The chronicle of a lonely do-gooder family doctor who survived.

Monday, February 23, 2009

10 Things I Love About Community Health

Well, it's been about a month in the new job and I'm still finding my feet a bit. New hospital, new patients, new computer system, new staff. It's about as disorienting as moving to a foreign country where you don't speak the language. You know what you've got to get done, you just have no idea how to do it. But people have been very helpful, and it's coming along faster than I thought. Today was my first day rounding at the hospital with the residents, which introduces a whole other dimension of complexity to the job, but it was fine.

So far, it's really lived up to my hopes and the contrast with the "normal," insurance-funded system of health care has been stark. I have no idea why I stayed away from community health for so long. Every day when I make the seven block walk home, it gives me pause to reflect upon all the things I'm loving about this job.

1. The patients.

It's a community health center; its mission is to see people who otherwise have no access to health care. You'd think the patients here would bring in a truck load of unfixable problems that have been neglected for years (and certainly there are a few of those), but for the most part the patients are really focused on their one or two big problems, they want to get better quickly, and they are extremely grateful for the care they receive.
Contrast this to my previous practice, where patients were paying through their noses for access to a doctor whom they viewed as an agent of an inherently unfair system. The average patient in B-town would postpone care, store up a laundry list of problems for their visit, and then expect the doctor to do all of the work taking care of them. Isn't that what they're supposed to be getting for their $1000 a month premium?

2. My coworkers.
Everyone I interact with, from doctors, to nurses, to social workers, to the janitor chooses to work here, to serve this community, and usually they are making a financial sacrifice to do so. And still getting a job here is competitive. Every day, it is obvious that everyone is thankful to be here. There is nothing like a shared mission from which to draw sustenance and motivation. And because everyone wants to be here, there is a level of competence among the staff that I frankly haven't seen anywhere in health care before.

3. Support services.
In the community health system, there is an acknowledgment that providing effective primary care to a needy population has to involve a whole lot of other disciplines that cross over with medicine: social work, behavioral health, dental care, nutrition, and education. It's incredible to me that, as far as insurance companies are concerned, a 15 minute visit with a doctor is adequate time to tell a patient everything they need to know about diabetes. Or to diagnose their complicated psychiatric problem. Or to counsel them on quitting drugs. Yet this is exactly what I spent the last 7 years in B-town trying to do, having no other place to turn to, or at least no place that my patients would go. On site here, we have social workers, interpreters, a clinical psychologist, psychiatry 2 days a week, a fully staffed dental clinic, a diabetes educator, 2 nutritionists, and several other support services.

4. The expectation that I will push myself beyond my comfort zone.

There's been a lot of times where I've been scared as shit over the last month. Having to deal with stuff I've only read about or haven't seen since residency. Things that would have been referred to a specialist without a second thought when I was in private practice. Complicated office surgeries. Small children with mysterious symptoms that don't add up. Really seriously mentally ill people. For the most part, trying to find a specialist that is willing to see a sick, uninsured patient quickly turns out to be more difficult than figuring out what to do myself. These patients come to me with nowhere else to turn and when I'm able to work through a complex problem, it's a total thrill. A little bit of cowboy medicine right here in Wallingford.

5. Not dealing with insurance paperwork.

Yes, medicaid, medicare, and the state disability program have paperwork, but it is nowhere near as pointless and time consuming as the insurance paperwork used to be. I cannot tell you how many hundreds of hours of my life I spent filling out prior authorization forms for non-preferred meds ("Because doctor, Prilosec makes me feel not right.") or wrangling payment for things that insurance claimed were pre-existing conditions or trying to get a wheelchair into the hands of a little old lady. Insurance companies put up a wall to deny payment for most everything nowadays, and all of that somehow comes back to the primary care doctor's desk. Now I have one set of forms that more or less make medical sense, and they are for important things like food and housing money for the guy who can't work anymore because of his cancer.

6. Delivering babies.

I love delivering babies and doing newborn care. I had planned to do it when I was in training, and did a bunch of extra obstetric rotations in residency before I got sucked into the toxic job from hell. After my first two years in practice, I figured there was no way I would be able to get my skills back, let alone find a hospital that would credential me to deliver babies. Very few family doctors in Washington state are willing to take on the malpractice insurance burden anymore. But it's something that is totally consistent with the philosophy of family-centered medicine and I've always missed it. The community we serve at the new clinic has nowhere to go for obstetric care, and because of the low reimbursement, the hospital and our back-up obstetricians are happy to have us do these deliveries. My partners are so glad to have another person in the rotation and have been extremely supportive in mentoring me through my first dozen or so deliveries.

7. Learning Spanish.

Who hasn't told themselves, "You know, it would be really good for me to become more fluent in Spanish"? With a patient population that is about 50% Spanish speaking, I might finally get beyond "¿Tiene fiebre?"

8. Teaching.

I have two mid-level providers that work with me, a nurse pracitioner and a physician's assistant, who are just great about knowing when to ask questions and refer people to me. In addition, I will be a clinical faculty member for the Family Medicine Residency program at the hospital. I love it when people ask me clinical questions or I'm teaching a new procedure to someone. It reminds me that at this point in my career I actually do know some stuff and it's really neat to help other providers develop new skills.

9. Loan Repayment.

Ok, I haven't officially heard whether this was approved or not (The Washington state government, from which this money flows has an $8 billion budget deficit), and I *did* take a pay cut to work here, but just the fact that this possibility exists is awesome. Last year, I was paying about $1500 a month in student loan repayment and it was going to take me about 25 years to pay it off. Since taking this job, I ramped up my repayment to get me done in ten, and should loan repayment come through, I can do it in five. For a guy who's not sure he's going to be practicing medicine in five years, with a kid on the way, this is huge.

10. Humane work schedule.

In the insurance-funded world of health care, salaries are entirely production-driven. If you're not in the clinic billing patients for your time, no one's getting paid. My old job was 0.8 FTE which meant I was scheduled for 32 hours of patient contact per week, which ensured that I would be in the office for 60 hours a week. For an 80% job.
Because our funding isn't entirely based on patient volume, our clinic acknowledges realistic schedule limits. A full day of seeing patients is pretty long: 10 hours on your feet, face to face with patients, often skipping lunch. Sometimes you're up in the middle of the night on call. Full time here is capped at 28.5 hours of patient contact, 23.5 if you're on call. Schedules are blocked out for meetings and medical education. As a clinic run by family doctors, it is expected that every one be able to go home to their families at a reasonable hour, a revolutionary concept in medicine.

So the job is still new and I keep telling people I'm waiting for the other shoe to drop. Certainly, hours will get longer as I get busier and I'm taking call. But this job leaves me with a sense of satisfaction that I haven't felt in medicine in a long time and I might just be able to stick it out for a few more years.*

*This should not be taken as evidence of any emerging optimism from Dr. Sour Puss. I remain firmly convinced that, in the long run, everything in the world is in a constant downward spiral and that the worst possible scenario is also the most likely one. Furthermore, everything bad that happens to me is someone else' fault and everyone is goddamn idiot except me.

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