“I know there’s a lot of you out there that are feeling disillusioned. You’re wondering why did I spend all those years in medical school and training, why am I hundreds of thousands of dollars in debt. I hate this. I hate this profession. I don’t feel like this is me. It’s because you’re in the wrong place. I have several friends (you know who you are) out there. You know that you are very unhappy. You are just racing to get to retirement as fast as you can so you can get out of medicine. What I say to you is dig down deep into your heart and reclaim that dream you had from when you were a little kid and all you wanted to do was help people and serve people, serve your community, and be part of the community in a respected way where you felt free. You can do it!” ~ Yami Lancaster, D.O.
“If you’re someone who has been wounded in such a deep way, I want to tell you the most important thing that I learned when I was in that exact position: you are not alone. There are people, many of us out there who are looking for you. We’re not waiting for you. We are looking for you. And if you just give us a slightest nod in our direction, we will come find you and we will help you heal.” ~ Gregory Mims, M.D.
“To those out there who are still in pain, there are options. The system is a lie. It’s fed you a false dichotomy that essentially you can be miserable, but successful or you can be destitute and happy. It’s not true. It’s not true. We are divided. We’re kept powerless, but there are those out there who want to help, help reform the system, help you heal to find something that is truly meaningful for you. It’s out there. There are options. You are not alone. And remember that the modern medical system’s unofficial motto right now is: the beatings will continue until morale improves.” ~ Bradley Michel, MS3
“It’s just that it is an abusive system, and you can quit and take time off. Find who you are. You can live your dream. And that’s all you need. Screw the system. It’s not meant to get people better. It’s meant to maintain chronic disease states and make a lot of money. So there ya go . . .” ~ Cammy Benton, M.D.
“What I would want to tell medical students or physicians that are suicidal or just want to quit medicine: I was there.” ~ Hawkins Mecham, MS4
“We as healers tend to isolate ourselves and ignore the fact that there’s a problem going on much, much wider than what we’re just experiencing personally. If you are someone who is struggling, I would encourage you to think about that fact that taking a little time away is very healing. When you have the time, don’t be afraid to take a break. Say, ‘You know what, this isn’t working for me right now,’ and take the time away from health care to evaluate because there are lots of options available to you once you take the time and stand back. But in that time, find who you are because you are an awesome person and there is so much more to you than just who you feel like when you are in this degrading system.” ~ Stephanie Whyte, M.D.
“If you need to take some time off, if you need to get rid of some of that PTSD that’s been part of this profession, our training, that’s completely fine. But don’t ignore that little voice inside you that still wants to do this, but in the way that serves your heart and is authentic to your self.” ~ Yami Lancaster, D.O.
“The transition that I’ve experienced from feeling exhausted and depleted and trapped and sad at work to feeling exhausted, depleted, and angry at the system—that transition has really helped to give me the motivation I need to realize that there is a better way.” ~ Caroline Schier, M.D.
“I know you feel like you are entirely stuck. I know you think that there’s no way out. There is. There are other options and I really, really hope that you will look around and try to find them because I know when you’ve been told over and over that this is your only option that becomes reality to you. But it’s not. It’s not really real. There are other options. There are other ways and you’re not actually stuck. So please try to get yourself unstuck. Please. And ask for help.” ~ Lisa Kozinski, M.D.
“Ask for help. We’re a profession that doesn’t like to ask for help. When you’re reaching out you actually are stronger for doing that and I just want to let you know that by reaching out you’re empowering not only yourself, but you’re empowering your patients and you’re empowering your other colleagues.” ~ Hawkins Mecham MS4
“To anyone out there who is feeling trapped, depleted, exhausted, unhappy, my message to you is that there is a better way.” ~ Caroline Schier, M.D.
“We’re all working so hard. We’re such compassionate, intelligent people. There are plenty of ways to pay off our debt and make money. We don’t have to work for system that takes the majority off the top and works us until we’re burnt out, abusing ourselves. I know the stresses. I know the temptations or the necessity to turn to substances, to be depressed, to be anxious, and it doesn’t have to be that way. If you’re feeling that, please take the time to step back because suicide is the next step with that and it is just not worth it. And hearing from peoples’ families that have lost medical providers, it’s heartbreaking. It is such a tremendous loss to a society that needs healers.” ~ Michael Latteri, MS3
“What’s been the most amazing thing for me is the connection that I’ve felt with my peers here and the joy that I have leaving here, the excitement I have because I feel like being amongst these people that just want to serve from their heart has given me hope for my profession.” ~ Yami Lancaster, D.O.
“There are people out there practicing medicine that are more caring and compassionate and creative and amazing and beautiful than I could ever have imagined and that they love me and they love you and they love everybody and they just want to heal.” Jenny Wheeler, M.D.
“If we can’t take care of ourselves and each other then we’re not doing it right so come join us. Pamela Wible and all these people are so awesome. We will always be here for you. All you have to do is contact us.” ~ Michael Latteri MS3
“I’m just joyful. I’m happy. I can’t wait to get out there and start building my dream and reclaiming my dream from when I was three years old and I feel like you can too. So have hope. You can get out of this. It doesn’t matter the debt. Just think about how you can help the world in the way that you wanted to since you were little kid. You can do this! I believe in you and so does Pamela Wible. That’s why I’m here and I’m so glad I found her and all these awesome, amazing people. I love you guys so much!” ~ Yami Lancaster, D.O.
“We know what it’s like and we don’t want to lose any more of our brothers and sisters in health care and it’s making us angry because this world needs us.” ~ Gregory Mims, M.D.
If you are a medical student, physician, or health care professional who needs someone to talk to, please contact: Gregory Mims: gsmims(at)gmail(dot)com. Yami Lancaster: Ycazorlalancaster(at)gmail(dot)com. or click here to reach Pamela Wible.
“You are not alone. You are loved.” ~ Pamela Wible, M.D.
Pamela Wible, M.D., has helped hundreds of physicians reclaim their happiness and their careers. She offers biannual retreats for medical students & physicians. Dr. Wible has been named the 2015 Women Leader in Medicine for her work on medical student and physician suicide prevention. Video by GeVe.
Christine Sinsky, M.D., from the American Medical Association interviews Pamela Wible, M.D., after her TEDMED talk. Watch periscope video here. Fully transcribed below:
Dr. Sinsky: This afternoon we’re here in Palm Springs, and I’m delighted to be here with Dr. Pamela Wible who gave a terrific TED talk last night. I’m Dr. Christine Sinsky, the Vice President of Professional Satisfaction at the AMA, and we’re here at TEDMED because it’s an important gathering of deep thinkers, of innovators, of practicing physicians. The AMA believes in bringing those key constituencies together. So Pamela, you really knocked it out of the park last night with your talk. It was really just terrific.
Dr. Wible: Thank you so much. It was really fun, amazingly fun to present a topic that’s so challenging.
Dr. Sinsky: I wanted to start out by telling you one of the things that is meaningful to me. That care of the patient requires care of the provider, and I could feel your passion last night around our need to be better as a medical community at caring for each other, at caring for our colleagues. I wonder if you’d like to start from there and move forward.
Dr. Wible: I think we really need more of a culture that is collegial and like a family, instead of a culture of competition. And that starts during premed and day one of medical school we could set the stage for more of a family atmosphere where we’re looking after each other like you would family members. I think that’s how it works in other high-stress professions like fire departments and police departments. People are really there for one another as supports.
Dr. Sinsky: So shoulder to shoulder, together. Picture for me, you are the Dean of a medical school. You have the ability to help change that culture. What would you do?
Dr. Wible: Day one of medical school I would introduce the students to the campus and welcome them home. This is where you will be with your family for the next four years. You’ve jumped through enough hoops to get here and we are here to support you. I would give my personal cell phone number to the students. I would have a panel discussion with some of our top leaders at the medical school who would share their personal struggles with despair and then triumph from professional liability cases, from deaths of their patients, from divorce, suicidal thinking and all of this so that we normalize the conversation of our human needs. And we can start to bond with each other beyond just the supratentorial lectures and multiple-choice tests.
Dr. Sinsky: You know, I was talking after your talk with one of my physician colleagues and we were thinking about how we each felt in medical school and some of that impostor syndrome that I think all physicians feel—that we are isolated and alone and no one else is feeling that way. Tell me more how this approach when you are the Dean can help to address that issue.
Dr. Wible: Right now students feel extremely isolated and that just continues through our entire profession. We are in a culture that glorifies self neglect. And so we end up working on our little islands and we don’t ask for help because, of course, we are supposed to be the helpers. We are not supposed to be receiving help. And so if we can just break through this and really look after one another. Create a situation in which people do not feel individually defective. Once we can communicate that you cried yourself to sleep after the stillborn and so did I and we had the same reaction to that case, it just normalizes our human experience. And that’s what we need to do is start to have conversations like real people, like we are now without the stiff starched white coat.
Dr. Sinsky: Right. And the isolation behind the strong man kind of front. So last night you really spoke very much from the heart, about the extreme when we don’t care for each other. The stresses and lack of support can manifest in the most severe outcome—death by suicide. Can you talk a little bit about why that’s important and the extent of it, and move to solutions, things that we as a medical community can do to help our colleagues in pain.
Dr. Wible: It’s important because we are losing an entire medical school full of physicians every year to suicide, so hundreds of doctors. Both men I dated in medical school died by suicide. In my small town we lost 8 physicians to suicide, 3 within 18 months. So it’s a huge public health issue. More than one million Americans lose their physicians to suicide every year so we must take this seriously. If not for the individual, the public health implications of losing that many physicians when we already have a physician shortage. Right? So that’s one thing. What was the second part of the question?
Dr. Sinsky: I just want to clarify that a full medical school every year.
Dr. Wible: Yes. And that’s not even counting the medical students that die by suicide. And what disturbs me is we are not tracking any of this and we could be tracking it because we know all the names of currently enrolled medical students and physicians in this country, so it shouldn’t be a mystery. We should have firm numbers. Some of this is not being tracked properly.
Dr. Sinsky: So who is doing it well? Who is addressing suicide prevention at the medical school level well? Or at the practicing physician level well? And if no one is what should we be doing?
Dr. Wible: Some schools like Saint Louis University and others are doing a pass-fail grading system so there is not the tension about grades that creates that competitive environment. So if we just take the pressure off of these amazing people. Medical students are already in the top 1% of compassion, intelligence, and resilience in the country. How much more pressure do we need to put on these high-achieving people? Take the pressure off and let them enjoy the love of learning instead of just shoving all these multiple-choice tests that never end with medical minutiae that they are not going to use in the future. So take the pressure off and create an environment where there is peer networking and peer support groups. Schools should have a suicide helpline that the students man themselves. We learn to take blood pressure on each other. We are using each others’ bodies to learn how to do the physical exam. Why not let these medical students in their first and second year learn some of these skills to help each other emotionally? Have them on call from first and second year so they feel like they are doing something other than just reading their books. Actually helping each other.
Dr. Sinsky: So you are getting at one of those issues that makes physician suicide such a challenging problem and that is for physicians there are barriers to getting mental health care and that probably starts in medical school. Getting mental health care from your boss or supervisors might be an issue and once we’re in practice. So what else can we do to reduce the barriers to getting help when we need professional help for depression that’s extreme, for example.
Dr. Wible: Well, one thing that I discovered when people call me is that medical students and physicians who do have extreme depression, anxiety, panic attacks that are occupationally induced were normal before medical school. Just listening to them on the phone helps. I am not giving them drugs. I am not their doctor. I’m just a friendly colleague on the phone. They feel so much better afterwards. I continue to drive home the point that you’re not individually defective. This is a system defect. If more than 50% of a group of people develop a condition we call “burnout”—which is really a victim-blaming term—then it is really a system’s issue, not an individual issue. Once they realize that they are not individually defective, they feel so liberated and they feel so understood. We should not wait until people are so far gone into psychotic depression that they need to go to a psychiatrist. The first day of medical school and as an ongoing continuum of care we can really listen to each other and be human with one another.
Dr. Sinsky: I want to make sure I caught this because I think this is a hugely important point. We need to think about the locus of responsibility for physician distress, for physician suicide, for burnout (if we use that term) in the external environment much more so that in the internal environment as a defect in the strength or the ability of that person. Did I understand you?
Dr. Wible: Yes. It is a bigger issue. It is not that the an individual was born with a resilience deficiency. You’re in the top 1% of resilience if you are in medical school so let’s honor your strength and capacity for learning and providing care for people. And one thing that I wanted to say since I think this is about creating your ideal clinic is that we should really teach to the personal statement, not just to all these multiple choice tests. People come in with a clear indication of what their soul’s purpose is and what their intention is and what they’d like to receive for their $300,000 of tuition and schools need to be teaching to these personal statements and digging them out of the file drawers and asking the students, “How are we doing getting you to your goals here? Are we doing well as a school?” There’s really only 2 types of practices that have emerged: relationship-driven or production-driven practices. What medical school seem to be doing now is driving everyone into assembly-line, production-driven practices which do not match what most people have written on their personal statements. So we need to go back and ask the students, “How are we doing? How can we do better?” and really help people live their dreams—because that IS the ultimate solution to suicide. When you are living your soul’s purpose, there’s no way that you want to take your life. It’s when you feel that’s been stolen from you [that life loses meaning].
Dr. Sinsky: So I want to ask the last question. What do you think organizations like your organization, the American Academy of Family Physicians, or the America College of Physicians, or the AMA can do to help reduce physician stress, reduce the risk of burnout, reduce the risk of suicide, and increase the likelihood that we’re practicing in an ideal practice?
Dr. Wible: I like to reference Maslow’s Hierarchies of Needs. During medical school you are thrown down to the lowest rung of physiologic instability (not getting to eat, sleep, and all that stuff). What Maslow did is he studied people who were high achievers who were self-actualized and that’s what we should do in medicine. Instead of talking about all the doom and gloom, start showcasing that doctors who have figured it out. Let’s have a panel of the happiest doctors in America so we can hear what they are doing and why they are so happy. Doctor means teacher. Medicine is an apprenticeship profession. We learn by modeling other people. So let’s start showcasing the people who are really having a good time, who’s patients love them, who are just really rocking it in medicine and that would be a really great way to learn how to do it right.
Dr. Sinsky: So this is not a set-up Pamela. You may not know, but part of the work we’re doing at the AMA is exactly that.
Dr. Wible: I really didn’t know that.
Dr. Sinsky: You didn’t know that. I guess we’ll close with this. We have put online a series of practice transformation resources to help to get back to our calling of relationship-based care. So that our physicians can spend the majority of their time on work that only physicians can do, relationship-building, and medical decision making. And they are all about creating an ideal work environment.
Dr. Wible: That’s lovely. That’s really great. I’m looking forward to seeing that.
Dr. Sinsky: Maybe we will call you in to be one of our authors. We also highlight places where people are doing a very good job. So, Pamela, I’d like to thank you so much. You’ve really inspired many, many people across the country with the work that you’ve been doing and the message you’ve been articulating.
Dr. Wible: Thank you so much. It is a joy to be here.
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Dr. Wible’s TEDMED talk was featured in the Palm Springs newspaper the following morning. Article here with great photo! When her TEDMED talk is released online, it will be posted here. Hopefully soon
Meet 3 physician entrepreneurs who are leading the way with innovative neighborhood clinics of the future.
Innovative Primary Care Practice Models Panel featuring: Yami Cazorla-Lancaster, D.O., pediatrician at Nourish Wellness and Pediatrics in Yakima, Washington. Pamela Wible, M.D., family physician at a community-designed Ideal Medical Clinic in Eugene, Oregon. Peter Lehmann, M.D., family physician at Vintage Direct Primary Care in Poulsbo, Washington. Facilitated by TaReva Warrick-Stone, second-year medical student and President of the Family Medicine Interest Group at Pacific Northwest University of Health Sciences College of Osteopathic Medicine.
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TaReva Warrick-Stone: Our panel today is going to be focused on primary care innovation and we have a wonderful group of physicians here breaking ground in primary care. I have three questions to get things rolling and then we will be able to open up to the group. So the first thing is just to introduce yourself and offer anything you like in terms of specialty, background, residency, training after residency if you did a fellowship or anything.
Dr. Lehmann: My name is Peter Lehmann and I’m a 52-year-old family physician on the other side of the state in Poulsbo, Washington, which is kind of near Seattle but over on the side that is not too crowded. I went to George Washington Medical School in Washington, D.C. and graduated in 1990. I chose to have the military pay for my medical school because it was and is the most expensive medical school in the United States, and I didn’t want to come out in a lot of debt. I did a 3-year residency just outside of Washington, D.C. and got board certified in 1993 (and have done it every 7 years since then). I spent 3 years paying back the military for my time. I was in Fort Campbell, Kentucky and moved to Poulsbo, Washington 20 years ago to join the group I’m in now and you’ll hear more later.
Dr. Wible: Hi, I’m Pamela Wible and I’m a family physician and I’ve been practicing family medicine for 20 years. I’ve had a wild ride through many jobs that were not ideal that I will share with you and I am now in my ideal medical clinic for the past 10 years. It is the BEST experience ever. You all deserve the same thing. I love going to work everyday. I really don’t plan to retire because I just love what I’m doing so much. I actually don’t even like going on vacation because I miss seeing my patients. Maybe I’ll just give you a little fill-in on what I did my first 10 years after residency. You shouldn’t make the same mistakes as I did and just continue taking jobs that are not your dream job. You can go straight into your dream job if you like.
I had 6 jobs in my first 10 years because I never found one that I really liked. I started at a multi-specialty group in Oregon with hundreds of doctors. Then I did a summer stint with Yakima Vally Migrant Farmworkers in Woodburn, Oregon, and then I opened my own clinic in a carport in my house for all uninsured which was really fun, but I did not see how it was replicable and would solve the entire problem with health care in the country and I’m a real systems thinker so I was really looking for something that could be replicated. After that I jumped back into what I call “assembly-line medicine” and I worked in Washington state at a hospital-owned clinic in Lake Forest Park, outside of Seattle and then I went to Olympia, Washington, and worked in a single-specialty group with 3 family physicians who wanted me to become a partner if I signed on the dotted line and in order to ever leave that job I would need to give an 18-month notice and find a “suitable replacement” and that felt like a prison sentence to me so I couldn’t really sign anything like that so I moved back to Oregon and worked in another family practice office, part time only Wednesdays and Thursdays. And that’s when I got to the point of feeling wow if I can’t even be happy in family medicine only working 2 days per week that’s pretty lame. Something is seriously wrong. So from there I had the epiphany that led to the whole idea that I could really have an ideal medical clinic designed by the community and I could work for them. So that’s pretty much what I did. I led a series of town hall meetings and invited my community to design their own clinic. I pretty much told them I would do whatever they wanted as long as it was basically legal and I’ve been doing that for 10 years and it’s a blast. So highly recommend not just saying patient-centered, but actually doing it. Put the patient in charge. Have them help you because then you won’t be so tired because they’ll be doing all the work and they’ll feel honored and respected because they really are the center. There won’t be that invisible tug-of-war that I felt all the time in exam rooms at other offices where you were trying to put then on an algorithm or a paradigm they didn’t want to be on and they were there for another reason. So that’s my little story.
Dr. Lancaster: My name is Yami Lancaster and I’m here because of her. Her glitter has been rubbing off on me for the past few months. I’m a pediatrician. I’ve lived in Yakima for 6 years and practiced pediatrics at Yakima Pediatrics Associates until September 18th. I went to medical school at Texas College of Osteopathic Medicine. I’m also a D.O. Yay! I also have a Master of Public Health and a Master of Science which I did all in 5 years during medical school because I’m crazy like that (plus my first son). I also did an osteopathic manipulative medicine fellowship during that time, but because I decided to go into peds instead of geriatrics like I was initially planning, I don’t use it quite a ton. Since medical school, I went to residency at Cincinnati Children’s Hospital Medical Center in Cincinnati which was excellent training and then this was my first job here. The reason why I took the job here is because I’m a national service corp scholar and I finished my repayment in August. I did 2 years full time and then I did 4 years part time for the national service corp. As soon as my commitment was done I was ready to break away from the traditional US medical system and do my own thing and have been learning from Dr. Wible about how to do that. I’m super-excited to tell you guys about what I’m doing.
In addition to all that, my biggest passion is nutrition and lifestyle. Some of you may have been to my class that I gave last year. I am certified in plant-based nutrition. I’m certified food for life cooking instructor through the Physicians Committee for Responsible Medicine. I talk a lot about eating more plants and sleeping adequately and meditating and all that kind of stuff. I want to be able to have the time to integrate that into my practice because I think that is going to save a lot of lives.
TaReva Warrick-Stone: Thank you all. We are super-excited to have you here. Dr. Wible started this for us. I’m curious you are breaking ground in pursuing different forms of primary care delivery presumably because the delivery model that you were working in previously didn’t fulfill your needs as a physician or the needs of your patients. So I am wanting you to describe what that environment was like in terms of size, patient panel, support staff, so we have an idea of what you’re leaving and why.
Dr. Lancaster: I wasn’t super-miserable or anything like that. I worked Yakima Peds for 6 years. There I was one of 5 physicians and we had NPs and PAs (3-4 at a time usually). I started full time for 2 years, but honestly I am a super-efficient person. I can see a lot of people. It wouldn’t be unusual to see 30 patients per day plus you have to do your charting and return phone calls and sign a lot of paperwork. There’s a lot of paperwork in medicine these days. It’s not like it’s torture it’s just like it’s day after day after day it can be a little soul sucking. Then I went part time after my second son and I was okay for a while, but what happened was that I had a dream of serving the community and really helping patients in the way that they needed to be helped and for me that’s really talking about lifestyle. You guys know what our major problems are in the United States. These 5-minute appointments. You really only get 5-7 minutes per patient if you have a 15-minute appointment because half the time you’re just staring at the computer typing and like rushing and getting to the next one. So it really wasn’t enough time I felt to do patients justice as far as what I felt they needed to live a healthy life and to prevent chronic diseases (80-90% of which are preventable through lifestyle choices). After a while I became dissatisfied, discontent with what I was doing. I didn’t feel like I was doing my best work. I felt like it wasn’t excellent and I want to be as excellent as I can so in order for me to be excellent I felt like I had to leave the traditional US medical system and try it another way. I am married to a physician, a hospitalist, who makes a much bigger income that I ever did anyway and because of that I felt like I had the luxury and freedom to be a rebel and try something a little bit different. But I loved Yakima Pediatrics. I loved who I worked with (some of you guys may know the physicians there and they are awesome, amazing). Everybody was great. It’s just that we were all part of this system and there was no way we could break away because we were part of a community health center. When you are part of a big system like that you can’t practice differently. You have to see a certain number of patients and have to practice a certain way and so I didn’t feel like I had that freedom and liberty to do things my own way.
Dr. Lehmann: Okay. I will try to keep it short because you’ve got so many good stories to tell, I’m sure. Some of the things I could really piggyback on when I left the military I debated whether I wanted to be in academics because I really liked teaching a lot, but I really valued the idea of being independent and just being able to be a doc because in residency you spend a lot of time teaching younger students and what not so I ended up joining group that at the time was about 35 doctors multi-specialty group and it’s about 75 now. I will say a wonderful group of doctors and I have never had any complaints or unhappiness being a part of the group.
Ten years ago I got diagnosed with muscular dystrophy. I didn’t even know adults could get it. Kind of a long story how that happened, but by the time I realized that was going on (about halfway through my career) personally it really changed my life. I lost the ability to pretty much do everything besides walking. The last 10 years being in fee-for-service (FFS) which FFS means all the services you provide get paid by a third party (could be an insurance company, Medicare, Medicaid). It costs a lot of money and you have to hire quite a few people and spend quite a bit of money to cover that and your only option to stay ahead is volume. You’ve got to increase the volume of patients that you see and I have never liked that idea. In fact, I have spent most of my career seeing fewer patients that all of my partners. I just made less income as a result. So how does the muscular dystrophy fit in? Well, initially it just impacted my personal life. Took me a year or two to get okay with that. The last year or two has become very difficult to see a lot of patients. If you need to see 20 patients per day to make a decent living, turns out that only 1% of patients in general on any given day have a reason to come to the office. So if you need to see 20 patients per day, you need to have 2000 patients that are yours to fill your schedule. I probably got about 2500 patients. For the most part I love all of them, but trying to provide care for 2500 people and seeing 25 patients per day and doing all the things that you end up doing when you’re not seeing patients really has made it impossible for me to continue to do that For the last year and a half I have struggled with saying what am I going to do. I want to work until I am 80. I love being a doctor. I just hate the job.
I had just the dumb luck to hear a 5-minute talk by somebody who’s a pioneer like Pam, Dr. Josh Umbher in Wichita, Kansas, who right out of residency began a clinic called Atlas MD, and he set a model up where patients paid a membership fee directly and patients basically got (lawyers don’t like us to say this) unlimited care, which is really true. You need to be seen, you get seen. You need to talk to your doctor at night, you talk to your doctor at night. You need to talk to your doctor on the weekend, you talk to your doctor. The focus is all on being your patients’ doctor and that’s your salary. Everything else you provide is to be of benefit to the patient. Between spending time with Josh and one other doctor in the country who is kind of doing the same thing, I said, “Aha! this is my salvation.” Because I can’t work on a treadmill anymore. I want to give the kind of care that is slow, “slow medicine” is what I call it. I always ask my patients, “What’s the one thing you wish I had more of?” “TIME!” I want time. That’s what I loved about being in medical school. You get time with patients because nobody expects you to go fast.
So about a year ago is when I found this out and I said this is for me. If I do this I can practice as long as I want. I want to be old Doc Lehmann and somebody say, “He’s been my doctor for 40 years and he comes to my house (which I will) and he’s been there for all the significant events of my life and my kids have seen him and they don’t get scared because they know him really well. I’ve spent the better part of the last year planning to leave a very secure job fro which I make a very decent living to do something that I have no idea how it’s going to work out which is to say $10 per month for kids and $50 per month for adults and I’m your doctor. I work for you only. I work month by month. You’re not happy with me, you don’t trust me, you don’t view me as your partner, you have no obligation to me. I will be opening January 1. Of my 2500 patients, I’ve got 150 patients so far that have said they want to join me. Along the same lines, I’ve said to my patients we don’t have to play by anyone else’s rules. We can’ be illegal. We can make this clinic whatever we want. I want you to make this clinic with me. I’ve always told patients I get as much out of the office visit as you do and I want to be able to have the time to do that. I don’t know exactly how this is going to work out, but I know this is the right thing. It feels right. I know I’m going to give patients the care they deserve and I get to be a doctor again full time. So I’m excited and frightened at the same time. Honestly, I don’t see any other way to go. It is what being a caretaker and partner is. You just have to have time for people. So that’s the story and the good thing is that even thoughI have muscular dystrophy, I honestly do think I can do this as long as I want.
TaReva Warrick-Stone: Great! Thank you. That actually leads quite nicely to the next question so maybe Dr. Wible and Dr. Lancaster can fill us in on the details like Dr. Lehmann did on the practice that you are pursuing now and what that looks like in terms of patient panel, reimbursements, time, support staff as well.
Dr. Wible: Okay. First I want to give you a cheat sheet. You’ve got to write this down because this will totally help you understand what your job options are in the future. There are only 2 types of medical practices. You’re either in a production-driven practice or a relationship-driven practice. You will know the difference on your rotations whether you are in one or the other. In a production-driven practice people will be very frantic about time, people will be really worried about no shows, people will be counting between 20-30+ patients per day, and that is all about numbers. It’s a numbers game. I often call it assembly-line medicine. The other option is relationship-driven practice which is what I think everyone wanted when they filled out their personal statement to attend medical school. You wanted to have those deep (especially in primary care) satisfying relationships with people over time and over generations of their family. So it’s your choice. You actually do get to choose one or the other and you should have the right language to understand what you are in. So those are the 2 options you have. Underneath that you could subdivide those into 3 other options: patient-centered, physician-centered, or administration-centered practices. Again, is the practice set up for the convenience of administrators and people make big salaries, middlemen and other sorts of people in a big box clinic? Or is it set up for the convenience of the physicians, or is it really truly authentically a patient-centered practice? If you asked patients if they feel that they are the most important person here and that you are the center and they would say yes. So those are another set of options. Then as far as payment structure there are only 2 types of payments. You are either getting paid directly from patients or getting paid indirectly from a third party. Under indirect (third parties such as insurance companies)I will add that you could subdivide that into local or non-local. Like in Eugene we have PacificSource Health Plan located in Springfield right next to my town. They are a local insurance company. If I have trouble with them I can go right down across the river and sit on the desk of the woman in the front and figure out what is going on and they have really good customer service and so that is an example of a local insurance company.
What I was in before (all my practices except my carport clinic) were production-driven practices and they were all administration-centric or if they were a single-specialty physician-owned practice they were physician-centric practices. They were not centered on the patient. They were primarily indirect payment model. Currently my practice is relationship-driven. It’s patient-centered to the truest degree that I have ever seen. It is a mix of indirect and direct payments. Primarily the indirect payments come locally. So it is a community-supported medicine structure clinic, kind of like community-supported agriculture. I will say that they further you get away from a relationship-driven, patient-centered, direct-pay practice (and throwing in there local indirect payments) the further away you are getting from your patient. If you want to have a very deep spiritual, emotional, physical relationship with somebody over the continuum of time with multiple generations of their family at that deep level, you will be able to do that more likely with a relationship-driven, patient-centered practice in which the patient has some skin in the game financially or through barter or trade. I don’t turn anyone away for lack of money. People have bartered and traded services with me.
Health care is not passive. If you allow a patient to receive passive care—like I do not believe in charity care—they need to do something. If they can’t pay you with money they need to pay you with time or devote an equal amount of time to the community that you have just devoted to them. You’ve spent an hour helping them with their pneumonia, then they need to spend an hour at the soup kitchen serving people. They need to do something. This is not about gimme, gimme, gimme, take, take, take, don’t contribute anything. I am sorry to take so much time on this, but I really want you to understand the basic clinics that you have an opportunity to join when you finish medical school. Yami . . .
Dr. Lancaster: Yes, I completely agree with what Pam is saying. One of the things I want to say before I go any further is that people go into medicine for different reasons, but I think most people go into it because you truly want to help people and you have that calling in your heart to serve and you want to put your hands on people and help them in their suffering. There are going to be a small percentage of us who go into it strictly for the money. You can make a heck of a lot of money as a doctor. You can sub-specialize and see a bunch of patients and do a lot of surgeries and make a lot of money if you want to; however, if you are the kind of person who went into medicine because you want to help people and serve and do the best thing for people, it’s going to really clash against your ideals and you are going to feel bad and you are probably going to get depressed. So one of the things I will warn you about is we have so many years of delayed gratification and right now you guys feel super-poor and you see other people and you think I can’t wait to get my fancy car and my big house and stuff like that. I will just say choose wisely what kind of lifestyle you want to go into because we just downsized our house and I don’t plan to buy a new car until it dies because I don’t want to sacrifice my ideals anymore. I want to be able to have the freedom and liberty to serve my community the way I want to and not feel chained to a certain income to pay my lifestyle. Does that make sense? So think about that now because once you graduate from residency you are going to be rushing to buy all this stuff and fill your house full of stuff and that may make you stay within a system that you are not happy with because you have to pay back all that stuff. So that is something I wanted to say that is more philosophical. It’s important. Just keep it there in your mind.
I left Yakima Peds September 18th and since this summer I have been working on starting my ideal medical practice as a pediatrician. I just signed my lease on Friday. I have a location. Yay! The way I want to do it is kind of more similar to Pam, kind of a combo. I thought about doing the membership model and decided not to do it exclusively that way. I’m going to start as an out-of-network physician fee-for-service. So I am going to charge for the service I am providing on a cash basis. Now, the really cool thing is that there are lots of changes happening in the United States because it is not just us who are dissatisfied, it’s the patients that are dissatisfied. There are some new kind of cool insurances that are presenting themselves. One is a co-op insurance. I actually already have patients who have joined me and they have this co-op insurance and they function as cash patients and then they get reimbursed through the system (I don’t understand it fully). I already know there are a lot of these patients in Yakima that would potentially be interested in coming to see me.
And what is really col is that Pam has given me the confidence to do this and she says, “Don’t worry! Do your job the way you want to do it and people will come to you.” And it is completely true! People are emailing me, “Oh my gosh! Do you still have space? Have you stopped taking patients yet? Because I really want to come see you.” They are so desperate to just have a doctor that actually has time and will listen to them. It’s amazing! Even though it seems like it is a really rebellious sort of thing to do, it’s what patients want and it’s what we used to do a long time ago. It’s old-fashioned medicine that’s coming back. It seems rebellious because the standard medical system is not like that anymore. Now I am going to practice part time and the reason is I still have other stuff I am doing. I teach cooking classes quite a bit, I have an online presence that I am trying to grow, so I have a lot of other things that I am working on that I feel will also contribute back to the world and humanity and hopefully get us all healthier and so I am going to be practicing part time. And, of course, I am also a mom, I forgot to mention that. It’s kind of important. So three days per week scheduled appointments; however, like Dr. Lehmann, I plan to be available for after hours and weekends and I will also be doing house calls which I already started doing which is SO FUN! It’s so fun!!! Oh my gosh!
Dr. Lehmann: Aren’t they great?!
Dr. Lancaster: I just can’t explain how fun they are. I was just sitting there on the living room floor with a baby on a blanket and the other kids were all relaxed. It’s like completely different. I love it and I can’t wait to do more of that and I plan to do all my newborn visits up until 2 months at home so they don’t have to bring the baby in and expose them to germs. So I am really super-excited about that. And what’s really fun is I get to dream and help patients design the clinic with me. I put out a survey on SurveyMonkey which is what mom’s my age are into that technology. I’ve been getting feedback about what they want. What do you think is the #1 thing that they want? TIME! They want to have time with their doctor. That’s not high tech. They don’t want fancy stuff. It’s the same thing you were saying. It’s completely true. They just want you. They just want a caring doctor who wants to sit there and talk to them and listen to them. And help them. And reassure them. Because pediatrics is probably 75-85% reassurance. For real. It’s kind of not that hard of a job guys. It’s not rocket science. I’m super-excited and hopefully I will get enough patients to keep me plenty busy. I am also open to you guys coming to shadow me anytime if you guys are interested in seeing how it works. I hope to open my doors in March. I’m already doing house calls. We’ll see how it evolves.
Dr. Lehmann: I’m such an idealist. I am naive enough to believe that the more of us that do this and show that the system does not support us or patients the way it should, it burns out physicians, the more of us that do this, I actually truly believe we can save medical care in America. People do need insurance. You have to have it, but your primary relationship with the doctor who is going to be spending most of their life with you does not have to be expensive. I don’t know how many people here are considering going into primary care, but across the country its dying on the vine because although it is attractive in terms of the relationship, students kind of know that the job isn’t all that great. So to be able to see this and we get more people coming into primary care and going into a type of primary care that patients love and we reverse the here’s all the specialist and here’s the primary care doctors and the solution to America’s health crisis come from within between patients and doctors not waiting for some other people who don’t honestly care about us or patients. So I really hope that all of us are doing something that will actually be BIG.
Dr. Wible: Two financial pearls: You have student loans to pay. I saw the tuition for your school and I know what you guys are having to pay to live in this beautiful small town. I just want to say that I realized when I first started my part time ideal clinic that I could make just as much money working part time in my ideal clinic as I could make full time working for the man. I really want to share all my financial stuff with you. Just email me via my contact page here and request my 10-page document with all my financial information that shows how you can earn more working less. I will just give you a quick example: A 99213 $100 appointment for sinusitis in the old job where I had an overhead of 74% that meant that I would only earn $26 pre-tax from that visit. I was able to get my overhead down to close to 10% at my no-staff (I do everything and I love it!) job and so that means that for that same person I would keep $90. It’s a real difference when you see a patient for sinusitis and keep $26 vs. $90. You literally can make 3 times as much per patient if you keep the money instead of working for a big system. Let’s just face it. These big systems eat a lot of money.
One other financial pearl I want to talk about is that we currently live in a country that handles an ingrown toenail the same way it handles a lung transplant. The same financing mechanism, the same infrastructure, the same overhead, and it makes no sense because I can do an ingrown toenail or she can do a well child check on the floor in your house for very little money, You don’t need a helipad, you don’t need a 5-star hospital, you don’t need a 5:1 staffing ratio, you don’t need the infrastructure—the 74% overhead plus that you would need to do a lung transplant—to do an ingrown toenail or a Pap smear. So I think we just need to understand that like car insurance, insurance is for catastrophes. It’s not for rock chips in your window, it’s not for filling up at the gas station, it’s not for changing tires on your car. Insurance is for a lung transplant. Insurance is for big cost items. And we should let people at the community level have their relationship-driven, patient-centered practices and those payments can be worked out locally in a way that serves everyone and that’s how things were done before 1965 anyway.
Dr. Lancaster: I can’t be super-confident like Dr. Wible is yet because I haven’t actually started, but from my projections seeing 30 patients per week, I should be able to make the same as when I was seeing 30 patients per day.
Dr. Lehmann: I’ll echo that.
Dr. Lancaster: But since I haven’t started yet, I can’t tell you for sure that it is going to work here in Yakima. I am hopeful. I am very cautiously optimistic that it might work. That’s what I have it projected out and my overhead is about 17%. My space is a little bit more expensive. But I also do some side jobs. I teach cooking classes and do those kinds of things so the actual medical overhead will be closer to 15%. I’m also going to be solo-solo just like Pam. I’m going to be the nurse, the doctor, the MA, the receptionist, the everything.
Dr. Wible: Which is super-fun!
Dr. Lancaster: I’m excited!
Dr. Lehmann: I’m doing one staff. My overhead is about 20%. For me, my medical assistant (who has been with me forever) we are doing this together. She is hourly in the system I work in and she is salaried with me because there is no way I’m paying someone hourly who is as intimately involved in making this as anybody else. I debated doing it by myself, but part of this being 52 and the muscular dystrophy and the getting tired, I said, “Gina you need to just stay with me. You need to make sure I get everything done.” My overhead is going from 60% to 20%. You can do a lot with that. You can keep your income the same. You can say, “I don’t need that income. I’ll take that loss of income and do all sorts of things that I wouldn’t have been able to do before because it’s going to cost . . .” It’s really freeing. Only your imagination limits you.
Dr. Wible: By the way, there’s no right or wrong way to practice medicine. If you love the fast pace of urgent care and you want to see 80 patients per day and you love it and the patients are getting great care, then go for it! My whole issue is that doctors should not be practicing medicine as victims. You can not be a victim and a healer at the same time. You need to live your dream, the one that brought you to medical school. You absolutely do to prevent depression and we have a high suicide rate in this profession. If you are going to stay here and practice medicine and call yourself a doctor, please be congruent with the original dream that brought you to medical school in the first place.
Dr. Lancaster: Yes.
Audience question: (see below)
Dr. Wible: To repeat the question, if the patient has trauma or needs tertiary care services, how does that fit in with what we are doing? For me it’s the same as if I were working in another clinic. If it’s out of my scope of practice, they go to the place where people can handle what their condition is. And it is paid for by their insurance probably.
Dr. Lancaster: It would be the same for me too.
Dr. Lehmann: Yes. Exactly. I tell my patients, “Okay, I’m a smart guy. I know a lot of different things. I’ve delivered babies. I’ve done all these sorts of things, but there are things I can’t do. What I am offering is not that. I am not offering everything.” Patients say, “What if I need to see a specialist? What if I need to go to the hospital?” I say, “How do you do that now?” They say, “I go to the hospital because it’s really serious.” I say. “Well, that’s how you are going to do it down the road.” For me, since I chose to do a monthly set fee, it’s a set fee whether they choose to come in every day if they are a hypochondriac and I say I’m going to make an appointment at 1:00 every day until you get tired of coming in. I couldn’t do that in the world I’m in now. I look and I say, “I work for you. You are paying me to work for you so I’m going to do everything I can to take care of you within what I’m allowed to do, what’s within my comfort level. I tell my patients, “If you call me at night and it really can’t wait until the morning and it’s not an emergency room visit (you cut yourself with a kitchen knife) I will say, “Can you meet me down at the office in 30 minutes and I’ll see you down there and we’ll take care of it tonight.” It doesn’t cost anything if someone sees me one time or 100 times because they are paying me to be their doctor so that’s they way I’ve set it up and I work for you only and I do everything I can do for you when you need it. Because nobody determines really when they need care and so to do this you have to be the kind of person who is willing to say okay I’m not just going to be in a group where I have to take call one week out of the month (which is very alluring). A lot of patients wonder well, I’m paying you and I have insurance so how does that work? You use our insurance the way insurance is supposed to be used for the things that cost a lot of money and they are so urgent you’ve got to get there. I can’t take care of heart attacks in the office.
Dr. Wible: And, by the way, even though I’m on call 24/7 for 11 years now, my patients rarely call me because they get 30-60 minute appointments. They get their needs met when they are supposed to get their needs met which is during an actual office visit. There’s rarely any random, oh-by-the-way phone calls. I also only do refills during appointments so I prevent the 30% of stray irritating faxes and phone calls clinics get because they are not thinking ahead. So being on call 24/7 feels like I’m on vacation because nobody calls me because they are all on autopilot. I’ve train them well. I do my job well. They know when to come in. People [who have no experience with this type of practice] can’t believe this. They feel they will never be able to get away from their patients. It’s amazing.
Dr. Lehmann: It’s like a two-way street because they respect you the way you are respecting them. Of course, I haven’t opened, but this is what I tell my patients. They say, “Well I wouldn’t bother you at night, Dr. Lehmann.” I say, “No, if you need to please. I’m your doctor. I’m here for you.” Everybody who I know who does this says they don’t get many calls at night. Because patients know they can get in and see me that day if they need to and we have a really close relationship and we value each other’s time and if they really call me for something. it’s because it is serious.
Dr. Lancaster: The current system is very depersonalized. The production-based system is very depersonalized and it leads to desperation for a lot of patients because when they call, they are not sure who they are going to get or whether they will talk to somebody who is an actual person. They don’t know how long it is going to be before ether get called back. And it makes people panic and then you overreact, overreact, and everybody is overreacting all of the time. Everybody is like crazy all day long. The way that you do it when you are relationship-based system like this, they know who they are calling and they kind of think about it. Should I call for that or not? What’s really important to call about and what can wait for the morning? It’s not the same as this desperation-based depersonalized system.
Audience question: 1) Do you initiate bartering or does the patient initiate bartering? 2) What is the demographic and how do you care for patients who can not necessarily afford it?
Dr. Wible: So the question is about economic disparity and how do we fit that into our practices and who initiates the whole bartering idea and what do you do? I personally do not turn anyone away for lack of money and I live in a town that has rich people and poor people and I see a mixture of people. I kind of like the blue-collar middle-of-the-road crowd. Also I love the people who are off-the-grid and live in the woods on hardly nothing in cabins. I get a lot of third-world-style medicine at least when I first started. The bulk of these people who see me they all pay their iPhone bills and their other bills every month and the things that they value they pay their $100/month bills and it’s not like you are charging them something that is astronomical ($10-50/month). That is cheaper than cable and cheaper than their iPhone and somehow we think that these people don’t want to pay. Well, they don’t want to pay for disrespect, for a system that abuses them—and us! They don’t want to sit in an appointment with you and argue about you putting them on a algorithm or paradigm that they don’t want to be on so if they are not paying you, look at yourself in the mirror and try to figure out why they are not paint you. In 11 years there have been < 1% of people who really could not pay me. In my practice patients get a 30% discount for paying at the time of the visit so people don’t want to give that up so they pay at the time of service to get that really good discount. For the rare occasion when somebody is really financially strapped, I’ve allowed them to make me handmade gifts for my gift basket that then get recirculated out to other patients as prizes. I let them donate what their love and work is in the world if they are an artist and I re-use all this and give it back to other patients. Because I don’t necessarily need all the things my patients make. What do you guys do?
Dr. Lehmann: I charge $10/mo for kids up to age 20 and $50 for any kid over the age of 20. My philosophy is that I don’t feel that $50/month is an outrageous amount of money for me to basically say that I am here for you 24 hours per day. I do think there are people who are destitute. Certainly in my current multi specialty ground I haven’t had to deal with that. I agree with Pam. I don’t think I would just give somebody care for nothing. Just cause if somebody gets something for free, there is a certain sense about how they value it. Giving something is important. I even thought, what if I’m doing really, really well a year from now, I could offer people a free membership. The more I thought about it the more I don’t want to do that. I want to have some other means, that they have some skin in the game, this is a two-way street. I also believe to me that someone who has a lot of money gets the same care as someone who doesn’t have a lot of money is very appealing to me. One of my mentors who practices back east, he’s got a picture of the CEO of one of the big insurance companies in the state where he works sitting in the waiting room literally next to a guy who lives in a box and scrapes together the money each month to be seen. They each get the same care. The guy who’s living in the box sees the guy in the fancy suit and knows I get the same treatment that he gets. I’m pretty big on this is what it is and you know the value I’m bringing to you and you can decide if that price is worth it because that’s they way life works.
Dr Wible addendum: As I’m transcribing this lecture, I’m reflecting on the patients I saw today: First patient: woman living in he car. Next patient: multimillionaire. (Just had to add that!)
TaReva Warrick-Stone: I just want say real quick that I know first years have anatomy lab so if you need to go, please do so. Just please sign in and grab one of Dr. Wible’s books. Also all 3 of these doctors are going to be at the banquet tonight so if you come from 6:00 – 6:30 it will be all mingling time so you can ask more questions then as well.
Dr. Wible: And I will stay here as long as it takes to answer everyone’s questions.
Dr. Lehmann: I’m not going anywhere.
Audience question: Similar to the access question that you just asked, what about language barriers? How do we improve on that? It raises some difficulties with the direct service model requiring that common culture, common language in a way that mass-production (I work for the farmworkers clinic) and I’m realizing that the direct service model (especially being that I am in academic medicine) puts the onus on the university to improve the access or the physicians in training to match the culture and language needs of the community other than individual desire to make sure you have those skills.
Dr. Wible: So the question is the language barriers for people who are non-English speaking, who is taking on the burden of this population? How do our models contend with this?
Dr. Lancaster: Well, I speak Spanish. I’m Panamanian. I didn’t really answer the other question. I’m still evolving the way I’m going to practice since I’m not opening officially until March. Bartering is legal. They kind of do ant you to pay taxes on it when I asked about that. You have to put a value to it somehow and declare it. Okay. Whatever. I just speak Spanish, English, and a little bit of French, and maybe 5 signs in sign language. Besides the English and Spanish, I don’t know how I will reach the other people. There are language lines you could probably use and stuff like that.
Dr. Lehmann: I’m going to give you 2 answers. I speak Spanish and it gets better and better because I have a lot of patients currently who I think will follow me who speak zero English. They may have been in the country 20 years. They live kind of in a familial, they are kind of insulated. I speak Spanish which helps. I don’t know if you’ll be able to hear this, but I think this costs about 4 dollars. This is an app called “SayHi.” I know it’s available for iPhones and I guess it’s available for Androids and you can go between English and any language and backwards. So I don’t know any Japanese, but I’m gonna say, “I’m very pleased to meet you today.” [the phone translated it into Japanese] alright? So it’s all in Japanese characters which I don’t understand. Ok. Let’s do Russian. “Thank you for coming to the office today.” [Phone translates into Russian and Russian-speaking student verifies that it is correct]. It shows me that it recognized thank you for coming to the office today so I see it in English and it says it Cyrillic characters I don’t know what. Here’s this little button here in Cyrillic characters in Russian so they can click over here on Russian, they say something and it comes out in English. It’s a little slower than, but there’s 30 or 40 languages in this and it is 4 or 5 dollars.
Dr. Wible: And with a 30-60 minute office visit, instead of a 5-minute office visit, you are likely to be able to do a good job.
Dr. Lehmann: Yes! It’s great! So I pick up some bits of language. In my clinic 30 minutes is our minimum appointment. I tell patients we do not have a maximum. We take what we need. Someone says, “My parents are getting older and we need to talk about maybe going into assisted living. I say, “Okay do you think 90 minutes is enough time? Can we get it down in that timeframe? Should we book a little bit longer? Because you’re not volume-driven anymore. You are quality-driven. And if I have 500 patients and 1% of people really need to come to the office that means on average I might see 5 patients per day physically in the office. I may talk with others, but time no longer becomes the thing that drives what you have to do. So something like this is actually fun!
Dr. Wible: Yep! And that is awesome! I majored in Spanish in college so I can handle Spanish-speaking patients as well and that was exactly the population that I wanted to care for primarily it just didn’t quite work out that way.
Audience question: How do you guys logistically deal with people you kind of get in the timeframe that you have for the patient. If you have some patients that take longer, are people in your waiting room just really understanding or . . .?
Dr. Wible: So what do [waiting] patients do if you end up in a 90-minute visit with somebody? I think you are scheduling the appointments yourself so nobody is waiting.
Dr. Lehmann: Correct.
Dr. Wible: I’m scheduling my patients myself so if I am running more than 10 minutes late I have a gift basket and people get to pick a gift like a locally-made soap or lotion. I know my patients like the back of my hand so I know when the traumatic brain injury patient is scheduling an appointment with me that I want to put her at the end of the day because it takes her longer to get her sentences out. You know what I mean?
Dr. Lehmann: If you live in the world that I’m leaving (and you’ve been in), you’re not scheduling the patient. You give maybe advice to the scheduler about these sorts of problems need kind of about this amount of time, but in the old days the nurse and/or doctor by themselves you know your patient, you know what they need, you’re not gonna get really surprised. Ya know we have patients right now who call in and say, “I’m coming in for a rash.” Well, that’s not really what they are coming in for, but they wanted to say something to the appointment clerk that wouldn’t be revealing of something really personal. Well, if I answer the phone and I say, “What are you coming in for?” They’ll be likely to tell me. Or I’ll say. “Is there anything else you think that you’ll want to cover? We want to make sure we have enough time.” We block the time out. What I would do if even that was beginning to push it (the gift basket is a great idea) is that I would say, “Gosh we booked an hour and I’m surprised that this is going to take longer than that, can we maybe follow this up with an appointment tomorrow or the next day because I know I have another patient waiting and I really want to respect everybody’s time.” If you are giving people a lot of time and you are running over, unless you just have to, it’s about respect and people get it. When you’ve got a 15-minute appointment and you say you can only really have one issue and pick what is the most important thing. I know you have a list of 4 things, but you’ve got to pick the most important because we don’t have time for 4.
Dr. Wible: What is interesting about your question is that it is a real reaction to a failed production-driven model so this isn’t really an issue for us. I rarely in 11 years have run more than 10 minutes late.
Dr. Lancaster: And we’re still using technology. She has her own homemade electronic medical system. I’m using a free electronic health system (EMR) and I’m going to do scheduling and I will allow some online appointments to be made so I don’t feel the appointment times will be vague for me. I like having times in my head. And like they do my minimums are probably going to be around 30 minutes and 45 minutes for a well child check.
Dr. Lehmann: We’ll block them out. We’ll block 90 minutes out.
Dr. Lancaster: Gone are the days of double-booking.
Dr. Lehmann: If I am going on a house call I will book on the schedule that I am going on a house call. It’s just an appointment that’s at the home so somebody else doesn’t get booked and wonder where is he. So you just book it that you are going to somebody’s house.
Audience question: What is the personal skill level required to see fewer or greater numbers of patients per day. When you are seeing 30 patient per day . . .
Dr. Wible: So the question is what is the skill required or that you would be developing if you are seeing 30 patients per day versus 30 patients per week?
Dr. Lancaster: Okay. So this is a great question! This is something we recently discussed in our little group that we had for her class. Whenever you are seeing 30 patients per day, there’s stuff that you could probably handle yourself that you don’t because you don’t have time so you are pretty much a referral machine.
Dr. Wible: Or a prescription machine.
Dr. Lancaster: Ya! You are seeing a lot of stuff, but you’re not doing it yourself. But I am so excited that now I’m going to be able to have time to okay let me look up the best treatment. I can actually call the subspecialist and say, “Okay what would you do for this? Let me handle it myself and see if I have problems and I’ll send him to you eventually. But when you are seeing that many patients per day you do not have time. You’re just like, “Okay, I don’t know how to do this off the top of my head so dermatology. Okay, I don’t know how to do this so rheumatology. Ya know? So that’s a really good question! And that is one way to think about it. If you see a ton of patients, you are gonna see a lot, but you are not going to be able to handle it all yourself. You don’t have time.
Dr. Wible: And one thing that I started doing that I highly recommend because it is so much fun is that if you do end up having to send one of your patients to a specialist after multiple 30-60 minute appointments with them, you have the luxury to now go to that appointment with them!
Dr. Lehmann: I already have that.
Dr. Wible: It’s so much fun!! Basically the way I practice I feel like I’m a smart doctor and a perpetual medical student at the same time. It’s like I can always approach every with the bright-eyed excitement of the first day of third year and spend as much time as I want. It is so much fun!
Dr. Lehmann: Yes. I tell my patients, “What if I came with you to your specialist visit?” They’re like, “What?”
Dr. Wible: For $10 per month I get all that?
Dr. Lehmann: Ya! We just block it out. Then I get to know what the specialist sys. I get to learn and they don’t miss something that I know that maybe the patient forgets to say. It’s pretty cool!
Dr. Wible: Ya!
TaReva Warrick-Stone: I want to give our panelist a big round of applause, I you haven’t signed in yet please do so and grab one of Dr. Wible’s Pet Goats & Pap Smears books. And all 3 of our panelists today are going to be at the banquet tonight for more questions.
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This panel was filmed on October 29, 2015 at Pacific Northwest University of Health Sciences College of Osteopathic Medicine in Yakima, Washington. Director of Photography: GeVe. Music by GeVe.
My mom is so awesome. Today she turns 75! So first things first . . .
For the record: Judith Wible is a straight shooter. And she doesn’t take any BS. She scared the crap out of me as a child.
My mom is not the typical mom. I never saw her in the kitchen as a kid. She doesn’t bake cakes and cookies. She doesn’t even use her stove. When she sold her house, the stove was actually still new—never used!
We do not have the typical mother-daughter relationship. We hate shopping. We hate cooking. No, we have never gone for a mother-daughter manicure.
What do we do? We talk politics, psychology, and medicine.
As a child, I spent nights hanging out with suicidal schizophrenics at the state psychiatric hospital with my mom. She’d read me her psychiatry journals before bed. She’d pause on every pharmaceutical ad—the distressed patient reaching for a Valium—and she’d ask me, “What do you suspect is going on in that woman’s life?” Classic move for a psychiatrist. Yep. She had me telling my own bedtime stories while she psychoanalyzed me.
She’s hard core. She had to be to graduate medical school in the 1960s!
In 1965 my mother, Judith Wible, received her medical degree from the University of Texas Medical Branch at Galveston. Of 160 graduates, eight were female. The dean and fellow students reminded the “girls” in the class that they were “taking a man’s seat” and they would never use their degrees. Even the anatomy professor refused to accept female anatomy and persisted in addressing women as men. Despite her protests, my mother remained “Mr. Wible.” Women were excluded from urology—from palpating male genitalia—while men dominated obstetrics and gynecology. Daily, the women were exposed to filthy jokes that demeaned female patients, and in the evenings they slept in cramped nursing quarters while the guys had fraternities complete with maids, cooks, parties, and last year’s exams.
The dean and other medical school instructors actually accused her of being in medical school just to get a man! With the kind of behavior she witnessed in medical “men,” she had no interest in marrying one! Believe me. Mom is lesbian.
Mom and I graduated from the same med school. We recently attended her 50th medical school reunion (my 22nd reunion). No, she never married any men in her class. Though I got to meet several of her classmates who married nurses during med school—and then divorced them just before graduation!
So here we are in 2015. Though women are now 50% of medical school enrollment, we’re still held hostage to a patriarchal medical model that values a male construct of the world. It’s not working guys. You men need us—and not just for doing laundry and cooking.
To support women in medicine, my mother has started the Judith Wible, M.D., Scholarship for Visionary Women in Medicine to help female medical students along their journey to become true healers.
If you’re a female medical student, a visionary who is overflowing with love and passion for health and healing, and if you have the Judith Wible invincible spirit, we encourage you to apply. Every year up to 3 medical students will receive $10,000 each toward their medical education so they can live their dreams.
On September 17, 2015, Pamela Wible, M.D. spoke to the students at the College of Osteopathic Medicine of the Pacific-Northwest. Enjoy the video. Transcription below:
Jay Anderson: Tonight we have Dr. Pamela Wible. She’s here to talk to us about the adventures of setting up a solo practice, how you can actually still be a happy solo practitioner—unlike many of the stories we’ve been told by a variety of our mentors the last several years (I’m sure you’ve read about many of them). I happen to know Dr. Wible. I’ve been following her for several years now. I’ve followed her in her adventure to address the institution of medicine itself and its profound effect both on students and doctors. She lectured here last year around this time on that very topic. And we are happy to have her here again tonight so without any further ado, Dr. Wible.
Pamela Wible: Thank you. So I was told there would be less people here so I don’t know if everyone got a book, but I found two more in my car. Pet Goats & Pap Smears is a book that I wrote in 2012 to help medical students be inspired, kind of like “chicken soup for the soul for medical students.” So if there are more people who did not get a copy of the book, I will just send them this way. If anyone else wants a copy just contact me afterwards. Leave your phone number on the list and email.
Okay so I have been asked to share some of my perspectives on solo practice and that’s got to be my favorite topic. I think I’m just going to read straight from the email that Jay sent me and then I’m going to answer your questions. So if you have any questions that come up feel free to write them down on the little scraps of paper that I’ve sent around or just go ahead and raise your hand and I can answer questions as I go through here. And then we’ll have a lot of Q & A at the end because again my objective is to leave everyone with all your questions answered.
So straight from the email: “Many of my colleagues, especially those interested in practicing in rural areas, would love to hear your insights on how we might shape both our training and our professional expectations for the future, so that we may serve the people in our communities with an emphasis on the rewards found in personal interaction rather than those of efficient production.” So there are 3 things I’ve pulled out of that paragraph that are pretty essential to discuss right now.
1) Personal interaction rather than those of efficient production.
Another way of saying that is relationship-driven rather than production-driven medicine. And that is a term that everyone should be familiar with because you will end up working in one or the other. There’s not really much of a middle ground. When you are going to work you will know if you are in a production-driven practice because everyone is very concerned about no-show rates and numbers on the schedule and how much time you are spending in a room and when you can get to the door soonest. You can only answer 1 or 2 questions and then tell them to reschedule if they have a third question. That is a production-driven practice.
A relationship-driven practice is what I’m in and what I think health care should be for everyone. It’s basically where the relationship drives your day. You are so energized by the deep relationships that you are creating with your patients and the healing that is coming out of those relationships that you are not really focusing on numbers of patients per day. You are not feeling rushed. I have 30-60 minute appointments with my patients versus 7-minute visits and double/triple-booking and all of that. So it sounds like you all would like to know how to do the relationship-driven model which is the healthier way to practice.
Another term that I sometimes use for production-driven is assembly-line medicine(watch this 54-second video to get the picture). So I don’t think anyone signed up for medical school to get involved in an assembly-line medicine career. And so I would like to drive home the point that you don’t have to do that even though many of your mentors might be practicing assembly-line medicine. That’s not the only way to practice medicine and I feel like [assembly-line medicine] really isn’t consistent with health care. It doesn’t make any sense to me and I would like to encourage you all to think about diving into relationship medicine which is pretty much the old style pre-1965 when people had doctors in their neighborhood. The Marcus Welby sort of thing if you remember that or you can look online on YouTube at those old reruns that were even before me really. People still talk about it, ya know. When I talk to patients that’s what they want is the house calls and the Marcus Welby type of neighborhood doctor. And that’s probably what you all wanted when you signed up for medical school.
2) Serve the people in our communities.
The second thing I pull out of that paragraph is “serve the people in our communities.” So in order to serve people in your community it’s really important to know what they want. So you could have a really cool idea of what you want to deliver and if you just hang a shingle and deliver that, you might not be delivering what they want. You might be forcing them onto an algorithm that they don’t understand and have really no respect for and it wasn’t even what they were looking for when they came in. So it’s very important to ask the community what they want and to ask your patients what they actually want from you instead of just holding them hostage to what you think they need to have because that is like a set-up for non-compliance when you put yourself in charge of what you think they better do. Not only does that create a scenario where they’re probably not going to follow your instructions; they might start to lose respect for you, and you might feel like you’re in an invisible tug-of-war. You are trying to pull them onto an algorithm that you think they need to be on based on what the EMR tells you that you are supposed to ask them next or something and what they really came in for is totally different. It is a set up for a completely frustrating life as a physician and it’s set-up for not having great outcomes on your patients and I don’t think that’s what you wanted either when you signed up for medical school. I will tell you a way that I was able to determine what my patients and my community wanted before I opened my practice
3) How we might shape both our training and our professional expectations for the future.
The third line I pulled out of that paragraph is “how we might shape both our training and our professional expectations for the future.” A really great way to shape your training is by aligning yourself with mentors who you respect who look like they are having fun practicing medicine, who are successful as doctors. You can spend a lot of time with cynics and naysayers, people who will tell you that your dreams are impractical and they can never come true. Maybe they are just projecting because their dreams never came true in medicine. I think it’s really important for you to meet people whose dreams have come true as physicians, who are happy and successful in their practices. Because if that’s who you ultimately want to be, I think that’s ultimately who you need to hang out with. Right? Because you can hang out with people who have never practiced medicine who just teach basic sciences. If that’s what you want to do in the future then hang out with people who teach basic sciences. If you want to be an actual doctor, hands on with patients, then you need to meet hands-on pediatricians or family doctors or gynecologists. Whomever it is that you would like to be when you grow up. Right?
There is a possibility that you can’t find somebody practicing exactly the way you imagine that you might want to practice one day. Then find other people maybe outside of your specialty. So if wanted to go into pediatrics and you can’t find a really happy pediatrician in Lebanon then maybe hang out with a happy family doc or come to Eugene and visit me or I can tell you other people around this area who you might want to do rotations with or spend an afternoon with, for example. So I think when you start to do that you will be that much closer to becoming that type of doctor. Also these people are a wealth of information. Another thing that would be fun to do and I’ve been recommending this to the people in my teleseminars and retreats is hang out with people who are outside of the industry of medicine. So say there’s a successful coffee shop in Lebanon or a bookstore that’s really doing well (when other independent bookstores may be going out of business there’s one that’s thriving), it would be cool for you to hang out with the business owners of businesses that are doing really well so you can learn from them what it is they are doing that makes them so successful. Hanging out with successful people. Aligning yourselves with people who are practicing the way you want to practice.
I thought I’d share my story with you and I’m all about being raw and honest and giving you the full dose of who I am and what medical school was like for me. So I’m not going to hold back. My first year of medical school was the worst year of my entire life and I’ve lived 47 years now on the planet and I can continue to say that it was the worst year of my life. I spent most of my time crying into my pillow at night. I felt disconnected from humanity. I felt like I was watching my classmates have their souls removed from their bodies like in a dehumanizing cult. It was really weird. It was not human. It was not normal. Reading my diaries from medical school, I feel like it’s like reading the diary of someone in a concentration camp or a prisoner of war. I don’t know. It’s very strange. It wasn’t at all what I had imagined. I knew it was going to be hard going to medical school, of course. You have to consume a lot of information and pass your tests. It’s not like I wasn’t used to doing hard work. I was totally prepared for that. I just wasn’t prepared for the inhumanity of it. And it is absolutely unnecessary for us to be having a medical education that’s inhumane. It’s like an oxymoron. You’re being trained to deliver health care, but you’re being abused (and dehumanized) at the same time. It makes no sense. Big wake-up call here: we need to change that. We change it by standing up for what we believe in, by calling things the honest truth. I’m just telling you the truth. You don’t deserve to be abused either during medical school, after medical school, by an employer, by a patient. You don’t. You are a human being with feelings who came into this for the great love of humanity to try to help people. Why should you be victimized in the process? It makes no sense.
That was my experience 20 years ago. I somehow thought that had changed in 20 years, but apparently not because I keep getting emails from people who are still suffering in medical school even today. I think your medical school is one of the more humane medical schools so thank God for that! You have colleagues out there who are not being treated well or they are in situations where somehow their teachers think fear-based training is still acceptable in 2015. Fear-baed teaching is really not acceptable anymore. Bullying has gone out of style. Bullying—you’re not allowed to do that in elementary school and other schools, right? Hazing is not allowed in fraternities and in the military. Why would medical school be the last one to catch on to this? Sleep deprivation is more dangerous than probably being drunk at work. Chronic sleep deprivation is a rite of passage in medical training. So I just think to stand up and tell the truth that medical students and physicians should not be sleep-deprived, hazed, bullied and that should be our expectation from here on out. If you see that [bullying, hazing, etc . . ] I would ask that you stand up for yourself and your colleagues who are being mistreated. First of all the person who is doing this might not have caught on that it’s 2015 and that’s not in style anymore. Second of all it gives a really bad message to others that you are willing to be complicit in watching this and not intervening. It shows that you are not a real healer if you are willing to witness something that is inhumane and not stand up for the person next to you who is probably your classmate or could be a patient. There is no place for this behavior in clinics or hospitals in 2015. I hope you’ll stand with me on that one. I even have anti-bullying cards I can hand out at the end which I got for you. I think they are really for elementary school students, though they seem to be relevant for medical students now. Wondering how to stop a bull on the loose in med school? Here’s how one medical school class stood up to a bully professor and prevailed.
My second year was a little better
So that was my first year—really sucked. My second year was a little better mostly because I was further away from first year. That was probably why I felt better because I could see the light at the end of the tunnel which was luckily not my death. During medical school I was really depressed. I was not suicidal, though I was sometimes having trouble understanding why it made sense to go on. I wasn’t actively suicidal. Although both the men I dated in medical school who were classmates died by suicide after I graduated. So this does take a toll on other people if you don’t stop this abuse and that abuse led in part to losing many of my colleagues, including both men I dated in medical school. We need a humane environment in which to practice medicine and we really need to be healers. Even though you don’t have your degrees yet I would like to encourage you all to be healers today, like right now. Just take on the role of a true healer. So anyway second year was better.
Loved my third and fourth year
Third year was a lot better because (if you haven’t figured it out) I really like people, I like talking, I like socializing, I like figuring out problems, I like being with humanity. I don’t like sitting alone in a study dungeon. It really helped to finally be able to be with real people in the hospital and to deliver babies and to do all the really amazing work that we can do for people and be there during their milestones in life. I loved third year. Fourth year was great because I was able to do a lot of electives and leave town and live in Maui, somehow I got credit, I don’t know how I did this, for living in a commune on Maui. It was really fun. All sorts of parties. I took an elective “The History of Childbirth” that made me really happy that I didn’t deliver a child in this lifetime or in a previous lifetime. It was just fun because you have a little bit more control over your electives and you definitely see the diploma coming up pretty soon so that was great!
Residency was awesome
Residency was awesome for me because I chose really well. I would like to encourage you all to choose your residency well. What I did is I knew I wanted to do family medicine. There are a lot of family medicine programs that are full spectrum and do C-sections and sigmoidoscopies in the grocery store parking lots and will teach you do to everything in any setting in the middle of Alaska. I wasn’t really interested in doing that. I’m more into behavioral health and so I went to a residency that did not sell itself on a lot of procedures, even though I do skin surgeries and minor procedures in my office. I really did not see myself doing C-sections on the weekends and doing sigmoidoscopies and other things like that for fun for a living. I would much rather talk to people. I went to University of Arizona Department of Family and Community Medicine. I loved it! It was much more fabulous than medical school. Of course, everything is fabulous after medical school.
Residency was good and then my first job . . . that’s when things sort of started to suck again. But one more thing about residency. The title of my program was “Family and Community Medicine.” I’m a big-picture systems thinker and I wanted to be able enact change at large scale. [In medical school] they tried to convince me to go into pediatrics. Well, I could spend all day with a child and not make much progress because the parents are smoking and they live next to a toxic waste dump. In order to deal with the problem that this child is having, I really need to look at the big picture which involves the incinerator next to their house and their parents smoking and all these other things. I chose family and community medicine because I wanted to have an effect on individuals and on the entire community. It’s really strange because I don’t think I learned anything about how to have an impact on a community. I think by nature I’m a community organizer so I just like to do this for fun, help communities and bring people together. I thought it was strange that I didn’t get taught any of this. On my own I developed my community-driven medical practice.
My first job sucked—and so did all my employed jobs
Into my first job, it was better than residency in that they start you off slow on the treadmill and you’re making more money. You’re getting paychecks and moving slightly slower than residency, but it doesn’t take long for them to speed up on the treadmill. Once you get sped up and you’re seeing double/triple-booked 30 patients per day, I was thinking I can’t imagine doing this, assembly-line medicine, the rest of my life. I tried 6 jobs in 10 years. I’m not one to stay anywhere that I don’t like so my resume looks just crazy for the first 10 years of my career. I’m like everywhere and that’s because I thought all my jobs pretty much sucked or they were not what I was looking for or could see myself continuing for more than a year. I tried a migrant farmworker clinic, a hospital-owned clinic, small private practices owned by physicians, I even tried a part-time job and I was really ready to kill myself at that point (not literally) but I just couldn’t believe that even working just Wednesdays and Thursdays at a part-time job I was still not happy as a doctor. Ya know what I mean? That just makes no sense. I’m hardly working and I still hate my life. Why is that? There is no amount of weekend or vacation that can make up for a crappy job. If you have a crappy job, the only cure for it is to get an ideal job. There is no way to string yourself along until retirement in a crappy job. You might look out and meet other doctors who are stringing themselves along in crappy ons because they feel trapped and victimized an they don’t know how to get out. They think they will somehow default on their student loans or not be able to send their kids to college. They bought the party line which is BS.
By the way, these employers and health systems they [management] go to weekend seminars where they learn the talking points that scare the crap out of doctors to keep doctor stuck in their jobs. You are essentially in paper chains. Your employers knows you are their only competition. Why would they put you in an empowering position? They don’t want you to have any time to think about what is going on. They keep you in survival mode so that you are literally slaves. Sorry to say you are high paid, in servitude, in paper chains. Have you heard the [African] story about the goat tied to the tree. It was so used to being tied to a tree that when they untied the rope it just stayed there. This is physicians. Physicians are standing next to the tree and they’re not moving because they think they can’t. You’re in paper chains. Your employers only competition is you. You could slip out and go across the street and make more money working for yourself than staying a a job that you will hate. Plus you’ll have a better life. Your wife or husband will like you better. You’ll be able to see your kids more. All the other good things in life happen when you like your job. Believe me, there are no amount of trips to Hawaii that will erase a crappy job. There is just no way to recover from it—even after a weekend. When you go back on Monday, it still sucks.
I had to get out of there. Here’s what I did. I basically hit rock bottom. I guess I’m one of those people who needs to suffer a lot before I make a decision to do something. I need to marinate in self-pity for a really long time. I don’t really recommend that. I’m trying to give you the easy way because I did 10 years of unnecessary misery. I took the hit for you guys so don’t do it. That’s all I’m saying. I’m recommending just from the get-go when you graduate that you start practicing the right way that you love and you don’t follow me through the 10-year detour into how many crappy jobs can you accumulate in a short period of time.
So here’s what I did: It suddenly dawned on me that no matter how many different jobs I tried, they were all playing the same song. It’s all assembly-line medicine with different faces, different clinic managers, same situation. I even went to Washington and Oregon. Multiple states. Same story. I did get really depressed at that point. I was born to be a healer. Both my parents are physicians. I went to work with them when I was little. I saw medicine in its heyday. I know this is BS and there’s another way and I can not believe I’m locked into this and I just had to figure something out or either go back to waitressing or do something else or kill myself. There was just no way I could do medicine like this.
So I had this epiphany that if the patients are not happy (believe me they are not). If you’re not happy, the patients are not happy. I thought what if I just ask the patients what they want! And then I’ll do what they want. They must know what they want. Right? And that’s what I did. I basically held town hall meetings. I call it that because I feel like it was politically subversive or politically active to bypass all the bureaucracy and hierarchy of medicine and go directly to the end user and with total sincerity ask “what do you want” because as long as it’s basically legal. I’ll do it! That’s what I told them. I got 100 pages of written testimony and over 6 different meetings. The smallest one was 4 people in a living room and the largest one was 30 people in a community center. I read and reread all their testimony and I finally understood what patients wanted. Guess what? They want exactly what I want! We were all on the same page. I don’t know what all these other people are doing in the room. Too many cooks in the kitchen. They need to get a real job because quite frankly I just listened to what the people wanted in my town and what they wanted was a small office and one doctor. They want accessible visits and house calls if necessary and they are totally happy to pay you. They want an integrative approach. If you can’t help them, let them know which acupuncturist to see. They want it to be fun, down the street, not a hassle. They basically want every single thing that you guys want.
There’s a word called DISINTERMEDIATION. Does anyone know what that term means? You should write it down. It’s really important. Disintermediation means removing the middle men—a really great way of life! You remove the middle men, then suddenly (check it out!) you are more likely to have that direct relationship with the patient. The patient is paying you and all those middle men who are taking huge cuts out of the patient’s payment (whether from insurance or self-pay) they’re not in the room anymore. See? So honestly at my favorite factory job my overhead was 74%. I brought in 500K per year (1 million in 2 years) revenue to that office and my overhead was 370K per year. I can think of a better way to spend 370K than on overhead at a clinic I don’t even own! The difference between doing that and practicing the way I’m practicing now here’s some numbers from 2000 and 2004. In 2000 at my favorite factory job, my overhead was 74% which meant if somebody came in and gave me 100 bucks for an office visit that 74 dollars went out the window and I was maybe getting 26 dollars before taxes. So that’s how much I was getting for treating pneumonia, for example. Now at my current practice (since I have like 10% overhead since I have no staff and do everything myself and it’s really fun and easy, you can streamline tasks with IT and online appointments etc . . ) I can see the same patient get $100 bucks and keep 90 and $10 goes to overhead. You can pay off your student loans a lot quicker if you keep 90 versus 26. Just FYI on that.
And the other thing I wanted to figure out because all these doctors look so tired, I thought there had to be a formula that would reveal why they are so tired. By the way, I’ll email you the document that has all my calculations so you can look at the numbers before an after. There’s another calculation I did called DNW (Days Needed to Work). %OH (percent overhead) you should figure that out for every job because you need to know how much money you are giving away just for the privilege of working there. Then DNW I needed to know how many days I needed to go into the office every year just to pay my yearly overhead. Well this will blow your mind. At my favorite factory job I worked 190 days per year on my contract and 74% of that is 143 days so I went to work 143 days every year for free. How do you like that? If you want to be abused definitely sign up for a job where you are working 143 days for free. They’re not easy days! Alarm goes off way before your natural circadian rhythm wants to get up. You are going to work and staying way later than dinner and you are seeing like 30 patients per day. And you are doing it for free!! And your student loans are not coming down at all because you don’t even get to keep any of that. So 8.6 months per year, I was working for free and that was my favorite job. I’ve had worse jobs than that. Now I can pay my yearly overhead in 11 half days. I work 3 half days per week for the most part over the last 10 years. I work afternoons and evenings so I’ve never set an alarm for work in 10 years. Doesn’t that sound great? I make the same amount of money working part-time on my own as I did full time on the assembly line because I was giving all this away! I was giving all my labor and my energy away. And my love. Everything.
The other number that really hits home is NNT (Numbers Needed to Treat). I’m sure you’ve heard that term used in other contexts. I use NNT in terms of economics. How may numbers of patients do I need to treat per year to pay my yearly overhead? In my previous practice, my favorite factory job, does anyone want to guess how many patients I had to see to pay my yearly overhead? Just guess. . . throw a number out . . .
Jay Anderson: 4000
Pamela Wible: Oh my God He’s so good! 4004. (Laughter) He’s going places! 4004 patients I saw every year for free! Can you imagine seeing 4004 patients just for fun and for free while your student loan interest is increasing and you can’t pay your mortgage? You have no money left over for preschool for your kid or peanut butter and jelly sandwiches. Come on. Wake up. You do not have to do this. You do not have to be abused. Physicians are being abused all across this country. They won’t even call it abuse. They just think it’s normal. Frogs in the hot water. They think it’s normal to be boiling over. Like really the next generation, you guys, have to put a stop to this! This is insanity.
In my current practice I can pay my yearly overhead in 88 patients. It feels so much better. Talk about freedom! Talk about feeling good every day! Talk about having time to come to your medical school and speak for free. It’s because I’m not on a friggin’ clock working 8.6 months for free. Why are other doctors not able to come here and spend all night and smile and give out free books? They don’t even have time to write a book. They don’t even know what their name is by the end of the day. They can’t even finish their charts over the weekend so they can start the next week fresh. They are completely a disaster zone. And they are living like that is normal! Please tell them it’s not. And don’t do this to yourself. Its unnecessary. So that is my little quick story on the 3 calculations that you need to know. (laughter)
And let me just point out a few other things that I think you should be aware of and then please ask me questions. Raise your hand any time if you have a question.
Mismatched Expectations in Medicine
I believe there are 3 big mismatched expectations in medicine. Ya know, mismatched expectations are really what get people in trouble. Even with dating or raising children, if you in your mind have one idea of how something is supposed to go and it doesn’t go that way then it creates tension in your relationship. I think you know what I’m talking about. A lot of times we’re not really clear on what we want so it’s not really the other person’s fault because they can’t read our minds. Right? I think there are 3 HUGE mismatched expectations in medical training that need to be stated out loud.
1) Medical Student Mismatched Expectations
There is a medical student expectation that is not met by medical schools. This has to do with your personal statement. You are writing what your end goal is, what your dreams are, why you even want to come to medical school. You get invited to pay 50K/year or more which you would expect would put you on the path of your personal statement coming true—your dream that brought you to medical school. Does anyone ever ask you again how are you doing with your dream? Or are we meeting your expectations? No. In fact, they may say the reverse. Your dream is impractical, impossible. You have to do assembly-line medicine. Med school does not give you the tools to live out your personal statement. To me that is a total breach of contract. You just paid 200K or more for tuition and you got accepted based on your personal statement and nobody taught you how to make that come true? That’s the whole reason you are here. That’s really strange. That is a mismatched expectation. I think it’s normal for a medical student to expect that once accepted to med school that the school would help you bring that to fruition. Somehow the personal statement gets filed in a drawer and never looked at again. Then you graduate and it’s a blur. I think medical schools need to teach to your personal statement or at least ask you to get out your personal statement and asses your progress. Let’s see how you are doing? It’s not all their fault. You have to do some work too. This is your call to action. Are you making your personal statement come true? Dig it out. If I were you I’d post it on your wall, put it on your bathroom mirror, put it everywhere. This is your North Star. This is what’s guiding you through your training. If you don’t have your personal statement which is your soul’s desire to even be here, there’s no reason to be here. You wouldn’t just do this because it’s fun. (Laughter) It’s up to you to live your personal statement. I would ask your schools to teach to your personal statement and help you find the mentors you need to bring your dream to fruition.
The second mismatched expectation is a humane learning environment. When I entered medical school, I just assumed it would be a humane environment. It’s heath care! I had a great college, Wellesley College, all women. They told us from day one that we were women and we shouldn’t take any shit from anyone. They told use we could be anything we want in the world. Hillary Clinton went there and Madeleine Albright, Diane Sawyer. I come from a place where women can do anything and the message was that nobody could stop you. Then I go to medical school and they’re like shut up, sit down, follow the rules, we don’t want to hear back from you for 4 years, don’t cause any trouble. I thought education was about asking questions, learning, and it’s okay to have a different opinion, and you are allowed to dissent. I didn’t think education was groupthink, right, left, right, left, shut up and don’t ask anything. That’s basically what medical school felt like to me—an indoctrination process where you were not allowed to have a different opinion and that was distressing and inhumane and that’s not an education, that’s indoctrination, that’s something else. A humane learning environment is an expectation that I think you all came in with and I think your med school is better than most. There are schools that still use fear-based teaching, schools that don’t encourage open dialogue, schools that are intolerant to dissent, that have a memorization-regurgitation cycle of learning. This isn’t working. I would encourage you all out there to demand the humane education that you are paying for.
You also expect that you will have mentors that you can look up to who will guide you. I hear from medical students all the time that they haven’t found any mentors. They describe medical school as an anti-mentorship program. You meet a lot of doctors you’d never want to become. You need to ask for mentors, You are paying for an education and you deserve mentors.
2) Patient-Physician Mismatched Expectations
This is a big issues in primary care. If you are getting a lung transplant, you get a lung transplant and hopefully you live. Primary care deals more with emotions, culture, community, neighborhood, behaviors. Medical school didn’t really teach me how to be a real primary care doctor. Helping people know what to eat, for example. I had to learn that on my own. I did learn to give the right drug for strep throat, what drug to give for what cookbook diagnosis. I did not learn what most people really need. I paid the money, yet did not get the training. I had to learn on my own and on the weekends. I learned from my patients. A patient would share what homeopathic worked for her insomnia. Oh great, let me right that down so I could tell other patients who want non-western medicine that they can try this homeopathic too. I’m learning medicine from my patients. Patients have an expectation that you know more than them, that you can guide them. They want to know more than just pills and interventions. They want a holistic approach. It’s 2015 and people don’t want the old patriarchal authoritarian model. They want a partnership and answers. They’ll Google the answers on the Internet if you don’t have them and then you’re gonna look like an idiot. We should have these answers.
Patients also want time. Patients come in hoping and praying they will get the time that they need with you and answers to their questions. Patients do not want 7-minute office visits and they keep getting shoved into these inadequate appointments. In some places like Kaiser my friend told me she has 20-minutes to do a physical. Think of all the holes in the body. Can you really look in all of them in 20 minutes without being like a complete ass. Can you actually do a humane and thorough physical on someone and still have them like you at the end? (Laughter) Probably not. There’s a mismatch between what patients want from you and what you are giving to them.
3) Primary Care Mismatched Expectations
It may be different here, but medical training is very tertiary-care focused. My training was in a tertiary-care environment. Tertiary care is what we were supposed to do. There was lip service given to primary care. You only go into family medicine because you aren’t smart enough to be a surgeon or you couldn’t get into radiology or a real specialty. The overall environment is very toxic for primary care. Some of us are belittled for choosing primary care. The other issue is that whenever politicians talk about health care, they should really just be talking about tertiary care because nothing they say makes much sense for primary care. If you need a lung transplant, for example, you do need a 5-story hospital and a helipad and a team and lungs on ice and it’s a big production and you need high overhead. You do not need that for an ingrown toenail or a Pap smear. When politicians talk about funding health care, they are lumping it all together. You do not need a team for a Pap smear. In fact, that would be offensive. Do you want a football team to come in and do your Pap smear? It doesn’t make any sense. Primary care and tertiary care are two different animals. Just look at your car insurance. Really. Every time you’re going to fill up your car, you’re gonna get approval from State Farm? Rock chip needing fixed in your window do you really want to call your insurance company? It makes no sense to involve all these people in the simple day-to-day events of life. If your car explodes on the highway or it’s totaled then you call the insurance company. That’s what insurance is for. Catastrophes. By forcing primary care into a tertiary care high-overhead model it leads to high cost 7-minute office visits. The average primary care visit is 40% more expensive because of all the unnecessary people in the room.
What Medical Education Lacks
Medical training should teach 3 skill sets: the technical skills, the business skills, and the human skills. Western medical schools generally do a really good job teaching the western technical skills. They do not generally teach the holistic technical skills (diet, exercise, lifestyle, herbs etc . . .). So basically we learn half of the one technical skill set. The business skills we learn zero. I had to learn all this on my own. These formulas that I shared with you today have changed my entire life. The business of medicine is very easy to learn. If you don’t control the business of medicine then who is controlling it? The people who are controlling you. They’d love to stay in power. They’re making a lot of money. They’re going on trips on the weekends. They’re playing golf while you’re working on a treadmill for them. They don’t have student loans. And they’re telling you that you’re not moving fast enough. So they are really in your way, especially in primary care. The third skill set is the human skills like how do you give bad news, how do you tell parents their 3-year-old died in the car accident? How do you grieve the loss of a patient? I did not get taught any of that. We we’re just winging it. Without learning those 3 skill sets that you need to be the doctor you described on your personal statement, you are graduating like an automaton robot because you did not learn the human or business skills so you are easy prey for anyone who wants a workaholic humanitarian to work for them. And they’ll run to the bank with all the money. And that’s al I have to say. (Laughter) I really hope you guys will stand up for yourselves and not be preyed upon. I want to answer questions.
Questions & Answers
Student: Can you tell us a little bit about your patient panel?
Pamela Wible: My patient panel: I work part-time Mondays, Wednesdays, Fridays afternoons/evenings generally for the last 10 years. I have 800 inactive patients and 500 active patients which is a manageable number that I can handle. I’m doing a good job for them and answering their questions in 30-60 minute visits. I can sleep well at the end of the day knowing that I delivered health care not doc-in-the-box or Arby’s sandwiches. I don’t want to feel like I’m doing a weird fast food job like McMedicine. 80-90% insured, 10-20% uninsured. I am now out-of-network with insurance companies which I love! I was a preferred provider for 10 years which meant that I signed all these insurance contracts and was willing to accept whatever they wanted to pay me. Oregon is the second highest reimbursing state in the country so it’s great to work in Oregon. I just got tired of following all their rules and personally I like the idea of being free to charge what I want and getting paid a fair amount for what I’m doing. If I’m delivering $150 of service and the insurance company says it’s only worth $109, It doesn’t feel right.
By the way, going back to the 4004 patients that I saw for free. I answered about 5 questions per patient. I’ll answer everything from marriage questions to medical to emotional issues. So I answered over 20,000 questions for free! It is so much nicer when you have a patient panel that you can handle and people who selected you because they love you. They did not select Kaiser or a large organization. They handpicked me. It’s kind of like going on a date with someone who really wants to date you instead of somebody in Eugene. It feels totally different. (Laughter)
Pamela Wible: I did hospital visits for the first 2 years. Then I gave up my hospital privileges because I only had 1 or 2 patients per year needing to be hospitalized and they mostly needed specialists so I did more like social visits since they were not often primary care admits. I really enjoyed seeing my hospitalized patients when they were mine versus I’m covering for 20 doctors and walking into the room of a dying guy I never met before and I have to tell his wife, “Sorry your husband died and I have no idea who you guys are.” The weird reason why I discontinued my hospital privileges is because the hospital I was associated with raised their hospital staff dues from from $300 to $700 per year. Yes, you have to pay an entrance fee to get into the hospital to see your patients. It would be a financial loss. Even if the 2 admits per year were primary care, I’d never make up the $700. Hospital dues has always been $300 per year and then suddenly they went to $700 after they opened a big new hospital in town. I called them to find out why my dues jumped so high. They only raised those dues on “courtesy” physicians and not “active” physicians on staff. Active physicians admit more than 25 patients per year and courtesy admit less than 25. So I was getting penalized as a low utilizer by a hospital who really didn’t give a crap about me.
Student: They were rewarding the docs who actually brought them business.
Pamela Wible: Yep. I did organize several of the courtesy staff docs to meet with the medical staff director. There were 94 courtesy staff and nearly 300 active. These docs are so busy they didn’t really catch on that they were being penalized. I let some of them know and 10 or so came to the hospital to meet with the med staff guy. So he wiggled around in his seat a bit and lowered it to $500. Still just the principal of it. And I had emailed another doc to let her know about this. She’s a dermatologist in town. She wrote back, “Just call 1-800-U-R-FUCKED.” I thought it was a joke, but it wasn’t a joke. You can dial it and it leads to the billing department at the hospital where I worked. (Laugher). You don’t even have to read between the lines. Sometimes you are getting screwed at your job. All you have to do is dial the phone number. It’s been their number for like 30 years. The Catholic nuns would not approve of this. (Laughter) I just couldn’t go on with it. I had to give up my privileges. I like to align myself with people who share the same ethics. Did I answer your question? You probably got more than you bargained for.
Student: Can you speak more about the kind of patients you have?
Pamela Wible: I got these really interesting group of patients who came to see me who hadn’t seen a doctor in like 20 or 30 years so I got a third-world medicine experience. These are people who distrusted western medicine, but because I did a town hall meeting and I seemed different than the assembly-line medicine doctor they were willing to trust me. So I got to diagnose all sorts of weird things. The second chapter in the book is the first patient who walked in, a guy with renal artery stenosis and we had to do emergency intervention. It’s been really fun. I have middle class patents mostly. Not many super wealthy. I kind of gravitate toward the regular person. I’ve got a regular person kinda clinic filled with really interesting people who are off-the-grid types. Lots of women. You know 70% of all office visits are women unless you are a urologist. As a female family doc, at least 70% of your clients will be women. If you’re a male doctor, you’ll get more males. I don’t get a ton of kids. I don’t really gravitate toward people who you can’t talk to. Not really into the diapered little kids. I don’t want to do veterinary medicine.
Student: You say you are no longer contracted with insurances so are your patients all paying upfront?
Pamela Wible: No. I’m still billing insurance. So there’s self-pay, people who pay cash and physicians who just break free of it all and do cash only. That’s one way of doing it. That was they way it was always done pre-1965, the predominant method until we had third-party insurances. Then there are 2 different ways you can deal with insurance companies. You can totally play their game and sign their contracts and be a “preferred provider.” That means you are in their “special clique” of people willing to take less money per patient and follow all their little rules and some of them you may think are dumb.
To contract with an insurance company you have to fill out a credentialing application. They want to know that you have a medical degree and you don’t have DUIs. You fill out the same paperwork that you fill out for everything (like hospital privileges, state licensing, etc . . . in Oregon there is a universal application that works for all so just keep a photocopy of that in your desk and you’ll always be prepared). Most insurance companies are straightforward and easy to deal with in Oregon. They will send you a 5-page contract that says we’re the insurance company and you’re the doctor, you see the patient and we’ll send you the money and they give you some amount they will be sending you per patient, per service. You can see what it is and you can see if you think it’s fair or not. They pay big hospitals and clinics more because they have a team of negotiators there and they cover more patients so they have more leverage. Reimbursement is very high here in Oregon so I never had a problem with accepting their rates to begin with. Most insurance companies are easy to deal with I’ve found.
Every once in a while there’s an insurer like HealthNet, for example, I wanted to contract with them. I was basically going to take all insurance and one by one as they pissed me off I would stop taking the ones I didn’t like. I wanted to give them the benefit of the doubt that they are all really nice and that I could deal with them which was not the case. HealthNet what they did was super funny. Before they would send me the contract, they sent somebody to drive down 2 hours from Portland and measure the space between the toilet and the wall. They wouldn’t even give me the contract until they made sure I had enough space between the toilet and the wall and a few other random weird things. It was a checklist of minutiae. Then they finally sent me a 30-page contract! It was so much longer than all the other insurance contracts. I read it all. By the way, if you’re an employee or even a resident, you will get all these contracts placed on your desk and they want you to sign them and you don’t have time to read them. You are signing your life away all the time on these contracts and you don’t even know what they say! I read them all now that I have time and there was a line in the HealthNet contract that read something like, “If we decide that somehow it was your fault then you’re responsible for all our legal costs.” Oh no! There’s no way I’m going to sign a contract that make me responsible for all the legal costs of a health insurance company. I bet a lot of doctors out there signed that contract because they didn’t have time to read it.
If you are a preferred provider what it means is that you are signing on the dotted line and you are signing things that you may not even agree with. You are signing away your income which if you have student loans you are signing away 20-30% of your income that you should be earning and that they are keeping. They’re still getting the premiums every month. You just aren’t paying off your student loans fast enough. Now the reason why people become preferred providers is you can get a high volume of patients really quick because they see that you are “in the book” listed as a preferred provider and the patient only has to pay $20 copay and you’re right in they’re neighborhood. You may not be the ideal doctor for them, but because you are cheap and convenient they will come to you. It’s a volume thing and not very personalized or relationship-driven. That patient may not want to see you if they have to pay a $40 copay. You spend all this time doing all this work and changing diapers on this patient you don’t even like that much and the minute it costs him $25 instead of $20, he’s out the door. Why not just get the people who really like you? Then it’s more fun to go to work and they will totally pay you you’re real fees.
Now that I’m out-of-network (OON), I can charge my real fees. I still submit claims to the insurance company as a benefit to the patient (because it’s just too hard for patients to figure out how to do that on their own and I already know how to do it online really easily 1-2 minutes after each visit I submit the claim). Instead of getting paid $109 for the visit as a preferred provider (PP) now that I’m OON I get maybe $70 and the out-of-pocket for the patient instead of $20 is now $39.64 or something like that. The patient has to pay more, but I get paid at the end of the day my fair rate and I do not have to sign any contracts with insurance companies. So that’s what it means to be OON. That’s a good middle road for some people. I’m happy at the end of the day. My patients still get to use their insurance.
Jay Anderson: You have a ton of free time from what I understand and one of the things you love doing is helping other physicians who are tired of treadmill medicine to move out and explore the idea of their own ideal clinic. Could you tell us one example of how that worked out really well and one that did not go well so that we might learn from those lessons.
Pamela Wible: It’s true. I do teach medical students, residents, and physicians how to open their ideal clinics through retreats (in October and May), teleseminars, private coaching, and I also like to help people for free. If any of you want to come to the retreat, there’s one coming up. Maybe Claire wants to say something about that and what it was like for her. She’s in the back. It is helpful to hear from one of your peers and then I’ll share some success stories and some unsuccessful stories.
Claire Donley: I’m a third-year medical student and Pam has been an amazing mentor for me during this time. I almost left medicine. I took a leave of absence for about a year and a half. That was after my first semester of school. I saw what was happening out there in the field and I didn’t want to be a part of it and I didn’t know another way so I did a lot of internal reflection and then I met Pam and then I went to the retreat and it was amazing. It was life-changing. I saw all these people who really wanted to make a difference and truly wanted to heal. What you put on your personal statement—its kind of funny that you forget about it because you get so involved in school and there’s all this stuff you have to memorize and you almost forget that—it really IS why we’re here! We are here to make a really big difference in the world and I just want to say it was incredible. I learned a lot. I learned about myself and I came out completely inspired and through that experience, I came back to school. That was the impetus of me coming back. I’m so happy I’m on rotations now and I had the most amazing summer!! Oh my gosh! I’m really interested in OMT and more preventative and holistic integrative care. Some of the stuff we did was just so unbelievable. These people that had chronic conditions and medication lists that were really, really long and saw all thee other experts that weren’t getting healed. They were just getting handed medicine that were causing all these side effects and it’s not their fault, ya know. That’s how their taught and doctors are taught that way and you can’t treat chronic conditions that way, but they’d come to us and we were able to help them. People were crying. I was crying during some of the treatments. It was unbelievable. It brings tears right now talking about it. This whole concept has been on my mind, ya know, too while I have been through this. Pam has been a huge influence because you need time with your patients. There are certain types of care where there is acute medicine and you have to go in there and you have to see someone with a myocardial infarction, ya know, or they have a broken arm. There’s a crisis right now especially with chronic care and we need time with people and there’s models out there to be able to do this and you guys it’s a big step for you guys coming here. Thank you. You are on an amazing path.
Pamela Wible: Thank you. Claire came as a medical student. The sooner you learn this, the better. Check out these happy doctor success stories and Google “The happiest doctor in Idaho.” That’s a really great success story. It’s a 10-minute interview with a physician who opened an ideal clinic. The success stories are a lot like my story. The people who are not successful: one man I know he started his own clinic right out of residency and was really into the IT stuff and he did not balance it correctly. He got more into the higher overhead and technology stuff and did not keep it simple enough so he went back to working for a group which is not so bad, but he is still dreaming of going back and starting an ideal clinic now that he is older and more mature and has figured out some of the things that he might do differently next time. I know one other (I only know 2 stories that weren’t super-successful) one other guy was open for almost a year and only had 30 patients, but he also had depression. You have to be well when you start your clinic. People are coming to you for health so if you still have PTSD from medical school you won’t attract people for health if you’re not healthy. That’s why it is so important to stay healthy during medical school. Get massages, get counseling off-the-books so you don’t have to report it, stuff like that. talk to your friends, keep a journal. Try not to graduate a mess because then you’re going to start residency not very stable and then when you graduate you’re not going to be in a position to open your own clinic because you’re not going to be well enough to do it. You have to be well and you have to keep your overhead low. Those 2 things are most important and I do think it’s important to reach out to the community because if you’re delivering something that you think is really cool and nobody else understands then nobody is going to come to you. You might be relevant but people may not understand how you are messaging yourself and your services. People need a lot of reminders about your scope of practice. I have a patient who is a friend of mine ad even though she’s read Pet Goats & Pap Smears she didn’t know I did Pap smears (Laughter) so you have to remind people all the time. They are smoking pot. They are too relaxed. You have to remind them “I do ingrown toenails, I do Pap smears, I can do your physical so you don’t have to go to Planned Parenthood.” Your patients have no idea what your scope of practice is unless you tell them over and over again.
Student: First of all thanks for coming. It’s great to hear from you. I’m a first year student and I’m looking for general recommendation for all the hoop-jumping that we do have to do. How do you maintain quality of life? I’m older and I’ve got previous master’s degrees and things. What am I giving up to do this? Will it be worth it in 10 years? How do you make it worth it during the process?
Pamela Wible: So as a first year medical student she wants to know how do you make it worth it during the process if you are older, wiser student and suddenly coming back to being treated like you are in kindergarten with all the hoop-jumping? How do you keep yourself happy and joyful and make this of some value while you are having to jump through all these hoops? 1) Have a firm North Star ahead of you which is your personal statement. I can’t drive that home enough. That has to be your motivation for getting up every day, the people that you are going to heal, the doctor that you are going to be. If that gets blurred out at all none of this makes any sense. 2) The other thing is to see your education for what it really is. Honestly some of you are ahead of your professors in certain ways. Your instructors are not the be all end all. They happen to know some subject matter in greater detail than you and so you can learn that little bit from them. You might be more advanced psychologically or emotionally or in other ways. Don’t give away your power, Understand that you are a super-powerful person and you are already a healer. So honor your teachers for what they are able to teach you and then quite honestly teaching is bilateral. You might be able to give feedback to a teacher that really helps them teach better in the future because you are seeing things in them that may not be working well in modern day life in 2015. Give feedback from a place of love and constructive criticism. If you can take yourself out of this hierarchy and see yourself as a strong individual who is worthy of love, respect, who is worthy of a humane learning environment and if you stand up for yourself. Interact with other people as peers versus a short-coat victim mentality. Sometimes medical students fall into victim mentality and they never break out of it. So don’t be a victim. Give constructive feedback so you can make your school a better place. You’ll make the learning environment better for yourself and the people who come after you. Stay completely fixed on your North Star. And align yourself with mentors who are actually practicing medicine the way you hope to practice. Does that help?
Claire Donley: I can piggy back off that.
Pamela Wible: Come back up . .
Claire Donley: I think a big thing that you need to do is keep doing stuff that you love, Whatever that is. Why you came into medicine. I love the preventative stuff. I love nutrition. I love exercise. I love connecting with people on a deep level. I love giving my heart. In Lebanon I dressed up as a carrot and taught elementary school students nutrition. They loved it! We danced around class and we played a bunch of music and I was on fire after that! I called my parents, “Oh my God! I’m so psyched right now!” I was jumping off the walls. You want to keep doing stuff that you love through school. It’s not like you are chasing this end goal and what is it going to be when I get there. It is continually finding things. This is why I am here. And then being on rotations for me I got lucky that I got to do OMT on the first few, but even I have internal medicine next and I talked to one of the doctors who I am now good friends with because we had such a good experience and he said, “Claire, on internal medicine see what it’s like in there and if they allow you then treat patients with OMT, go ahead.” People love to be touched. That’s a huge thing too. That’s a benefit that we have at osteopathic school. It makes a huge difference. If they see that you care you can make so much more of a difference in their lives just really, really connecting with them. So I think it is really important to find that true connection, why you came into school. Find these things and make it clear what you want and what you stand for and Dr. Junkins calls it your brand which is perfect because it all aligns together and helps you get into residency. It’s authentic and it comes from your heart. Keep doing that kind of stuff and it really fills you up. It really does. You make a big difference in people’s lives.
Pamela Wible: And I’ll echo what she said about dressing up as a carrot. I didn’t quite go that far, but during my intern year I went to a bunch of different 4th grade classes and talked to them about nutrition on my own. Later on we had a project to do something with the community and I just used all the material I already gathered on my own. I basically took all these weird and unusual vegetables (watermelon daikon radishes, leeks) basically fruits and vegetables that I thought these lower demographic elementary school kids had never seen before and I put them across the table and I had everyone eating them and people were running up to get dried figs and then I got all these love letters afterwards because the teacher made the students write these letters. I still have them and I still read them and they are so funny! I had them eating raw beets because I told them if they eat enough raw beets it will turn their urine red and they could scare their parents. (Laughter). They all ran to the front to eat raw beets. People always say you can’t get kids to eat healthy.
Oh my God! I went to this drug company cholesterol-sponsored dinner one night and all the doctors there were so stuffed with steak and chocolate mousse that they were sliding under the table and the guy there was talking about Lipitor and all the docs were like, “Yeah I’ll prescribe it tomorrow.” I was the only one on my edge of my seat raising my hand to say there’s another way. I’m vegan and he’s like, “Nobody can do that.” All the doctors are snoring and under the table because they are so tired. The guy leading the talk looked just like Homer Simpson, the doctor paid by the pharmaceutical company to come teach us how to prescribe high-cholesterol drugs. Of course, people who are in the business of putting you on cholesterol drugs aren’t gonna tell you how easy it is to get 4th graders to eat raw beets. The fact is if you go and have a good attitude and share fun stuff about the human body and how when you eat certain foods how it makes your urine smell and look, kids think that’s really cool! If you eat asparagus, your urine could smell like asparagus. If you tell kids that they’ll run around and eat raw beets and asparagus all day. (Laughter). The point is you have to make it FUN! So get out of school sometimes and go into the community and help people with their lives and their health! Touch people.
Jay Anderson: What you are saying is don’t wait!
Claire Donley: Don’t wait!
Pamela Wible: Don’t wait. You are a healer now. Live your personal statement now. Look at Patch Adams. He even gave up his medical license. A lot of what he does doesn’t require a medical license. Look how many people he is helping in war-torn countries and refugee camps. He’s made kids smile who are near death and starving. What is that worth? You don’t need a medical degree to do what matters in the world. What we really need in the world now just requires your humanity and not a degree. So just do that. You’ll feel really good now.
Claire Donley: I just want to say that it may seem like you feel like you don’t have any time to do stuff in the community sometimes . . .
Pamela Wible: Just dressing up like a carrot and wandering through the grocery store, you can do that in 30 minutes . . . (Laughter)
Claire Donley: We had a lesson in less than an hour. It didn’t take very long. We had to plan out the lesson beforehand. We had a fixed lesson. After you do this you feel really good. You become a better studier. You become better in school because you now have a purpose through it. You become more efficient when you’re happy and you work better. I feel like it’s hard in med school because you have so much information downloaded to your brain and so you become really intellectual and it’s hard to get here (to the heart) because you are so much up here. You have to do this stuff too! Ya know, that’s why we’re here. So just find that stuff that’s true to you. And continue to do that.
Pamela Wible: And even the town hall meetings that sound like, oh my gosh, it must take a lot to do a town hall meeting. It only took an hour. And if you want to do one, something that is really fun during med school, then go to a classroom and either do a nutrition talk or go ask a bunch of 4th graders what an ideal clinic would look like and let them design their own ideal clinic. They would love that! They have so many good ideas. They could tell you exactly where to put the scale and where not to put the shots and what to do with the receptionist and whether you even need one. And they’ll decorate the walls, ya know what I mean? They are so full of ideas! If any of you are into pediatrics, you might want to go take care of kids, start now! Collect the data from kids right now in Lebanon and ask them, “What do you guys want for am ideal clinic?” Then when you do your pediatrics rotation you can be like, wow, this isn’t really measuring up with what the kids told me they want or maybe it is. We’ll never know whether we’re doing the right thing until we put the end-user in charge. And not just with the “patient-centered” term, that’s such an overused bad term that is often used to control us. So just go out and be real and do it. You can’t get to the end-user soon enough. If you’re a healer you need somebody to work on. Go do it now. You don’t have to prescribe drugs. You can just touch them. You could just share a carrot with them.
Some of my favorite love letters from 4th graders! (You could get these too!)
So get up and go outside and talk to some elementary school kids! You need a study break anyway!!! Be inspired! Go share a carrot with a 4th grader
Pamela Wible, M.D., founded the Ideal Medical Care Movement. She has been awarded the 2015 Women Leader in Medicine by the American Medical Student Association for her inspiring contributions to medicine. Contact Dr. Wible. She loves to hear from med students and docs.
Burnout is a complete mental and physical collapse from overwork. Psychiatrists define it as “a job-related dysphoria in an individual without major psychopathy.” Which means—your job sucks. You’re normal.
When your job is sucking the life out of you, deep breathing won’t save you. Mindfulness is not the solution. Emancipation is. Burnout is a diagnosis of oppression that blames you, not the perpetrator. You’re just not fast enough, smart enough, dedicated enough.
Guess what? It’s not your fault.
Remove the smokescreen. You’re a healer not a factory worker. I walked away from churn-and-burn medicine to be a real doctor. Follow me. And be free.
Pamela Wible, M.D., has helped hundreds of physicians reclaim their happiness and their careers. She has been named the 2015 Women Leader in Medicine for her work on medical student and physician suicide prevention.