Thursday, August 4, 2016

How Marcus Welby Can We Be?

I was already a doctor when Marcus Welby, M.D., came onto TV screens.  It wasn't something I would watch. I was busy, it was network TV, it was sappy, it was suburban WASPy Republican without the Beav's charm, and he was a general practitioner (who amazingly seemed to have one patient a week). Even though my grandfather had been a general practitioner before he died of a brain abscess in 1933, my Dad was a neurosurgeon, so in our family specialty trumped general practice. My Dad's distrust of other doctors, like GP's, was such that he said each generation of a family needed at least one doctor, to protect them from the shit that is out there. So for his generation, he was it.
(Many will remember neurosurgeon Ben Casey, which was nearer and dearer to my father's heart.  He enjoyed the lionizing of his specialty, his face lighting up with reflected glory. I think he watched it. I didn't; I was busy in college and med school and didn't have a TV.)
So, my Dad organized our care, either dispensing it himself, or choosing the doctors personally and carefully. When I broke my leg sliding home on an ill-conceived steal attempt, he took me to the hospital and his friend Chuck Kambe operated. When my Mom needed back surgery (twice), my Dad did it personally, saying there was no reason his patients should get better care than his wife. If we were sick he might call in his GP friend Dave Cohen to help, after Dad checked our Babinski reflex to make sure we were neurologically intact (first things first), and Dave gave us our shots, but Dad never really gave up the reins. When I went to a Harvard recommended dermatologist for a skin lesion that wouldn't heal and the dermatologist failed to help me, Dad sat me down with the Medical Letter and we treated it successfully with griseofulvin. I went with him once on a consultation to a community hospital ER, and I said afterwards, didn't the patient really need a neurologist rather than a neurosurgeon? My Dad growled his answer: “What that patient needed was a smart doctor.” QED.
Then I became a pediatrician. Not easily. When my Dad told his colleagues at the hospital lunch table that I had decided to go into pediatrics, they said, “Henry! Those guys work their tails off and they don't make any money! ...Can you talk to him?” They knew where their bread was buttered, for sure.
It took me a long time to become a good pediatrician. I had graduated from a specialty program that had little primary care – actually, nearly all residencies are specialty programs, and the outpatient clinics are models of poor organization – so I didn't know much about practicing, but some of what my Dad taught me probably stuck. I didn't realize it at the time, but my learning to practice took me, inevitably, to the importance of caring for each individual person. I found out that what people wanted was, predictably, Marcus Welby.
They wanted someone who cared for them (preferably only them), someone who was competent, caring, and reliable. And accessible, very accessible. The caring came naturally to me. The rest I had to work on. Thankfully, I had a gift for organization, so the practice became a success.
Marcus Welby functioned well, however, only in the idealized atmosphere of TV and the time when we had so many fewer tools, and so many fewer specialists than we have today. He saw some patients in the hospital, called a specialist at times and dropped into Xray to read the films, I guess, and I think I remember that he showed up at odd times at the family's house. My Dad would approve of that – he said that trust in doctors eroded as soon as doctors no longer shared a cup of coffee at the patient's kitchen table.
Well, those days have been put to rest by the plethora of tests and treatments and specialty care. Modern medicine can do so much more for patients than old-fashioned medicine, that a single doctor can't keep it all in his or her head. There is too much to do to be tooling around town, showing up and kibbitzing. Patients might still want Marcus, and doctors might still want to be his disciples, but to meet these expectations, care has to be organized in a new way.
The question is, how do you do it? How do you organize your practice so that you get Welby-like results in the modern environment, trust and intimacy linked to modern science?
I have to hand it to my fellow pediatricians. I've talked about our American Academy of Pediatrics listserve for the Section on Administration and Practice Management (SOAPM). If my Dad could have seen what goes on on the listserve, how my primary care pediatrician colleagues struggle to do the best possible, to think everything through, he would have been gratified and amazed. So, to illustrate the point I'm making, here are two recent exchanges 0n the listserve about how we are facing the dilemmas of practice.
First, Kerry Fierstein of Long Island:
This weekend, I had one dad call at 10 PM Saturday night needing a camp form filled out before 9AM when they were driving to soccer camp, and at 12:30 AM another dad called for a Lialda Rx because teenage son with UC ran out and they were leaving on a cruise at 7 AM and GI didn't have an emergency number.” These are extreme patient demands, but Kerry accommodated them! Amazing, to me. Part of her thinking apparently was that, as a Patient Centered Medical Home, her practice needs to honor patient needs as much as possible. More on the PCMH below.
Second, from Ashraf Affan of Jacksonville: “Can any one recommend a good pediatric call center that can handle calls during the day to schedule visits, etc, for a fairly large private practice. We are trying to weigh outsourcing the job vs. housing in.” He received many answers from the group, most replying that you have to do it yourself in your practice.
Michael Sachs of Los Angeles told of his experience: "We're about to (reluctantly) go to an auto-attendant and voicemail during office hours for the first time ever. It was either that or hire more people to answer incoming calls, but we don't have the physical space and would prefer not to pay one or two additional salaries. … We're not big enough to use a scheduling center or outsource, but having been on the patient end of scheduling a visit for one of my kids at a local major medical center, it was a time consuming PITA. First talk to an intake person and be told that a nurse would look over the information. Then receive a phone call back a day or two later with the great news that a nurse has approved the visit.....and the same scheduling person I'd spoken to the first time now wanting to know when I'd like the appointment. 'OK, I'll see if that's available and will call you back' Couple of days later, a call back with more great news - that time is available! Now the appointment is scheduled. A few days before the appointment, the same person calls back again to confirm the appointment time. But he doesn't have the appointment time, he asks me when I show the appointment is scheduled. Tell him, he puts me on hold for a few minutes, then returns and confirms that it's the same day and time he shows in his system. Now I'm getting a bit concerned since it seemed that he didn't know WTF he was doing so I called directly, spoke to a receptionist in the physical office, and she confirmed that the day and time were correct. Whew, that was a relief. Total time scheduling and confirming the appointment: at least 30 minutes.”
Suzanne Berman of Crossville, Tennessee offered another alternative: “We have a 'call center' model (although our call center is physically located in our office) staffed with 4 nurses and 1 one receptionist/non-nurse. Going to this model cost us a lot in the beginning, because nurses make 30-40% more/hour than receptionists (on average, YMMV). BUT we found that the nurses could do triage AND scheduling ('yes, that belly pain needs to come right in; no, your bug bite is not a 5:30 PM emergency'). They could also more holistically look at the whole chart and the whole family. Like, they're making an appointment for sib A and they say, 'Hey, I notice Sib B needs a checkup. Are you bringing him with you? OK - wanna do his checkup?"'

This improved our recall/compliance an awful lot. In short, we found it was more cost effective to have nurses evaluate the possibility of 'super-sizing' the visit on the front end (when the patient was pretty much already committed to coming into the office anyway) than using lesser-paid receptionists trying to do recalls post hoc on overdue patients. (I mean, we DO do recalls too, but it's a lot easier to get them in in the first model.)”
First, Kerry's situation and her heroic efforts to accommodate her patients. I think you can look at this as a spectrum of how we balance patient convenience with doctor convenience. Way on the left side of the spectrum is the old model clinic where my father used to work at Philadelphia General Hospital a half-day a week, where care was free and the doctors unpaid, when it was an honor to be chosen to work there, and where appointments were probably given at 8 AM for every patient who was to be seen that morning. The care would be excellent, but the amenities not so much.
Way on the right side is Marcus Welby when that was feasible, and in the present day, almost to the end of the right side of the spectrum (but not quite), is the Patient Centered Medical Home (PCMH). A PCMH centralizes all care for the patient, keeps all records, not only makes referrals but helps the patient make the appointments and follows up by telephone to make sure the referral was completed, teaches patients how to care for themselves, etc. To do this, the PCMH employs non-physicians to help and practices what we call team care. It's the center for the patient, it's the place they get treated like they are at home.
Even farther to the right, however, way out there for the modern equivalent of Welby-care, is concierge care. In this model a practice cuts way down on the number of patients it serves. Given the extra time thus available, the concierge practice does all the PCMH does, and in addition offers exquisite availability of the same doctor nearly every time on the same day you call, extended time for consultations, extended counseling and coordination services, and great concessions to patient convenience, like call to the doctor personally 24/7. I've probably left out other important services. Examples of concierge care that would not be expected in a PCMH would be: meeting the patient in a parking lot or on a sports field for patient convenience; sending a patient to two or three different allergists for consultations, speaking personally to each of them, and then meeting with the family to come up with an allergic plan; giving the patients a traveling kit of common medicines, including antibiotics, so they don't have to go to a pharmacy. This is Welby-plus care in the modern age.
Of course, PCMH and concierge care cost more. In addition to the normal fee-for-service payments, PCMH care requires a yearly fee, and/or per-patient-per-month capitation fees, or fee-for-service payments at a higher level. Concierge care requires even higher, paid in advance fees – sometimes, the payment is unbelievably high, from what I've heard. In contrast to the PCMH model, the concierge model actually decreases staff overhead, since fewer patients are served and the operation is thus simpler. It's an interesting model, although clearly not for every doctor, and not for every patient. Office automation lies behind both models – you can't do all this on paper. Automation actually enables decentralization, and in these cases, enables more Welby-like care with modern medicine modalities.
So, the dilemma is faced: how do you operate like Marcus Welby in a modern context, and these are the answers. It takes work, but in the end it looks to be very possible. It costs more, but since most medical costs center on the hospital, the extra cost for high intensity primary care is probably budget dust.
Second, Ashraf, Mike, and Suzanne's case of how to handle the phones. Once again, I would apply the “poverty clinic to the left, concierge to the right” spectrum. Clearly, at least to me, the medium is the message. Phone tree or outsourced call center, and you are moving left, where doctor convenience trumps patient comfort. Talk to a person, have that person kind and focused on you and taking time with you, and you are moving right toward Marcus. But note Mike Sach's experience in making an appointment himself with a hospital-based practice – it's a corporation! Corporations – and hospitals are very much corporations -- feel they have to centralize, they have to be impersonal, they have to impose their will on you for their own good and their own convenience. The doctors can be fine, once you get in, but with corporations in charge, the feeling often gets to be that it is you the patient along with the doctor fighting corporate practices and policies! So far, they just don't know any better.
So, here it is in some of its details, the modern dilemma of organizing primary care. Will it go corporate? The thumb on the scales is in favor of the corporations, who get more money per patient by their superior insurance contracts. Or will the smaller, more personal, more Welby-like practices, empowered by personalizing automation, survive and prosper? Or will the corporations change their spots and learn to incorporate personal care in a personal way? (The keys here will be, I think, one, how competition can be organized to work in favor of patients' needs and desires, and the needs and better-angels desires of doctors, and how doctors can muster the skills of leadership and organizational change – but more of that later.)
Modern medicine is great; we can do so much more than my Dad's generation, and each year is better than the year before. But even if we can't share a cup of coffee at the kitchen table, and even if we can't pop up at the patient's house at odd hours, we can preserve the personal relationship that is the key to medical practice, as I learned, and be competent, caring, and reliable – and non-bureaucratic. It's just a question of organization, and of competition that spurs better organization and better, more personal care.
Budd Shenkin


  1. I hope you cleared it with those physicians before you posted their list serve comments!

    1. Yes, I did. All responded yes, except one who did not respond. If he protests, ready to delete his name. I appreciate the need to be careful with people's understandable sensitivities....