Why I opted out. My decision not to wait for a healthcare fix.

Early in my medical training I envisioned myself as an old-fashioned family doctor. Marcus Welby, MD was well before my time, but he seemed like a good fictional role model for a naive student-doctor. (Especially considering Dr. Cox of Scrubs was my alternate choice.) After finishing my primary classroom studies, I was eager to leave the stacks of paper behind and to learn from real clinicians caring for real people. After donning my short white coat (sans leisure suit), I quickly realized my romanticized vision didn’t mesh with my new reality.

As I advanced through medical school and into my Family Medicine residency, I was increasingly exposed to the “inner workings” of health care. Behind the scenes I saw much of the doctors’ time spent on issues other than patients’ health. Seemingly, the documentation about what they did took more time that what they actually did. My mentors frequently vented behind a mountain of charts about the decline of their profession. (Maybe the TV show just failed to show Dr. Welby filling out 5 pages of paperwork after he treated a simple sprained ankle?)

Hospital and clinic staffs consisted of small armies of people to do coding, billing, following up on denied claims, prior-authorizations and on and on. To financially support this administrative structure, the doctor(s) would take on more patients. The average primary care physician is now responsible for 2500-3500 people! I was frequently told “efficient” doctors could handle double and triple booked schedules - and it would be required to keep a private practice afloat. Unfortunately, this efficient pace allowed very little time to answer patient questions, educate about chronic diseases, calm somebody’s fears or listen to a patient’s bad joke.

During my training patients would frequently tell me about frustrations with their health care experience. While most people personally liked their physician, many felt disconnected and fed-up with the complexities of basic communication. After hearing the same stories again and again, I started to feel sympathetic towards these complaints. Despite our hard work and good intentions, medical practices often treated patients merely as vessels for billing codes. Doctors seemed to be unwittingly insulating themselves from the very people whom they committed to providing care. And this sympathy was directed towards the fortunate insured people with so-called ‘access’.

Don’t get me wrong, I met numerous amazing, compassionate physicians whom cared deeply for their patients. From my perspective, the doctors and patients were both losing in this system. I increasingly asked my colleagues, “Why do we do it this way?”, “Wouldn’t it be more efficient if . . .” and other annoying questions. Usually my inquiries were met with puzzling stares and flippant answers such as, “Because this is just the way it’s done.” Despite everyone agreeing that the system “sucked”, all parties seemed miserably complacent.

Sure, many doctors were passionate about “reform” and had wide-ranging opinions about political fixes to our problems. I was encouraged to join (give money to) organizations, write representatives, march in the street, wish on birthday candles, etc., etc. But why should anyone be hopeful that such advocacy will be productive? Over the past 40 years, our country’s health care has been reformed by numerous rounds of bureaucratic acronyms - only to have the Gordian knot become increasingly tangled. A perpetual Groundhog Day was not my idea of a fulfilling career.

While people hold their breath about the fate of the Affordable Care Act, I remain skeptical about any topdown solutions to our conundrum. I am not waiting for another round of regulatory tweaking to improve the value, access and quality of my professional services. We all deserve better, but we are not going to get it without some disruptive innovation from the grassroots. I believe doctors and patients can and should return to a direct, cooperative relationship for most health care issues. Maybe physicians never have been the caricatures from the golden days of television, but I’m happily and stubbornly naive. Something has been lost and we should fight to get it back again.

“Dr. Neu” is the physician and owner of NeuCare Family Medicine; a Direct Primary Care practice. He is a board-certified Family Physician (American Board of Family Medicine) and Fellow-candidate in Wilderness Medicine.

For more information about NeuCare, visit them online or Facebook.

NeuCare Family Medicine is a paid sponsor and advertisor of Wellcommons.com and Lawrencemarketplace.com

Tagged: obamacare, direct primary care, NeuCare, health care, reform, affordable care act


Brenda Brown 5 years, 11 months ago

I met Ryan a few months ago. He, his wife Andi, and the staff are such warm and caring people. Lawrence is lucky that they chose Lawrence to open their practice. Thanks Dr. Neu!

daboyd01 5 years, 11 months ago

I work with Andi and shes the most upbeat positive caring person I know.. I just love being around her. Her personality is contagious and that's the kind of people I love being around. She and Ryan are a awesome couple and very caring.. we need more Dr.'s like Ryan that love what they do and truly care about the patient and is willingly to find the problem and fix it and not band-aid it with medicine. Thanks for all you do! Keep up the good work.Iknow you'll be saying 1,000 patients and counting real soon.. :p (and I expect to get a call for being your secretary) teehee

chicago95 5 years, 11 months ago

Put aside efficiency for a moment and consider effectiveness. The health care industry resisted adopting or adapting available technologies for the storage, analysis and synthesis of medical records for at least 30 years (undoubtedly to defend the "medicine is as much art as science" shibboleth.) As a result, the only data widely available for quality measurement was insurance data. The National Center for Quality Assurance (a private certifying organization) depended on this information for decades because of the expense of sending nurses into doctors' offices to locate and decipher paper medical charts. Payors (typically employers, also the US Government) seeking any objective measure of value for the services that they purchased, used what they could find. If doctors had earlier supported data that supported science, we wouldn't be as dependent as we are today on the accountants.

Ryan Neuhofel 5 years, 11 months ago

I would totally agree that the health care industry has been slow to adopt technology. I can remember working on electronic medical records in the late 2000s that resembled MS-DOS in design and functionality. However, to defend my physician brethern I would note that most of the computer systems that has been "pushed" upon us has been designed to serve the needs of third-parties (public and private payors, research entities, etc.). Doctors and patients are an afterthought in nearly all electronic systems - and rarely do anything to improve clinical efficiency or quality of care. I'm all for evidence-based medicine (in fact I have an MPH), but I don't think a lack of data-mining can explain the mess we're in.

chicago95 5 years, 11 months ago

It's a Catch-22. Systems only improve by getting used. If potential adoptors sit on the sidelines until the offerings are near-perfect -- and let's face it, there are myriad excuses not to act -- then innovation stops. It is a lot to ask a small practice to take on a new burden with uncertain consequences, but most of the major associations except for one that I know of -- the American Association of Family Physicans -- were on the wrong side of this issue for years. There are many ways to balance risk. (Medicare's recent financial incentives for "meaningful use" seem to tipping that balance. What does that tell us?) Rather than focus on the past or try to place blame, though, I think it is appropriate to ask how technology (including social networks) can transform the doctor-patient relationship. In my view, this takes us far from Marcus Welby. I like patient-centered medical homes and patient controled health record trusts (all of which could be implemented with far less bureaucracy than we will eventually get.) I am interested in your views. Also, please describe how your philosophy of practice (which might carry its own danger of devolving into concierge medicine) enables you and your patients to take advantage of computer-assisted clinical decision-making. (Drug interaction alerts -- even for prescriptions that your patients forget to tell you about -- are one easy example.)

Ryan Neuhofel 5 years, 11 months ago

The technology needed to improve health care already exists and we use it in nearly every other aspect of our lives. The vast majority of the technology innovation and incentive programs (including Meaningful Use) are designed to serve third-parties needs (primarily financial entities). As they control the monies, it only makes sense. Yes, many doctors jumped through hoops last year to get an extra $44k, but will it improve health care at the ground level? I doubt it. In fact, I fear the Meaningful Use program stalled the innovation of true patient-centered systems.

I want to meet people on their own turf and where they are comfortable. We communicate with patients like they are friends and family - email, Facebook, mobile phone, etc. It only improves my opportunities for education, follow-up, etc. Yes, I understand the societal fear of becoming electronic zombies, but it can be used as a tool (and not a substitute) to improve relationships. I think Marcus Welby would've had a sweet ass Facebook page if it existed! Many of my patients aren't tech-savvy and choose not to communicate with us via the interwebs - and that's okay too.

The term "patient-centered" gets thrown around a lot these days and I generally agree with most of it's objectives (the PCMH project). However, third-party money managers are inherently NOT "patient-centered" and they are ultimately whom insurance-based doctors work for. Case in point: Accountable Care Organizations. ACOs are just a re-dressed version of the HMO.

"Concierge" is a very vague term and hasn't taken so many different forms, so it's difficult to even talk about it as a singular type of practice. I hope to provide a "concierge" level of service and have every incentive to make it as accessible (affordable) as possible.

chicago95 5 years, 11 months ago

Thanks for your detailed reply. I don't quite agree, but we can leave it there.

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