport. John, the onetime landscaper and baker disabled by severe arthritis in his right foot, also has a family history of high blood pressure and heart disease. It bothers him not in the slightest that Wible does not take Medicare and he has to pay for his visits out of pocket. After a big welcoming hug, she gets a balloon from the back room and hands it to him. John laughs.
“Before we go into the other room and do your physical, what’s on your mind today?” she asks.
“With my arthritis, I’ve really been trying to watch my diet,” says John. “I’ve really tried to eliminate the inflammatories you told me about—wheat, tomatoes, potatoes.”
“Did I give you the recipe for the soup?” she asks, handing him a sheet of paper headed Doc Wible’s Medicinal Dal Soup. “You wouldn’t put the tomatoes in, but you could use the rest of it. You’ll find it will help keep your turmeric, cumin and ginger levels up. I sometimes drink the broth as a tea.”
“You come in here, she gives you a smile. She gives you a gift. You feel like she really cares about you, and you know she does. That makes such a big, big difference,” says John, who uses the word “accountant” to describe other doctors he’s known. “Pamela’s like a friend. She’s known me for years.”
Many visits ago, when John’s blood pressure was higher than normal and he expressed his desire to stay active and volunteer and maybe even have a woman friend, Wible wrote him two prescriptions. The first was for a small dose of a beta-blocker for his high blood pressure and anxiety. The second bore these words: “John is a great guy. He needs a wonderful woman in his life. I highly recommend him.”
“Different things help motivate you through life,” says John. “You have your physical well-being and your emotional well-being and your spiritual well-being. I come here and I get all three.”