Sunday, February 4, 2018

Back to Business

The proverbial "waiting room"

When I was growing up in the 70's : (
... the waiting room was where dad's would wait while babies were being born. 
The stereotypical scene was several dad's pacing back and forth anticipating the
good news.  Now the dreaded waiting room associated with western medicine
is where you wait for hours, read outdated magazines (that sick people have leafed
through) with a sign that says no phone use.  In this culture of immediate reward,
it rubs everyone the wrong way to have to deal with waiting. 

So even before I see anyone in the exam room, an unsatisfactory review is brewing.
One wonder why a doctor would care about reading reviews when they all should be
focused on patient care ....but.... salaries are dependent on satisfaction.  The current
design structure for getting paid by a hospital has efficiency and patient satisfaction
built into the formula (RVU's).   It was started in the early millennium when large hospital
organizations had to be accountable to medical insurance payers to be efficient (and
not order too many expensive tests) but insurance companies also wanted their
clients to get the "best" health care.  One parameter of measurement was patient
satisfaction surveys.  Reviewing wasn't as hot a tool in 2000 as it is now.  Additionally around
1999...there were a still primary care doctors that owned their own medical practice paying
attention to utilities, salaries, billing, malpractice insurance...even answering their own
phones and pagers at night.  (I remember someone paging me at 2am just to say they
couldn't sleep!!!)  With medicare reimbursement decreasing back then about 3% every was only a matter of time before being a small business owner of a medical practice
would cave in to being a salaried employee.

I left medicine totally disgusted in 2005 and moved from Illinois to Florida where I was
going to start over and just be a dad.  The last thing I remember was being told by
administration that the hospital paying my salary was changing and if I didn't get
on board with the new salary structure (less pay more hours because I wasn't producing
the same as other primary care docs in rest of the country) then I should leave.  But in theory I couldn't leave even if I wanted to, there was a restrictive covenant in place that would bar me
from opening my own practice within a 15 mile radius and I would have to pay for a malpractice
insurance "tail" to cover any potential law suits filed against me for the prior 10 yrs.
-most patients don't see primary care docs > 15 minutes from their homes
-tail coverage costs about $10,000-20,000 to be paid all at once
-new malpractice insurance would have cost me $50,000 before I even opened my doors
-electronic medical records were being pushed by the government as an attempt to decrease
paper waste and have efficient doctor to doctor communication (more like doctor to insurance billing efficiency)
-offering medical insurance to future employees as a small business owner was impossible to afford (and still is)

But I had work to pay mortgage, kids education, medical insurance.....(I didn't have medical insurance
for about 2 yrs as I couldn't afford it...prayed every day to stay injury free).  So I signed up to be an immediate care doc.  See patients that I didn't have attachment to, finish work right on time and hand
off the the next doc.  No phone calls middle of the night.  "Treat em and Street em" was the motto.  That was not why I stayed in school until the "21st grade"  (I am now on my 24th grade / year of study).  I was disillusioned from medicine due to the harsh words of an administrator saying that my practice style of medicine didn't make a difference in the community as compared to the national average "I was below average"....until the phone call.

I remember being okay with life in Florida, payed hourly for immediate care coughs colds sutures injuries....then I got a call from an old patient from Illinois.  They were looking for my help as all the docs they were assigned to didn't give many options. He was dying slowly of cancer.  With the acupuncture training I finished before leaving for Florida, I remember designing a few options no one else thought of.  He died eventually but I hope my suggestions gave a small sigh of relief for at least his family.  This is the part of the movie where the hero thinks back in time and pieces together the keys to conquering the the big Boss bad guy.  I re-awakened my core thinking ..."I wasn't below average and all the weird things I invested in -acupuncture, breath, yoga, nutrition, exercise...gave options no other doc was offering.  They made a difference to my old patients who looked across north America for me, they made a difference for me during the time I had no medical insurance, I had to make major lifestyle changes to stay out of the hospital!  So I came back albeit slow, I still worked my way back into private practice (kinda) still holding onto my style of medicine.

So how does this pertain to the waiting room?  I learned from Andy Weil, Herb Benson, Deepak Chopra and Joseph Helms that the answer to the disease manifestation is in the patient.  Getting the answer out will take more than a blood pressure reading, a throat swab or blood testing.  There is a gentle teasing out of information from the human sitting in the exam room with you.  An exam is not just a physical should be a bio, psycho, social, nutritional, educational, introspective  interaction between healer and patient.  Look at the word 'patient'....connoted the need to take time for healing.  Done properly, the time spent in close proximity to a good healer will reveal the most direct path to heal-ing.  When we truncate the time spent in planning out the journey on our path to being disease free, there is more chance for error.  Making a mistake means back tracking and starting again.  This time loop of only inquiring about the biggest symptom and then treating with a temporary medicine till another symptom pops up to be repeated again...doesn't get anyone (doctor or patient closer to "healthy".  In fact this stutter stepping pushes healing farther away and brings chronic suffering into younger ages.  The answer is in the patient, to know the patient inside and out will be the best way an architect can design change, empowering change will beat disease.

This take more than the standard 20 minute visit (15 minutes actually but I have 20 years of experience!!!) so when I run behind by 45+ minutes, it is usually to accommodate for the 20 minute slot given for a "wellness check up" that turned out to be a multi-system, multi-symptom chronic presentation that needs fixing now.  I'm not blaming patients, they don't know that the majority of medical insurance payers are following the state's reimbursement of 49.95 for the most complex of visits (that usually takes about 45-60 minutes of face to face time to listen to plan out and diagnose.  Tag that onto a 6-9 month turn around on payment is a business supposed to survive? Then at the same time I have to make sure service is with a smile or I wont get my "potential" annual salary.  I am not embarrassed to say...I am getting the same salary I was paid during my first years of working for a hospital.  (in 1995)  I have the potential to make what the average primary care doc makes in the US but I would have to see more patient and practice medicine like everyone else...just contributing to the time loop, but I choose not to.

I know my body mind spirit won't tolerate practicing at this pace forever BUT for now:
-I take my salary as is (at least I have a job)
-continue to change lives (check my drricsaguil instagram posts)
-save up some money doing other things (like my youtube channel and maybe an acupuncture clinic on "days off")
-hit the lottery
-vote for change
-opt out of taking medical insurance BUT charge a reasonable fee
-continue to create a sense of calm in the "waiting room" so that patients are actually healing before I walk in to start the healing process.

My faith tells me if I provide the keys for people, the Universe will open the door for both of us.
Guess I have to take a seat in my own waiting room.