Every few years I experience the impulse to communicate with my patients about matters of general interest. It has struck again. I know that a number of you have read my letters to the Capital-Journal, but those are only accidentally connected to my practice of medicine. This letter is for all of you, as doctor to patients.
But it is also (and I hope you can feel this from its tone) from a doctor to his friends. I have often mentioned to my wife how much I enjoy my practice, because I serve so many interesting people whom I genuinely like. You have made my life full and fun. Thanks for your patronage, and your personalities. Some of you are real corkers.
There has been a rumor that I’m considering retirement. What?! I’m in the prime of life, and working with you folks is a good part of my social life. I would do this for entertainment, even if I didn’t have 3 kids to get through college.
The direction of this practice: where we’ve been, where we’re going: When we opened this office in 1986, I had spent the previous six years in the Stormont-Vail emergency room. I was fed up with treating catastrophes. My interest, personally and professionally, had always run toward preventive medicine, as opposed to breakdown maintenance. But when I arrived in Topeka in 1980, I spent so much time getting Cair Paravel School off the ground I just couldn’t spend the time which a practice demanded. Hence the detour into emergency medicine.
In 1982 Dr. Laccheo and I had visited the famed Cooper Clinic in Dallas, Texas, and were inspired to follow the practice model of the man who popularized the importance of aerobics. But we didn’t want to charge the $1500 he did for a good physical. I don’t think I have much originality; my gift seems to be copying somebody else’s good idea, only cheaper. Cair Paravel was like that: it was modeled after Stony Brook, a classical Christian college prep school on Long Island, but for one-third the cost. I thought I could do a Cooper Clinic physical at 80% off, deleting only the least cost-effective items. I think we have succeeded, and to this day our database physicals are the most valuable service I provide. That’s where we find the catastrophes waiting to happen.
However, the old “yearly physical” is a waste of money. That’s why we recommend complete physicals only every 5 years from age 40 to 50, and every 2 years thereafter. We’ll continue to send you reminders at the appropriate intervals. But if you’ve been ignoring them, don’t!
The practice of family medicine changes with science and society. The most significant change in the last decade has been the fattening of Americans. Never in the recorded history of the world have so many people gotten so fat so fast. With those added pounds have come an epidemic of adult-onset diabetes, high blood pressure, high cholesterol, sleep apnea, snoring, fatigue, arthritis, gallbladder disease, and acid reflux.
As I pointed out in a recent letter to the Capital-Journal, obesity is the engine driving the locomotive of health care inflation. The “greedy” drug companies have (thank God) plowed so much of their profit into research and development that we now have wonderful new pills targeting these problems with greater effectiveness and precision than ever before; and when the pills fail, the surgeon is waiting. But the cost of technology to overcome our bad habits is truly shocking, and we have only ourselves to blame. It’s not the drug companies, folks. It’s our eating and exercise habits.
Most of you know that I don’t believe in sugar-coating problems. I try to be straight with you. I hope you also find me non-judgmental and supportive, although it is a difficult balancing act to pull off. The truth is that I do not think Americans are morally worse than our grandparents. It’s the culture. Really! We’re the most productive people on earth-- up to 50% more productive than the Germans and Japanese, who are a distant second and third. We take one-third the vacation time of the French. We work very hard, and we’re very busy. Whole industries have sprung up to meet the needs of busy people, including fast food, snack food, fizzy beverages, and chain restaurants. The average American eats 22% of his or her meals at restaurants, but those meals supply 38% of the calories! And these things, when they replace home-cooked meals and hand-packed lunch boxes (remember the lunch box?), and when car trips to the Wanamaker corridor replace walks to the corner grocery, and when gym class is replaced by-- wait. What does replace gym class? Few high school seniors in Shawnee County attend school more than half days, so it can’t be academics; maybe it’s bad choices by school boards.
The solution to this cultural crisis will not be as easy as hounding the poor smokers out-of-doors and suing the bejabbers out of tobacco companies. Restaurants and Frito-Lay are less inviting targets; maybe Hill’s could branch into health snacks, since our pets presently eat so much better than we do. Fortunately, remedies need not imply less total pleasure. Most of us eat like pigs, shoveling down our food as fast as possible so we can get on with our next compulsion. A Parisian spends 3 hours over dinner consuming less calories (better-tasting calories, too) than I do in 30 minutes at Outback. We need to learn to savor our food, enjoying it more while eating less. And we absolutely have to quit buying the really bad stuff. I remember many years ago when I forced myself to learn to tolerate diet beverages; it took 2 weeks, but it has saved me hundreds of pounds over the last 3 decades.
Here’s where I’m heading: I have often joked with patients that if I could only check them into a military boot camp, I could make them feel better, look better, and be better. I’m only half-joking. Lots of you are headed for a miserable old age-- we’ll keep you alive, all right, between your pension, social security, and Medicare, but you won’t feel like doing the fun things you always dreamed of, and ought to. You won’t be traveling, because you’re too tired and carrying 14 medicines through customs is too risky. You won’t be golfing, because your knees hurt too much to be worth the effort. You won’t be shopping, because edema makes your legs weep when you’re on your feet too long. What you’ll do is sit in a Laz-y-Boy (boy, was that brand well-named!), eat your potato chips, watch soap operas, and wait to die--and if you’re lucky it won’t be long.
Or you could hire a personal trainer for a year, or check into a fat farm for a couple of weeks. That will set you back $5000, and might be worth it. After all, we live in a society where ordinary middle-class people take $10,000 cruises to Alaska, buy $30,000 cars, and pay $5,000 to make their boobs bigger or liposuck the cellulite our of their hips-- but if you can’t climb a set of stairs when you’re 68, what would you pay to breathe again?
So I’ve servicemarked a concept called Basic Training. God willin and the crik don’t rise, I’m planning a 12 week boot camp for adults (ages 45-65) who just can’t do it for themselves. The first class will start in April of 2004, and consist of 3 lecture/Q&A sessions, 2 hours each, covering Exercise, Eating, and Disease-- those are the Basics, and in that order. The Truth is short and simple; only the Lies and Myths are complex. Then we will meet for 12 consecutive Saturdays at the Iliff Commons for 2 hours of walking and maintenance work. There will be assignments for every day of that 12 week period. It will be disciplined, enjoyable, and doable-- no matter how out of shape you are.
The cost will be $500, cash on the barrelhead, and I’ll refund $400 if you make every session. It’s worth $500, but I’m not doing it for the money. My self-esteem has suffered because my patients aren’t following my advice, and we all know how important self-esteem is. If this doesn’t work, or maybe even if it does, I may try an “inpatient program” I’ll call The Hollows Ranch (a Canyon Ranch for cheapskates). I promised Frank Henderson I would consider a program where I could lock him up and feed him through the bars. This would be for you, Frank.
Good habits are the framework of a life well-lived, but it takes time to establish a habit. That’s why almost all the resolutions you have ever made have failed. I can establish a set of habits in 12 weeks, and you might be surprised at the results. When I was in my early 40s I was curious to find out if I could re-establish my high school running program, which consisted of two-per-day workouts. Turned out I couldn’t run twice a day-- my joints wouldn’t take the strain. But I substituted Nordic Track workouts and swimming for the second training episode, and ended up running a faster mile at the Sunflower Games than I did at Shawnee Mission East a quarter-century before. I think most of us have no idea what we could do if we set our minds to it. Would you like to find out?
There is an application process for Basic Training, because I don’t want to waste my time or yours. The requirements are outlined on the last page of this letter.
Advances in diagnosis: now available. In January of 2002 we obtained 3 devices which represent a real step forward in office practice. Here’s why.
I’ve already talked about the fattening of America. And yet we have always relied upon the crudest of diagnostic tools, the height-weight chart (or, recently, the Body Mass Index, which is--hoo-hah!--derived directly from the height-weight chart and pretends to be an advance). Problem is, we all know that bone and muscle mass significantly affect our weight; we are concerned not with weight, but with fat. It’s fat, not muscle or bone, that makes you insulin resistant, leading to adult-onset diabetes. It’s fat that turns estrogen into androgen, causing women to grow beards and pimples. From now on, when we weigh you at the office on our professional-quality impedance scale, we will obtain a reliable estimate of your body fat. So when you come back after a year of workouts at the same weight, we’ll know if you’ve really turned fat into muscle, and when you want to know your ideal weight for your body structure, we can give you an intelligent answer.
For many years we’ve known that osteoporosis is a significant risk for post-menopausal women. My reservations about bone-density testing has been twofold: first, the tests were very expensive, and second, no matter what the results I ended up giving the same advice-- exercise, take calcium and vitamin D, and replace estrogen unless there are contraindications. Advances in machines and drugs have changed my mind. We have just leased an inexpensive but reliable bone densitometer, and for $15 the screening is affordable even if insurance won’t pay for it. And Fosamax, though still a hassle to take, is now available in a weekly dosing form, which I think more women will tolerate.
One of the persistent questions in primary care involves blood pressure outside my office. As most of you recognize, some people have “white coat hypertension,” in which their pressures are probably normal most of the time. I don’t wear a white coat, but I still wonder. Now we have an ambulatory blood pressure monitor which you can wear home. It will check your pressure at intervals over a 24 hour period, and give us a much better picture of your control in real life.
Research in primary care: Two years ago 23 of my patients with high cholesterol levels volunteered to participate in a research project of my design. I was struck at the time with the amazing effectiveness of Lipitor, which has since become the best-selling drug in history. Because Lipitor hangs around for days in the body, cholesterol levels change slowly, and many patients are over-controlled on the starting dose, I thought it would be interesting to see if we could save money by weekly dosing.
Turns out we can, at least for many patients. The results of this study were published as a letter in The Journal of the American Medical Association, and then as a brief report in The Journal of Family Practice. This is most unusual for a paper from private practice, but there is no mistaking the importance-- we could be talking about $billions in savings if confirmed by further studies. The Lipid Research Center at St. Luke’s Hospital in Kansas City designed an experiment to investigate the daily variation in cholesterol following weekly dosing in a double-blind, placebo-controlled trial. Unfortunately, I couldn’t find a grant for the $20,000 it would take to maybe save $billions. So I’m grudgingly putting my patients back on daily Lipitor. Oh, well.
America has lots of quiet heroes, including blood donors and those of you who volunteer for research.
How to Make Health Care Affordable for your Family: 1. Make wise choices with health insurance. If your employer offers a good plan, take it. But what if that’s not the case? Don’t panic. Ask yourself an honest question: am I (or my family) at higher or lower risk than the average? Remember that commercial health insurance is not a fair deal for many people. If you are not overweight, don’t smoke, wear your seatbelts, and exercise regularly, some of your premium pays for the bad habits of your neighbors. More of it subsidizes the care of Medicare and Medicaid patients (who don’t pay their fair share for medical services by force of law) and those who fail to pay their medical bills. So buy a catastrophic policy to insulate yourself against financial ruin, and self-insure for the rest. You’ll end up ahead in the long run. If you have an unhealthy lifestyle or existing medical problems, insurance is always a good deal at any price you can afford.
2. Tell me you’re short of money. I write a lot of prescriptions, and drug reps give me a lot of samples. I am in and out of the sample closet all day. For acute problems like infections, I try to give you enough free medicine to more than pay for the cost of the visit. For problems I’m not certain that medicine will help, I try to give you enough to make sure it does before you have to buy it. And for chronic conditions, we can maintain some patients who can’t afford medicine on samples alone.
3. Take care of yourself. Go for a walk outdoors every day, fast enough so that you can’t talk in a complete sentence. Keep it up for 30 minutes. Avoid crowds during the October-March cold and flu season, and get your flu shot every year. If you’re on medicine, take it as directed. Get a good night’s sleep every night. Eat regular meals with lots of fruits and vegetables and limited carbohydrates and trans-fats. Sounds kind of like your mother, doesn’t it?
Breakfast of Champions: My long-standing recommendations: Vitamin C 2000 mg, Vitamin E 400 I.U., 1 good multivitamin, 1 dose of Metamucil or Citrucil, and 1 baby aspirin. Forget everything else in the supplement aisle unless you have an emotional attachment; there’s no evidence anything else works. Just for the record, men: nothing makes your penis longer except losing fat over your pubic bone. Just for the record, women: hormones don’t cause weight gain.
Newborn Home Visits: For some time I have been considering doing first newborn visits in the home. The reason doesn’t have anything to do with quality medical care. Mostly it just sounds like fun, hearkening back to the horse-and-buggy days when my great-grandfather was a family doctor in Cherokee, Kansas.
Home visits don’t make any sense these days because so much of what a doctor offers is dependent upon the facilities of a modern medical office. But we’ve lost something by never seeing our patients in their home.
So if I am serving as both obstetrician and pediatrician, and this sounds like a good deal to you, we’ll back up the first office visit to one month instead of two weeks, and I’ll come by your house on a weekend around a fortnight from the birth. My wife wants to come too, and bring a meal, because that sounds like fun to her.
If you like the idea, just tell my receptionist when you call the office. She’ll schedule your baby for a month, and tell me to call you to arrange a home visit. On the other hand, if this sounds weird or embarrassing or uncomfortable, just come see me in the usual two weeks.
There is no charge for the home visit.
What’s different about the way we run our office: I’ve been interested in medical practice management, as well as medical practice, since I taught in a family medicine residency. In the past few years I have contributed to the literature on this subject (you can find my article on this subject on the Internet: search for American Academy of Family Physicians, then link to Family Practice Management, the Academy’s journal, then to the February 1998 issue), and have read with interest the experience of other FPs. A consensus is developing that a doctor’s practice system may be much more important than knowledge or ability in delivering quality health care.
For example, everyone knows that to delay care puts the patient at risk. We have many patients who transfer to our office because it took them a week to be seen for a cough, or 3 months to schedule a physical. For a long time I wondered how this could be, because it never takes us more than 24 hours to see an acute problem, or two weeks for a routine visit-- and yet from Blue Cross data I know we are the busiest practice in Topeka! The answer is surprisingly simple: we just never let ourselves get behind. Research has revealed the inefficiencies, not to mention the dangers, of not keeping up with the flow of work, and the solution is very painful-- a doctor has to work overtime for months to get caught up, and most are unwilling to dig themselves out of the hole they created. There is only one efficiency associated with procrastination, and that is financial. When you’re booked weeks in advance, you know the money is coming in. When you save appointment slots every day for acute problems, and they aren’t needed, a practice loses revenue. However, our experience has been that the finances always work out okay, and patients get much better care if they can be seen on a timely basis.
Other practices use centralized reservation systems, and pools of telephone secretaries or (worse) automated telephone triage which leave you listening to a slow-talking lady outlining a menu of choices you don’t need. We use a real person, and before long you know her voice and she knows yours. Your chart is less than 10 feet away, a nurse is 15, and I’m no farther than down the hall. We don’t have to be smart to avoid mistakes; we have a superior system, based on something as old-fashioned as personal relationships.
My payroll is double the average family physician’s. There are two reasons for this. I pay my employees well, and that, plus a policy of never missing an important event in the lives of our kids, means my turnover is almost non-existent. Show me a doctor who hires a new head nurse every other year, and I’ll show you a dangerous doctor. Second, I hire RN’s where other doctors scrape by with medical assistants. Most people have no idea how much information gets processed by a busy office every day, and how many decisions we make and implement. Mistakes will be made, but highly trained people make less, and they also catch more of mine. The lesson is that you can’t replace good people in the practice of good medicine, and I never intend to try.
Good medical practice requires layers of review to minimize errors; that’s why, too, I always prefer a local pharmacist to a mail-order prescription house. And don’t forget the important role you play-- we give you a notebook to store important information. Use it to keep track of tests we order, too. Until you get a call or note with results, consider it lost in the system. Call us back if you haven’t heard in a reasonable period..
Charges for missed appointments: We’ve never done it before, despite the fact that when someone cancels within 24 hours of their appointment, or forgets altogether, I’m twiddling my thumbs while the overhead rolls along at $175 per hour. With Americans becoming increasingly frantic, I’m finding that missed visits are more frequent. I hate to do it, but from now on we’ll charge $25 for failure to cancel a routine visit within 24 hours, and $50 for a physical or procedure. It won’t pay for the lost time, but may serve as an incentive to improve organization.We’ll waive the charge for really, really good excuses.
Free services: You’ve probably noticed that when you visit your lawyer or accountant, you get a bill for the time your consultation required, even if it was a phone call. Your dentist charges by the procedure, but the nature of the work makes phone calls unnecessary-- there is no lab work to follow up, and rarely questions that can be answered over the phone. Medical care is unique in that regard. One reason my overhead is so high is that well-paid professionals spend a good part of the day helping you over the phone-- for free! In fact, one of our objects is to keep you out of the office. But there are limits. I have known patients who generated a dozen nursing contacts for every office appointment, but still complained about having to be seen! Others seem to resent routine follow-up visits for chronic problems or infections. When we insist on an office visit, it is because we care about your health; it is also the only way we can generate income. The main reason doctors won’t give you e-mail access is that the medical system hasn’t figured out how to charge for it, and nobody can run a business giving away services. Please be understanding.
Want to enjoy the best sledding in Topeka? My wife and I would love to have you and the kids out to the Iliff Commons on snowy weekends, starting next winter. We have graded a long run down a steep hill through virgin Kansas woods. Send your e-mail address to: email@example.com. Sorry, only e-mail will give us the quick notification you will need.
Are we still taking new patients? Always have, and will for a long time. We are very selective about the insurance plans we join (only Blue Cross and Century this year), and so we lose patients every year because their insurance changes (and when it changes again, we hope they’ll come back). We particularly appreciate referrals from our patients, because you will have already matched your friend’s needs and expectations with the way our office works. Personal recommendations beat choosing your doctor out of the Yellow Pages every time.
Active Vacations: I know lots of people like cruises or beach vacations, because they represent a sure-fire way to completely escape our frantic lives back home. Without alienating the travel industry, let me advocate a different kind of experience which will be better for your health, and will set a better example for your children-- because, as I keep harping, inactivity is killing us.
My favorite vacation is a Colorado dude ranch. There are lots of them, but if you need a recommendation, my family’s favorite is Lost Valley Ranch in Deckers, Colorado. Unfortunately, the valley just burned in the fires of 2002, although the ranch survived. But I go for the horse training, cattle roundups, bushwhacking, and hiking in the surrounding mountains, and that remains even when the pines are gone. Kids, in particular, have a great time. The only problem is that it’s expensive, so we always tried to go in the fall or spring when the rates are more reasonable.
I have also enjoyed skiing, snowshoeing, and hiking in the mountains around Keystone and Breckenridge, so much that I bought a two-bedroom, two-bath condo in the River Run area of Keystone several years ago. It is rented out most of the ski season, but from spring through fall the rentals are erratic and the cost falls dramatically.
Here’s a good deal, if you are interested in a low-budget active family vacation that will leave you healthier than when you left Topeka: You can use my condo during the off season for $500 per week (less than 40% of the standard rate-- since I pay 50% to the rental agency, renting direct to you only costs me 10%, and I get a user I trust) plus a $68 cleaning fee at the end of your stay. You won’t get maid service, but I’ll supply you with a where-to/how-to list of activities to fill up every day, ranging from free (mountain hikes to secluded lakes and century-old log cabins, biking, swimming, sauna, billiards, hot tub, off-roading to old mines on top of a mountain if you have a truck-based 4WD) to cheap (canoeing, kayaking, wall climbing, miniature golfing, sailing, mountain biking, horseback riding) to pricey (river rafting, golf, alpine sliding, shopping). River Run has great family dining and fast food, and within Keystone are four of the best restaurants I have ever enjoyed if you happen to be a gourmet. The kitchen of the condo is fully equipped for cooking and eating in. For simplicity, all rentals will be Sunday-in, Sunday-out. Call me at home (357-1854) if you would like to check dates for a reservation.
If attitude isn’t everything, it’s way ahead of whatever comes in second: I grew up in the Episcopal Church, reciting The General Thanksgiving every Sunday (written by English reformer and martyr Thomas Cranmer nearly five centuries ago). I don’t think it affected me much as a kid, but it sure does now. Try this once a day, and see if your attitude improves: Almighty God, Father of all mercies, We thine unworthy servants do give thee most humble and hearty thanks For all thy goodness and lovingkindness To us, and to all men; We bless thee for our creation, preservation, and all the blessings of this life; But above all for thine inestimable love in the redemption of the world by our Lord Jesus Christ; For the means of grace, And for the hope of glory. And, we beseech thee, give us that due sense of all thy mercies, That our hearts may be unfeignedly thankful, And that we show forth thy praise Not only with our lips but in our lives; By giving up ourselves to thy service, and by walking before thee in holiness and righteousness all our days; through Jesus Christ our Lord, to whom with thee and the Holy Ghost, be all honor and glory, world without end. Amen
Home exercise: I’m not a big fan of gym memberships, because most of us are too busy to use them. The following constitute a complete home gym, if you add a TV set to keep you from going nuts. A treadmill or exercise bike are reasonable substitutions for the Nordic Track or Concept2 rowing machine, but won’t give you upper body work at the same time. Bowflex PowerPro at bowflex.com, $999. Nordic Track Classic Pro at nordictrack.com, $599. Concept2 Model D at concept2.com, $850. Buy these specific models for the best value.
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