Death of a Practice

I did not think that I would ever stop practicing medicine. Yet here I was, alone at the office door, withdrawing my key from the lock for the last time.

This office was my soul. I had deliberated over the location, negotiated the lease, and planned all the furnishings. I had painstakingly drawn the floor plan, meticulously selected the texture and tone of the heather green carpet, and carefully considered the color and pattern of the wallpaper.

This office was also the home of a staff of five familiar faces that had gradually become a surrogate family.

Elizabeth and Jillian were the senior members. Elizabeth was just two weeks out of business school when she arrived, resume in hand, nine years ago. She would spend almost a third of her lifetime at this office. Jillian was our office-family matriarch. A former orthopedics nurse, she adopted us seven years ago when her own mid-sized home health agency fell upon hard times. She was nearly my age and was a redhead in more ways than one -- direct, blunt, and practical, Jillian was reliability personified.

Then there was Francie, our perennial friend and transcriptionist for 11 years, who visited our office-home daily to deliver the consultations, notes, and letters I had dictated the previous day and to pick up that day's tapes. A single mother of two young girls, Francie relied on our practice for a major portion of her home business' income, especially after one of her other physician subscribers moved to the Southwest and another retired early.

Those physicians were looking to escape Pennsylvania's crushing malpractice insurance crisis, which now would claim yet another casualty: us.

What about the patients?

But not merely us -- that is, the victims of our pain management practice's closing would not be limited to those who depended on it for a living. We hosted daily a score of reluctant but grateful guests -- our patients. My heart went out to them; many were doubly afflicted with chronic pain and scarce options.

Jane was a cheerful woman in her fifties with two college-age sons and a recently retired husband. She suffered for years from a feedback loop of neck spasms and migraine headaches. When the spasms worsened, the migraine attacks increased.

Jane had a remarkable outlook despite her crippling problem. She knew the blinding pain behind her eye, the vomiting, and the throbbing frontal headaches would confine her to bed for several unpredictable days a month. Yet she refused to live in fear of the next episode or in preoccupation with the last. She dutifully presented herself to our practice a few times a year for injections that relieved the neck pain, in turn diminishing her headaches somewhat. She was grateful for the limited relief, surprised that no one had suggested the treatment previously -- and disappointed that her caregivers were now departing.

In contrast to Jane's occasional disability was Peter's constant one. A man in his thirties whose optimism belied his grave condition, Peter had suffered a spinal cord injury about a decade earlier in a tragic fall from a roof. The fall left him quadriplegic with little function below his neck except for limited movement in his thumbs. Yet even as it robbed his body of its natural abilities, Peter's injury cruelly left spinal reflexes that tortured him with painful spastic convulsions.

At the university medical center, 150 miles away, where Peter was airlifted after his accident, the neurosurgeons implanted in his abdominal wall a computerized pump to deliver a powerful antispasticity drug, baclofen.

The drug alleviated the unpredictable spasms that disrupted Peter's remaining functionality, but the pump required monitoring and frequent maintenance, and this brought Peter to our office regularly. We evaluated the effectiveness of the baclofen dosage, resupplied the pump using special equipment, and monitored Peter for hypotension and other side effects.

Peter, his pump, and we had become a profane, secular trinity. Peter relied on us to maintain his pump and sustain his functionality. We found in Peter's care our purpose and validation. But soon we would be leaving, and the only other local physician with similar expertise was a neurologist who'd left about 18 months previously. Upon our departure, Peter would return for care to the distant university hospital.

An impossible situation

We resisted leaving Peter, Jane, our other patients, our office-home, the surrogate family. But we had no choice.

As the years passed, the mountain of paperwork had exploded. We expanded staff, restructured, and upgraded our computer system. But the paperwork mountain kept growing and the price of reining it in climbed.

The costs of malpractice insurance mounted while its availability dwindled. Our record over the years was perfect, yet the premiums rocketed upwards, local policies were canceled, and all but two of about a dozen liability insurers that had once provided coverage here had abandoned the state.

Revenue declined even as we became busier and busier. Payments by private and public payers were arbitrarily delayed for months, reduced drastically, or denied completely. Slashing even our most senior employees to part time did not make up for the draconian reductions in reimbursement from payers.

One insurance entity had dominated the regional market for years. It could act imperiously and autocratically. The Pennsylvania state government seemed disinclined to rein it in. Insurers would refuse payment without prior approval of a procedure, but securing the approval did not guarantee payment. Some payers avoided releasing their fee schedules. This made it impossible to forecast practice viability.

Medicare payments were sliced by more than 5 percent while overhead consumed almost two-thirds of revenue. Thus, the reductions translated to more than a 16 percent loss in the final analysis.

We worked longer, harder, and faster.

A typical day: I would arise reluctantly in the wee hours and rush in the predawn darkness to one or two of the five scattered hospitals that we served. With espresso helping to keep my eyes open, I would make hurried rounds on bleary patients until the sun rose and my beeper vibrated, summoning me to the office.

Scarcely settled in, I would dart among the exam rooms, recorder in hand, seeing patients and dictating notes in a voice so fast that its transcription demanded decelerated playback.

Lunch was consumed while reviewing MRI reports and X-rays and followed by more darting and dictating, interspersed with calls to the hospital in pursuit of missing films and misdirected reports. I agonized over what intervention, if any, would help this sad patient, while in the next room the nurse haggled on the phone for insurance permission to treat the last one.

I would depart the office for a quick dinner and another drive to the hospital to complete a consultation. I would detour to medical records to complete some unsigned charts and to radiology to review the consultation subject's films before hurrying to the patient room to complete the consultation. At last, consultation notes in pocket, I would head home late in the evening, totally spent.

It's over

I had never thought I would abruptly and completely stop practicing medicine. But I could not bear this killing pace indefinitely, nor could I afford to slow down. Even so, I thought that if I could endure a little longer, things might somehow improve.

But when Elizabeth reminded me that our lease would soon be due for another renewal, I knew it was over. I had held the lease on our little office for a dozen years through numerous renewals, unhesitatingly executed. They had always been routine events, but this time I realized I would be committing to succeeding years of conditions that were only likely to worsen.

I could not sign this lease ... I simply could not do it.

So here I was, alone at the office door, withdrawing my key from the lock for the last time. For me, departure was liberating. Now I would indulge other interests -- writing, teaching, and listening to Verdi. But departure also raised uncomfortable questions. Would my greater contributions have not been as a clinician? What would become of Peter, of Jane, of my staff? And most urgently, how we did we allow blind bureaucracy, capricious monopoly, and errant circumstance to have such unrestrained and devastating influence over the lives of real people?

This article originally appeared in the May 2003 issue of  Physicians Practice.