From the Governor's Desk
December 2007
Dear Oklahoma ACP Internist,
I would like to tell you about my professional circumstances so that you understand my biases in a future piece about where I would like to take the Chapter with your help and advice and that of the Governor's Council.
As you may know, I have been in solo private fee for service only (i.e., no managed care, whether PPO or HMO) practice, for 23 and a half years. I participate in Medicare but I don't accept assignment unless the patient is going thru tough times. I don't have a contract with Medicaid or the Oklahoma Worker's Comp. system and I avoid car accidents like the plague (unless the patient needs a "Real Doctor" due to a prior existing illness requiring care during the hospitalization). I have a staff of three, including a "Real Nurse" who functions mainly as a medical assistant so far, due to the nature of our patients' medical conditions: they are almost all very high maintenance and require an average of 20 minutes of her time before they are ready for my evaluation and management services (30 or 60 or 120 minutes of my time) in the office. My other 2 ladies are superbly efficient, productive, kind and compassionate front office persons. I am in the office from 7:30 AM to 5:30 PM Mondays thru Thursdays, with an hour off for CME at my walk-to hospital at 12 noon on Thursdays. I see 8 to 14 office patients a day,with no break for lunch,except on Thursdays.
I intend to hire a Physician's Associate to help me take care of the large number of stable patients who require chronic disease management, and those who call in every day with minor acute illnesses that I would otherwise treat over the phone because I don't have office time to see them that day. I will continue to see new patients (2 hours each) , preventive health visits/chronic disease management reviews rolled into one visit (1 hour) ,all of my patients with depression, pain issues and complex care management (30 minutes to an hour each depending on the patient personality and medical diagnoses), and chronic disease management patients not at target ( BP, A1C, LDL, HDL etc) levels.
I make rounds in the mornings and/or evenings at a 250 bed community (almost full service) hospital (Mercy, in OKC), every day of the week, 365 days a year unless I am at an ACP meeting out of town. Occasionally, I also round on a patient who had an ACS or a PCI intervention despite my extremely aggressive preventive cardiology efforts, at the Oklahoma Heart Hospital (also within walking distance). I follow my Rehab patients to the in-house Rehab unit after their stroke (see above comment about preventive cardiology), and their TKR/THR. On Tuesdays and Thursdays evenings, I attend a usually non-CME drug company sponsored program to hear a speaker address a topic of relevance to my patients.
On Fridays, I have been doing scheduled house calls, within a 10 mile radius of my office, both in homes and in assisted living centers, and Skilled Nursing facility visits for 4 years . This year, I started following my patients to one of 2 Nursing homes, to make sure that all the work I did for years before that does not go down the tubes. For almost 3 years, I have been a Medical Director of a private Hospice: this has allowed me to both take care of my own patients, in the setting of their choice, with compassion until the end, and to take care of other doctors' terminal patients while maintaining their dignity, autonomy and comfort.
At my hospital, I have chaired the CME program for almost 20 years: As a result, it is a thinly disguised ongoing IM Board Review program for compulsive information driven Internists). I also sit on the Pain Management committee (7 years, where I have learned lots of pearls from my friendly Pharmacist and Clinical Nurse Specialists co-chairs), the Quality of Care committee (so that I can influence the way my patients are taken care of on a system level), the Medical Records Committee (to successfully introduce some patient care documentation forms), and on the Medical Informatics committee to learn as much as possible about our future Hospital based EBMR and to hopefully improve its functionality. I also attend the Mercy Medicine Dept. bi-monthly meeting to both keep my finger on the hospital pulse and update my Internist colleagues on ACP's activities.
On Saturdays and Sundays, I attend to my ACP work that can wait till then, and I e-mail you relevant filtered information from the Governors' Information Center and the ACP InternistWeekly. I also do my journal reading on weekends (Annals, JAMA, and NEJM).
You can see that I have a lot on my plate: As I like to say, it keeps me out of trouble. It also gives me a very fulfilling professional life and therefore a tremendous amount of satisfaction and happiness. Financially, I have stayed afloat and ahead of the curve by billing for almost every service I rendered (with the exceptions of phone consultations), by paying my bills on the time and not taking on any unnecessary personal or professional debt, and by keeping a tight leash on my overhead and personal expenses.
That is not to say that you must emulate me to be happy, since different personal circumstances apply to each one of us. I just believe that my satisfaction with my career is within reach of those who are in private practice (whether you are in solo, a group practice model, or a multi-specialty clinic) with variations on the above theme.
I realize that this practice model does not apply to medical students, interns, residents and fellows, but it is a glimpse of what your future could look like, if you are in training and if you are willing to put in the hours. If you are in Academic Medicine, which is not as different from private practice as it used to be, I realize that teaching and research commitment will take away rewarding patient contact time, but I hope that you are getting your positive strokes from your academic pursuits. I also hope that you can tell the students and the house-staff that is a better life after " The Medicine Wards and Clinics."
If you are in an Institutional Setting (Hospitalist, Dept of Corrections, VA or other), I doubt that you can replicate my professional track , but you could have that model to look forward to if you ever felt that you wanted to leave the protective cocoon of your current practice.
In a future Governor's communication, I would like to tell you about the vehicles I will use to promote Internal Medicine externally (thru the Media), and to address the problem of the Oklahoma uninsured (thru working with the Oklahoma Insurance Commissioner, members of the Oklahoma State Senate and House, as well as the OSMA and some very dedicated Oklahoma Physicians).
I will also continue to work tirelessly on addressing the Medicare Fee Schedule and do everything that is legal, ethical and moral to protect Evaluation and Management Services, the backbone of every Internist's livelihood. To that effect, I will be on Capitol Hill in Washington, DC in March with the OSMA delegation, and again, in May, with Dr James Rooks, our Health and Public Policy committee chair to represent you at ACP's Leadership Day.
I have already started promoting the ACP's Patient Centered Medical Home concept thru both my local hospital, and thru the Insurance Commissioner's inspired Health System Reform plan. I am convinced that the ACP's PCMH is going to be the ticket to our professional survival as it will also allow us to capture a patient care management fee, beyond the encountered-based fee for service charge, once your practice is certified as a PCMH.
Only when doing all of the above will we insure the future of both Internal Medicine and the availability of an Internal Medicine work force to take care of the ever increasing number of patients who require the truly superior skills of properly trained Internists, who can integrate large amounts of complex data into a personalized, comprehensive, and appropriate care management plan.
As you can see, my agenda is ambitious and my plate is full; I will need your feedback and your advice to succeed. Forgive me if this was long winded, but nobody said that fixing our Health Care System was easy or that being a College Governor was easy!!!
Please accept my best personal wishes for a healthy and productive 2008.
Dean Drooby, MD, FACP
Governor, Oklahoma Chapter, ACP
drooby@sbcglobal.net
Page updated: 02-04-08
Contact Information
S.A. Dean Drooby, MD, FACP, Governor, Oklahoma Chapter
Kay Bickham
Ph: 405-341-3169
Fax: 405-341-3173
E-mail: kaybickham@sbcglobal.net