Friday, April 23, 2010
Solo Doctor with Solo Nurse: Blast from Past with Plea for More Personal Future Care
Key Words: solo practitioner, office nurse, primary care, medical home, comprehensive care
Summary of Interview with Donald Copeland, North Carolina primary care physicians
Prelude: Dr. Donald Copeland and I go back a ways. We were among the early organizers of the High Performance Physician Institute. We were dedicated to the proposition that information technologies could be a boon to medical practice. Now Don is not so sure, nor am I, nor is he confident that bigger organizations or tighter management are the answers to the doctor shortage, and to addressing the problems of primary care.
“Q: You have strong views on primary care. For example, you think people are making it more complicated than it needs to be.”
“A: When I first started practice 1965, the main thing was to have a doctor and a nurse. We took care of everything, we managed our practice, admitted and discharged patients from the hospital, and referred them to the proper specialists.”
“Q: I have heard you say you think the medical home is nothing more complicated than the nurse and the doctor.”
“A: Not exactly. There are other people needed to support a practice. It depends on the economics. It’s expensive to hire a lot of people. In my other practice, I had a lab girl, a radiology girl, and a business office. “'
“But the key person is a personal nurse to communicate with my patients, get the chief complaint, to set up the room, take vital signs. The idea of a team approach in the medical home is not anything new.”
“Q: The medical home people say you need to hire a chronic care coordinator to put the team together.”
“A: That’s a nurse. I conduct a chronic care clinic over at Lincoln County, I have a nurse, and that’s it. I have a great lab, but not a lot of other people and a receptionist. That’s the team. You don’t need a patient coach, a nurse educator, and a nutritionist. The people following up patients on the outside don’t need to be in my office. The social service people can do that.”
“Q: You have said the solution to the primary care dilemma is quite simple. You just double the coding rate for office visits.”
“A: I was talking about Medicare rates. Those rates are too low, and barely cover overhead. The overhead rate is about 60%. I’m a firm believer that everybody who graduates from medical school should make at least $200,000 a year. I think of that figure when I’m paying my lawyer $300 an hour when I make a 10 minute phone care. He charges a minimal hourly rate. It’s ridiculous. A hospital CEO in Charlotte makes $4 million a year.”
“Q: President Obama has recommended the government spend $50 billion over the next five years to make electronic medical records mandatory, and there is underlying threat to restrict payment only to those doctors with electronic records. What do you think?”
“A: I think it’s ludicrous. You and I know that I know enough about electronic records to know that all EMRs are just a way to keep records. You can teach how to practice primary care or judge how they perform with medical records How can EMRs transform medicine? EMRs advocates say EMRs are a way of teaching or telling us how to practice medicine, but most of the people promoting them have never practiced medicine.”
“Q: You’ve practiced solo, you’ve practiced in large groups, and you’ve trained people to practice it.”
“A: At Bowman Gray, we trained our doctors to practice in rural areas. The problem with some of these residency programs they are training people to be half-trained internists. You have to train people to deliver babies, perform minor surgeries, even an occasional appendectomy, sew up lacerations, apply a cast, inject a joint, biopsy a suspicious skin lesion, treat a skin rash, make a tough diagnosis. That goes with the territory.”
“A: In other words, you teach them to practice comprehensive medicine. You teach them to practice in modules as personal doctors with personal patients with a personal nurse to help. Our residents had personal patients, and they took personal care of them."