Is solo practice the way of the future?
An interview with US “ideal medicine” activist Dr Pam Wible
A pioneer in the movement seeking to re-humanize medicine, Dr Pamela Wible, a family physician based in Eugene, Oregon, is a passionate advocate for relationship-based medical care. In 2005, she reached a personal nadir as a doctor after realizing how many in her profession had died of suicide. Having been suicidal herself given the deplorable working conditions physicians face and the poor “big-box medicine” delivered to patients, she called nine town meetings where she asked her community, “What does your ideal medical clinic look like?” After reviewing the 100 pages of notes she had compiled, she opened a clinic within a month. She did it without outside funding; it met 90 percent of the community’s criteria.
Dr Wible describes her clinic as “a sanctuary, a safe place, a place of wisdom where we can learn to live harmlessly, listen with empathy, and learn without judgment.” Her clinic has sofas in the waiting room, no front counter and no staff. There are purple robes for patients and free massages. Dr Wible answers her own phone, schedules appointments and takes patient vitals. She also submits insurance claims without the help of a billing clerk. She avoids unnecessary tests and procedures, and makes 85 percent of diagnoses simply by listening to the patient. Appointments usually last 30 minutes to an hour during which there’s ample time to build what Dr Wible calls “a complete human relationship.” No one is turned away for lack of funds, and though she gives patients her home phone number and accepts calls 24/7, her phone barely rings because she’s able to handle her patients’ issues comprehensively during office visits. She works three half days a week, and makes more in take-home pay than she did when she worked four long days at a big clinic.
In addition to her belief that vulnerability, joy and humour are keys to success in medicine, Dr Wible has business smarts. In her old job, 74 percent of her earnings went into overhead: receptionists and staff, rent, elaborate computer systems and other “unnecessary” technology. In her current practice, start-up costs were only 3K, which covered furniture, decor, first and last month’s rent, an exam table and supplies. She already owned her only two crucial pieces of technology: a laptop and a stethoscope. Her total annual overhead is now just 10 percent, allowing her to keep 90 percent of her earnings.
Dr Wible has abandoned the white coat and favours Levis because she believes people value authenticity over authoritarianism. “The patriarchal medical model is obsolete,” she says.
Physicians and other health professionals can download a free guide to opening their own ideal medical clinic on her website idealmedicalcare.org. To view one of Dr Wible’s TED Talks, search “How to get naked with your doctor” on YouTube.
DR: What would you say is the essential difference between medical care as currently practiced and “ideal medical care?”
PW: Most doctors have been funneled into assembly-line medical clinics that are production driven. Ideal medical care is relationship driven. Patients are seen as whole human beings and not just body parts. The most progressive clinics place the end user in charge of designing their own ideal clinics.
DR: Do you think that ideal medical care could be practiced everywhere? Even in high-speed, high-stress, understaffed locations and in hospitals?
PW: Absolutely. Ideal clinics are most aligned with the traditional way medicine has always been practiced for centuries. Assembly-line medicine is a recent failed phenomenon. There are hundreds of ideal clinics all over America. I’ve also been hired to create community-design ideal hospitals. The basic concepts are scalable and can be applied successfully to all health care facilities.
DR: How does practicing ideal medicine affect earnings?
PW: I have been able to triple my income per patient working just one quarter of the time. When I worked at a big-box medical clinic my overhead was 74 percent. When I opened my own ideal clinic and my overhead was 7 percent. What does that mean for you? Well, here comes a patient who is bringing you $100 for a medical visit. And guess how much you get to keep if your overhead is 74 percent? You get to keep $26 (before tax). Here’s your income for seeing one patient at the big-box clinic: $26. How does that sound? But if you see the same patient at your ideal clinic, you’ll end up with a nice income of $93. What do you prefer: an income of $26 or $93?
DR: If all doctors used your model wouldn’t we have a shortage of doctors?
PW: That’s a great question. If all doctors limited their practice to a smaller panel of patients, whether full-time or part-time, would there be enough docs to take care of all the patients? The Ideal Medical Movement actually inflates the physician workforce by decreasing the burden on each doc. Here’s how:
1) Less per-patient burden on the health-care system. More comprehensive care visits help patients be more self-reliant so that one 30-40 minute visit may be worth four shorter rushed visits. Patients don’t need to be seen as frequently. Patients also feel more confident knowing that they have a stable relationship with an accessible doctor. They don’t get anxious about getting in. There’s no hoarding of perceived scarce resources that is what desperate patients do when they can’t get the services they need.
2) Inflates the physician workforce. Physicians are retiring early, searching for niche specialties, or leaving medicine as a profession because they can’t stand the current model. Physicians also have a high suicide rate. They are searching for any exit strategy, especially from primary care. In my last employed practice, three women in their prime left medicine completely because it was “undoable.” In a humane ideal-medical care model, we can attract these physician drop-outs back to the office. We can get our early retirees back to work. We will also recruit more physicians. In the first two years of my new practice, I’ve had three patients tell me that they plan to pursue medicine as a career! I’ve inadvertently served as a recruitment centre for physicians! This never happened in the assembly line!
3) Embraces other health care professionals. It’s time to work together with other health-care professionals, rather than have adversarial relationships. Let’s work with NPs, PAs, naturopaths, chiropractors, massage therapists and any other accredited and certified health-care professionals who have our patient’s best interests at heart. Share the workload! The Ideal Medical Care Movement renews hope and a sense of purpose in our physicians, ultimately inflating the physician workforce. Shortage of physicians in primary care has more to do with onerous and unnecessary regulations, absurdly complex bureaucracy, and disproportionately low reimbursement in primary care compared with more lucrative specialties. Let us deal squarely with the real issues that undermine primary care. The ideal practice model is the savior of primary care medicine.
DR: What are some first steps that a doctor steeped in the current system can do to begin to practice ideal medical care? Is opening an ideal clinic the only answer?
PW: Physicians must practice in alignment with their highest values, the dreams that brought them to medicine in the first place. Docs must break free of their victim mindset. Meet other docs who have opened relationship-driven clinics. There are many physicians practicing medicine in fulfilling solo and independent practices. Ideal is a relative term. Ideally the “ideal” clinic would be designed by the patients and physician in collaboration.
DR: Since you opened your ideal clinic, have you noticed physiological changes in your patients’ health, as compared to your patients at the big clinic?
PW: YES! Relaxed and better blood pressures. They are actually excited to come to the doctor and some tell me that it’s the highlight of their day!
DR: What are some invigorating challenges that you face currently in your work?
PW: Balancing patient care with leading the Ideal Medical Care Movement, and dealing with the medical student and physician suicide crisis. I run an unofficial suicide hotline for physicians out of my home. I also host physician retreats multiple times per year in which I help colleagues heal from the trauma of medical training and launch their own ideal clinics.
DR: Have you seen a shift in medical culture since you opened your clinic in 2005? Do you think that the success of vulnerability researcher Brené Brown’s work (ted.com/talks/brene_brown_on_vulnerability) is a sign of a changing social climate in our broader culture?
PW: Absolutely. People are ready for real healing and deep authentic relationships with one another. They are less tolerant with hierarchy and artificiality. I welcome anyone who wants to enjoy medicine again to reach out. Contact me at IdealMedicalCare.org.
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