Thursday, September 8, 2011

Dragging My Feet

For efficiency, I have been recording thoughts about the future as they arise on my digital recorder or iPhone.  Thematically, the phrase "dragging my feet" has cropped up recently.  I have been dragging my feet for the past two-and-a-half months since being fired, trying to figure out what to do and where and when and how to do it.  It is 8 September 2011; two years ago on this day of the week I started at my last job.  Now I'm 45 and seasoned.  Yeah, seasoned.  That's what they diplomatically call getting older, more experienced.  I know what it will take to do what I want to do and invariably that will involve more than what I have.  So I have to figure out how to change that equation in keeping with my general belief structure.

I certainly have a lot of time to think, particularly when walking my dogs.  My dogs are the most walked dogs in the world, I suspect.  Probably borders on abuse, but never was such abuse so welcome by them!  Our house is against a forested greenbelt and there is a little path out back through the woods that we use.  Last night the dogs chased some whitetail deer, some Larsonian taunt on the deer's part, to be sure. This morning it was an imperious red fox.  The weather down here in south Texas has been great lately, with clear skies, low humidity, and early mornings in the upper 50s.

I bring a covered mug of hot black tea (properly steeped), my pipe, and a book, and settle down at the dog park nearby for an hour or two.  Lots of time to think, though the wildfires down here have us all on edge a bit.  Everything's so dry that they seem to spark up spontaneously.  One popped up just 17 miles away (Magnolia), but is now contained.  I would say that this place is a tinderbox, but, really, who has ever seen, much less used a tinderbox?

You have options, my friends tell me, a reminder to me that there are circumstances where there are NO options.  I would like to continue to be a physician and to care for people.  I think I'm actually pretty good at it.  I suppose I could work for GE, or the Texas Medical Association, or some other lobbying organization.  But I really like doctoring -- it's great fun and always interesting.  My father used to regularly remind me to pick a profession I would enjoy, as I would be doing it for a long time.

I enjoyed starting my last clinic because in it I had ideas about constructing and maintaining order that were, at that time, cutting edge:  completely paperless, maintaining a carefully structured database of patient information using scanned material in a very limited fashion only, getting the patients to do the data entry, developing a web portal for individualized communication with patients, incorporating images into the database, automating backend functions and other aspects of care in the office.  I had my ideas about order and constructing order in a win-win environment for patients, physicians, and insurers.  In 2001 it was unexpected, a new world awaiting exploration; now it is more familiar and expected.  This is still the sort of legacy that I would like to leave.  Better healthcare through better structure.

Friday, September 2, 2011


This blog is primarily a narration of starting a private primary care clinic, from a physician standpoint, in real time.  It will subserve the core of a documentary, to be developed in the future.  Responses and discussion are welcome.

Background:  I am a 45 year old male physician trained in family medicine at the Baylor Department of Family and Community Medicine, a division of the Baylor College of Medicine, in Houston, Texas.  I actually started out in general surgery, but after 3+ years of residency training, I transferred to family medicine on philosophic and pragmatic grounds.  I graduated from the Baylor program in 1998 and started out working for a physician in south Texas, for $150,000/year for two years.  Because I did not have my contract carefully reviewed by an attorney, I ended up being paid only $270,000 for that time, however.  In those days, it was fairly typical for a physician graduating from a residency program to take a job for $120,000/year, or $150,000/year if the individual did obstetric work as well.  When that contract expired, I left the acrimony behind, and started my own clinic, de novo,  in a nearby larger city.  That office opened on 15 January 2001 in a 1,500 square foot office with two employees, completely paperless, with what was then Millbroook's Paradigm practice management system (handles demographics, accounts receivable, electronic transmissions, etc.) and Medicalogic's Logician, a comprehensive electronic medical record.  I had used the latter company's internet version of that product for a year or more prior.  Those were exciting and trying days, as I learned about the business of medicine, and the complex world of information technology (IT).  For almost nine years that practice grew and flourished, taking me from an income that necessitated filing earned income credit (EIC) in the first year, to almost $300,000/year in the end.  Personal changes, however, lead me leave that practice, and to move to The Woodlands, Texas, over 150 miles away.

The Woodlands is a beautiful and surreal world of affluence and expectation.  Residents refer to it as "The Bubble," suggesting an insular non-reality.  Think Stepford Wives, or perhaps utopian conformity.  The average income here at almost $120,000, but I did not move here for those reasons.  I moved here for the most common reason men move anywhere.

Initially I worked for a 15 member group of healthcare professionals locally, with an option to buy in later.  The work was demanding; the environment, oppressive.  While it was personally and professionally challenging, I persevered and offered suggestions about changes that would benefit the patients and practitioners alike.  Nonetheless, I was more than surprised to be suddenly and completely unexpectedly terminated after 20 months with the group, reason not given.  Later it was suggested to be a cost-cutting measure of some type, though I am am certain my average productivity was far from the least on the team.

Considering my transition from surgery to family medicine, my difficulty with my first employer and associated fiscal loss, my recent personal challenges, and this most recent job loss, I rationally must consider in what way I may be flawed that I do not maintain fluid relationships.  I am generally not bombastic or short tempered.  I am regarded by most as gentle, sensitive, and patient, perhaps too much so.  I believe that I have conditioned myself to believe that I can do a better job in a small work environment than in a larger one.  So here I am, jobless, capable, and searching for a better way to do medicine.  Commencement.  More to come.