Viewpoint: An internist shares his vision for the perfect practice

October 17, 2008

If you want to have time to listen to your patients, to provide the care they need when they need it, and to enjoy your work, this may be the right system for you.

In my view, the current system of health-care delivery doesn't work. Doctors and patients detest rushed visits and the obstacles inherent in obtaining even routine medical care.

Faced with the prospect of seeing a new patient every 15 minutes, carrying a patient panel of 2,500 to 3,000, and entering a call group with weekend coverage reminiscent of residency, I thought about how I'd like my practice to be different. I established these goals: Provide half-hour visits; allow patients to see me the day they call, regardless of the chief complaint; offer unscheduled visits; offer house calls for acute-care problems; provide office, home, and pager numbers so patients can reach me conveniently; keep my practice small enough to keep my sanity and to remain available; and provide nearly continuous coverage for my practice.

I anticipated these obstacles: Insufficient income. Spending more time with patients means seeing fewer each day.Burnout. Continuous availability might become onerous, if ostensibly practical.Unpredictable schedules. Offering same-day appointments might mean long days.

Six hundred patients remained on my panel when I began, and I limited the practice to fewer than 1,000 patients. I offered half-hour visits, same-day appointments, unscheduled appointments for urgent visits, and house calls.

I listed all my phone numbers, guaranteed coverage of my own practice for all but two weekends per month (when another physician with a small practice of his own would cover mine), and hoped for the best.

I required a $12 monthly payment in exchange for the services outlined above, and credit-card verification so I could forgo mailing statements for outstanding balances. Twenty percent of my patients complied, and 20 percent left my practice. When the 60 percent who did not respond came in for appointments, I asked them to consider enrolling; 90 percent of them did, and the rest left.

A typical day begins with hospital rounds at 5:30 a.m. At 6:30, I'm in the office for the first of about 14 half-hour appointments. I see my last patient at 3 p.m. Average visits last 22 minutes, and two patients per day typically cancel, giving me time to answer phones, check labs, complete notes, etc. I answer the phone when not seeing patients, submit billing electronically, and post my own EOBs. My office manager and I speak continuously during the day about the calls she receives. We finish at about 4 p.m.

We use Wednesdays for walk-ins only, and I get billing work done then, spending about three hours per week on it. I make roughly one house call per week.

I get about two phone calls at home per week. The number is low because I carry a patient panel of 750 at this point, and patients know they can see me the day they call. For the same reason, we have relatively few calls in the office.

The EMR (eClinicalWorks, in which I have no financial interest) allows printed and faxed prescriptions, and provides instant access to patient charts, so I can handle phone-call requests from patients, pharmacists, and other providers immediately. I'm also able to access charts at home via a remote desktop.

Patient feedback has been positive, with most comments addressing ease of access, length of appointments, and continuity of care. This type of practice represents a return to the days when doctors were simply available. If you want to have time to listen to your patients, to provide the care they need when they need it, and to enjoy your work, it may be the right system for you.

The opinions expressed in The Way I See It do not represent the views of Medical Economics. Do you have an experience you'd like to share with our readers? Submit your writing for consideration to manuscripts@advanstar.com
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