Friday, March 19, 2010

A canary in the coal mine

It's been another year and I'm just getting back to this dusty blog which has been on the backburner. To make a long story short, a lot of changes in circumstances have occurred since I last wrote here.
  1. My practice has been altered to adjust for changes in my personal life (new addition to the family!). I'm still practicing 3 days a week and 2 of those days I'm working for a child abuse assessment center as its medical director. I'm doing evening clinics now so I can spend one day a week being available to do errands and life-important things in the daytime.
  2. For the past year, I've been secretly (it's no secret now) working on a soon-to-be released open source electronic medical record, programmed in PHP, MYSQL, and works under the Apache web server system. I've gotten so fed up with the recent changes with my existing electronic medical record system Amazing Charts. I'm making constant changes and additions for myself, that finally I said to myself, "What the heck?! I've got to re-invent the wheel because the wheel is broken!!" I then starting looking into using OpenEMR but again, I came across the problem of a broken foundation - just didn't fit the needs of my practice and what I think most doctors and other health professionals really feel would be user friendly; I said to myself again, "Another broken wheel, might as well re-invent another one." So, here I am, announcing that my stubborn, perfectionist attitude has, yet again, resulted in the birth of a new monstrous creation. My first creation, if you didn't catch it was my solo practice, much sooner than I anticipated to have done in my lifetime.
  3. Sooner or later, it was going to happen, and it happened this year; my computer server failed and I eventually migrated to Ubuntu Linux for my new quad-core server and mostly ditching Microsoft for good. I couldn't tell you how many times I've had to deal with corrupt registries, frequent unexplained freezes resulting in numerous reboots, and crazy stuff like daylight savings time stupidness. Besides, Microsoft Windows 2000, the most stable (I think) of the Microsoft operating systems, is no longer supported by Microsoft anymore, uh, like 3 years ago... Oh, and being a geek for building my computers from scratch, I finally bit the bullet and got a pre-configured system only to find out I can't buy one at a big-box store because Windows Vista was being retired for the transition to Windows 7; so I ended up having to go underground to find a system that had Vista so I could just wipe it out to put on Ubuntu. Sheech...
  4. Health Care Reform - or more like, Health Insurance Reform, only that the reform doesn't mean anything for another 3 years, and we still have millions of uninsured despite the reform, and well, "what kind of reform are we talking about" reform? Sounds like the storyline to the Wizard of Oz to me too...
So on the subject of reform, I have waited and watched to see the events unfold only to see that the health insurance and pharmaceutical industry is going to do very well after all that is said and done. If you read my other postings, you know where I stand about this. And my concerns about my specific specialty, my profession, continue to go on. I got to watch Michael Moore's Sicko a few weeks ago (a couple of years since it's initial release) and it's just sobering how far away we are from reaching any kind of meaningful consensus that health care is a right for everyone. It's so sad that other industrialized nations and some third-world countries already figured this out and we are so behind. In some ways, living in Portland, Oregon has insulated me because there are a lot of like-minded people who feel the same way I do; however, I'm reminded every now and then that the rest of the country is living in fear and paralyzed by the threats of socialism, evoking and inflaming racial and social class tensions.

So as I see the end result of this reform in the short term; I see that my ability to sustain my practice in it's current form will come to an end. There has been no effort to change in the bills to address the reimbursement formula to increase pay for primary care physicians which will continue the hemorrhaging of prospective, highly qualified, medical students into the field. I see no immediate change in the bill that will address the byzantine and labyrinthine billing/prior authorizations/pre-existing conditions/eligibility procedures for all these different companies with different contact information. In fact, it appears with the entrenchment of the insurance companies in this current reform, not only do I not see this changing dramatically anytime soon (I fear, not in my lifetime), I see a very distinct possibility that things will get much, much worse.

I recently read an opinion by Dr. James Kibbe, MD, MBA who had expressed concern about some of the problems with enticing doctors to adopt EMRs without address the foundational problems of the current US system. I wholeheartedly agree - our foundation that we stand on is the wrong approach, unsustainable, unethical, and an anathema to common decency. Insult upon injury, it also is punitive to doctors who are trying to do the right thing and we are now further pushed to go into a system that rewards profits over care, rewards being a production man machine (NOT a doctor) feeding the ravenous insurance-drug-procedure industrial complex.

Furthermore, Dr. Kibbe coined the concept of some of these smaller/solo doctors as the canaries in the coal mine. As a solo family practice doc in a low-overhead model where I get exposure to all of these different aspects of navigating the health-care maze; I instantly understood what he meant. Of course, I wouldn't be writing all these concerns in this blog had I not experienced first hand what it was all about. And now, as the canary seeing a dark end of a tunnel that goes nowhere and meaning certain death, I am now making a critical decision so that I can try to survive; knowing that the direction of this country's health care policy is veering towards certain destruction. It's never an easy decision; it's always nice to have everything you want and in the idealized way. Certain dreams have to be laid to rest until another day. It's just that sometimes each one of us has to decide when to step off that moving train going towards a cliff.

Just as we all hope that someone else will solve our problems; once again, I am destined to solve these problems my own way. Just like when change happens in the grassroots, at the local level, I will need to make changes both personally and from where I can influence own practice. I can no longer wait for salvation.

Just to add my icing to my depression cake, I would like to point out a new film made by a young emergency room doc called "The Vanishing Oath" which talks about the tolls and tribulations of primary care physicians and where it all comes from. The "why" highlighted in the film is not so surprising if you have followed my's all the same stuff. The "where do we go from here" remains, unfortunately, unanswered; I think we're just skimming the surface.

So, in my next post, I will talk more about my plans for change in my practice...