Friendly and confidential phone consultations about your plans for a direct care practice

When I decided to jump ship and open a direct care practice a few years ago, there was no one I could ask questions to on the spur of the moment.

Certainly, I received invaluable help by joining AAPS, by attending one of their “Thrive, Not Just Survive” workshops, and by following a few leaders online.  But I still had a million concerns and questions for which answers were not always readily available.

At the time, all the business and marketing consultants who knew something about healthcare mostly knew about the traditional insurance-based way of practicing medicine.  They were also used to having large medical groups as their clients and their fees were set accordingly. (more…)

Interview on “The Price of Business”

A couple of weeks ago I was interviewed by Kevin Price on his radio show “The Price of Business” which runs on Houston’s 1110 AM KTEK radio station.  Also present was Dr. Geetinder Goyal.  We talked healthcare economics, free markets, and direct patient care.  I hope you enjoy it.

Good medicine starts with friendship

Advice from the ancients

Photo credit: Don't Let Go by Sam Caplat, via Flickr. CC license.
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Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look.  What’s that supposed to mean?!

At a recent meeting of an editorial board on which I serve,  the reaction to my suggestion was more forceful and perhaps more honest.  The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better.  I timidly proposed that, as physicians, we might want to start by being our patients’ friends.  The physician sitting next to me immediately objected: “I wouldn’t go that far!”

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How to safeguard your career in a treacherous healthcare environment.

Economics, ethics, and philosophy for medical students

Image credit: Pixabay (Public domain).
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the following post is a slightly edited version of an article kindly commissioned by In-Training,  a website run by and for medical students. The advice I give in the article is based on lessons I learned long after finishing medical school, so I hope you will find this piece of interest, even if you are well established in your healthcare profession.

Dear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

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Is assisted suicide “medically necessary?”

Canada may soon debate the question

By D. Gordon E. Robertson (Own work) [CC BY-SA 3.0 ( or GFDL (], via Wikimedia Commons.
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André Picard, one of Canada’s foremost healthcare journalists, published an article today in which he analyzes the funding rationale for his country’s healthcare system.

Canada has the most singularly bizarre health-funding model in the world. It is, to use the technical term, bifurcated – meaning there are two distinct categories.

“Medically necessary” care, defined as hospital and physician services, is paid 100 per cent from the public purse. Selling these services privately is, with few exceptions, illegal or subject to punishing penalties…

The rest of health care is, by default, not deemed medically necessary, but still gets varying degrees of public funding. Only about 6 per cent of dental care is paid publicly, as are almost half of prescription drug costs, and about two-thirds of long-term care costs.

Given Canada’s perennial healthcare budget deficits and notorious waiting lines for medical care,  Picard adds:

Getting the mix of public and private care right means ensuring everyone has access to essential care in a cost-effective manner, and still allowing patients a modicum of choice, and the ability to supplement their publicly funded care with other services.

At some point, we have to make some clear, coherent decisions to ensure that happens. Doing so begins with asking, and answering, the question: What is really “medically necessary”?

The final question Picard asks couldn’t come at a more opportune time.

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The suicide Robin Williams was denied

The double standard of assisted dying laws

Photo credit: Ver en Vivo en Directo, via Flickr. License under Creative Commons Attribution-ShareAlike 2.0
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The autopsy performed after Robin Williams committed suicide showed that the actor had widespread Lewy body disease.  His widow Susan just revealed that information and told reporters that depression was only a small part of the myriad of frightening and incomprehensible symptoms that beset him for more than a year before he took his life.  As the disease progressed, he suffered from impaired movement, anxiety, paranoid thoughts, and depression.

Last month, Governor Jerry Brown signed into law a bill that allows doctors to prescribe a lethal medication to terminally ill patients who wish to end their lives.  In the letter he issued as he signed the bill, he wrote: “I do not know what I would do if I were dying in prolonged and excruciating pain.  I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

But apparently, Jerry Brown and those who support the law would deny “that right” to people who, like Robin Williams, suffer from Lewy body disease.

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“Podcast interview with Jeff Deist”

Mises Weekend

Last week I was honored to be interviewed by Jeff Deist, president of the Ludwig von Mises Institute, the world’s foremost educational and research center for Austrian economics.  I hope you enjoy our discussion.

How doctors became subcontractors

In our healthcare system, the "middleman" is not who you think

Photo credit Nichole Burrows. via Flickr.
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During my recent podcast interview with Jeff Deist, president of the Ludwig von Mises Institute, I remarked that third-party payers are not, in fact, intermediaries between doctors and patients.  In reality, it is the physician who has become a “middleman” in the healthcare transaction or, as I argued, a subcontractor to the insurer.

Important as it is, this reality is not well recognized—not even by physicians—because when doctors took on this “role” in the late 1980’s, the process by which healthcare business was conducted did not seem to change in any visible way.

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At the tribunal of Jerry Brown’s conscience

Assisted suicide and our peace of mind

Locke Memorial Stone, Christ Church, Oxfor.  Photo by Nathanels via Flickr.
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When California Governor Edmund Gerald “Jerry” Brown, Jr. signed into law ABx2 15, legalizing assisted suicide in the state, he issued the following statement explaining the reasoning behind his decision:

ABX2_15_Signing_Message cropped

In his 1993, John Paul II had this to say about the kind of examination of conscience through which Governor Brown would become “certain” about the comfort that the law would provide him and others:

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Neither expert nor businessman: the physician as friend.

Arguments against the outcomes movement

Alexander of macedon trust's the doctor Philip  by Henryk Siemiradzki - National Arts Museum of the Republic of Belarus.  Licensed under Public Domain via Wikimedia Commons.
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In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes!

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