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.
ALL MEDICAL STUDENTS: Please download this guide to opening your ideal clinic I put together just for you –> Medical Student’s No B.S. Guide To Launching An Ideal Clinic.
My story from medical school to my ideal clinic
My first year of medical school sucked!
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)
ALL MEDICAL STUDENTS: Please download this guide to opening your ideal clinic I put together just for you –> Medical Student’s No B.S. Guide To Launching An Ideal Clinic.
Student: Do you still do hospital visits?
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 🙂
ALL MEDICAL STUDENTS: Please download this guide to opening your ideal clinic I put together just for you –> Medical Student’s No B.S. Guide To Launching An Ideal Clinic.
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.
