Tuesday, January 27, 2015


      My vision of structuring my clinic along the lines of a Direct Primary Care (DPC) practice this month was partly successful. Before describing the changes I've made, I must first give a bit of background. For most of last year, I simply tried to see as many patients as possible each half-day in order to make the quickest progress toward the 1650 patient visits required for graduation. Often, than meant feeling rushed and not fully addressing some of the more peripheral concerns patients would bring up during the course of an encounter. As I reflected on this and became exposed to the DPC model, I came to realize I was practicing sub-optimal medicine, which unfortunately cannot be labeled sub-par because it is the norm in our current third-party payer fee-for-service model.

       This month, however, I've been taking as much time as I feel I need with each patient in order to do a good job, and have resisted the urge to feel rushed at any point or even check how many patients are waiting as I interact with each patient. Sometimes, this has meant spending the better part of an hour with a patient who presents with multiple conditions and complaints.  Fortunately, these visits are often balanced out by quick 5 to 10 minutes encounters, many of which are prenatal visits or well-child checks. My rock-star nursing staff helped me at the few points where I did fall very behind, for example when I did a circumcision in the clinic on a patient who turned out to have mild hypospadias.

       Two crucial recent modifications of my schedule are that I have asked to only be scheduled to see 7 patients per 3.5-hour half-day (which seems to be my sweet spot) and having the first slot of the half-day always double-booked. Only once did one of the two patients scheduled for the first slot have to wait more than 30 minutes; all the other times the first visit was fairly brief or one of the patients did not show up. Though this is not something I plan to do in my own practice, double-booking is a necessary evil given the waiting room wait times and significant time needed for nurses to room each patient in my clinic, neither of which can I change. In my future practice, it will likely take no more than a minute for a patient to be roomed by my nurse (if they are roomed by a nurse at all), and I will likely have a much lower no-show rate, obviating the need for any double-booking.

       A final piece I have made progress on is my and Brandon Alleman's longitudinal project for the year, the Paleo Health Group. I recruited a few patients in the course of my clinic and have started to solidify the structure the meetings will likely take. Brandon and I just discussed our plans with a few attending physicians today at a Research Meeting, and they essentially reinforced our plan. Also, I booked the space for the first meeting and started a GroupMe text messaging group for us to start using in a few months. I was also able to hit two birds with one stone by making this my Practice Management project, which was nice.

      As I peer into February (and early March), I am re-motivated to pursue my goals of 21 intubations, 21 surgeries, 21 French words a day, and 21 blogged cases from my trip to Togo. I will probably type the cases up on my computer and post them all sometime in March, as internet and time will be limited. But we'll see; I'll try to post at least something on this blog while I'm there!

      I'd like to end this post, and every future post this year, with a reminder for you to quantify your goals and put them out there for the world to see, whether it be on a blog, a facebook post, in a small group meeting, or on your front door. In what specific way do you plan to better your life during the month of February? What skill set can you master or project can you complete that will make you healthier, wealthier, happier, or more filled with love? Seriously-- give this some thought. You grow old fast and Old Man Time is not your friend.

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