Reimagining Geriatrics

A little over a year ago, I found myself burning out and realized that my work life was unsustainable.

 I’d been working at a Federally Qualified Health Center, and had become the site’s medical director a few months before. I was practicing as a primary care doc, trying to improve our clinical workflows, problem-solving around the new e-prescribing system, helping plan the agency’s transition from paper charts to electronic charts, and working on our house calls and geriatrics programs. 

 All of this was supposed to be a 50% position — plus 5% paid time for follow-up. Needless to say, this job was taking far more than 55% of my time, and seemed to be consuming 110% of my psyche. I very much liked my boss and colleagues, was learning a lot, and felt I was improving care for older adults.

 But I was also irritable, stressed out, and had developed chronic insomnia. And clinic sessions were leaving me drained and feeling miserable: try as I might, I couldn’t find a way to provide care to my (and my patients’) satisfaction with the time and resources I had available.

 One evening my 3 year old daughter looked at me and asked “Why are you always getting mad and saying no?”

 Good question, kiddo!

 A few weeks later, I told my boss that I’d be resigning my position in 5 months. And I started trying to reimagine how I might practice geriatrics.

 My current clinical practice, which I launched last October, is the result of that reimagining.

 My goals for a new geriatric practice:

• To keep practicing the part of my work that I loved the most. For me, this means person-centered outpatient care with a focus on geriatric syndromes and on helping people navigate the medical challenges of late life. 
• To be able to promptly meet the needs of patients and families. It often took me days to get back to people in my conventional job, or it could take weeks before a clinic appointment was available. I wanted to try a more “open-access” approach.
• To try to offer the most help per unit of my time. Since there is a national shortage of geriatricians (currently 4 per 10,000 Americans aged 75+), I think it’s important to consider how to best deploy us for society’s benefit.
• To leverage technology to better meet patients’ needs, and improve efficiency. Technology allows us to do some things faster and better. I wanted to see how that could be used in helping older patients with their geriatric needs.
• To have some flexibility in my day and my week. Flexibility is very very helpful to the working parent, especially when children are very young as mine are.

  To do all this, I’ve relaunched myself as a direct-pay solo micropractice offering house calls and geriatric consultative care. Here’s how it works:

•  I offer geriatric specialty care that is meant to complement existing primary care, so for the first time ever, I’m not a primary care doctor, I’m a specialist. This feels a little weird (it’s a change in my professional identity) but I’m getting used to it. Also kind of quirky: I’m a specialist who is mainly recruited by families directly, rather than via referral from primary care doctors.
• I charge a flat hourly rate for all time spent providing service ($200), whether it’s in person, by phone, by email/secure messaging, coordinating care with other clinicians, or otherwise assisting a person with his or her health care. There is no membership fee or monthly subscription fee. I regret having to limit my practice to those who can pay out-of-pocket, but unfortunately I cannot provide care in the way I believe in through the current insurance system.
• I return all phone calls within two hours, and all written messages within one business day. House calls are available within 1-2 business days.
• I let patients and families decide how much time they want with me, although I do advise them as to what I think is the minimum needed time for the issues they want me to help them with.
• I don’t provide care after-hours or on weekends. I do explain to all patients and families that my practice is not meant to provide urgent or emergent care, but instead is meant to provide additional support and service regarding geriatric issues. I also try to help families really understand the medical issues, so that they are better equipped should they need to urgently engage other clinicians.

 How the new practice is working out:

 The people who contact me are usually concerned adult-children, or sometimes geriatric care managers. They like that I provide a comprehensive overview of the older person’s health, can help them make sense of what the other involved clinicians are doing, have lots of experience managing geriatric syndromes, and am available easily by phone. (The home health nurses like that too!)  They also like that I follow-up promptly by phone on a management plan.

 As for me, I like that most of my time goes to meeting the needs of patients and families, rather than dealing with insurance, prior authorizations, or other administrative hassles. I also like that I don’t have to manage anyone else, or be managed by anyone else. However, I still feel I’m part of a team since I collaborate with other doctors, assisted living personnel, home health agencies, private caregivers, geriatric care managers, and family caregivers.

As for Medicare and society at large, I’m sure they don’t like that I’ve opted out. I understand. I don’t like it either. Until a few years ago I was a big proponent of Medicare-for-all, so it’s dismaying to find myself having left the fold.

On the other hand, Medicare currently makes it absurdly difficult for geriatricians to focus on just practicing geriatrics, and on creatively rethinking geriatric care. For instance, with Medicare it’s usually hard to be reimbursed for phone time, or for care coordination. Opting out is what allows me to spend as much time as people need when I make a house call, or when I’m on the phone with families or with other clinicians.

Instead of chasing face-to-face visits, and wrangling with the complexities of billing Medicare, I can often answer my phone when people call me, and I can look for new technologies that might improve their care.

And since I don’t have a packed clinic schedule, it’s easy for me to rearrange things when one of my kids gets sick, or if something else unexpected crops up.

In short, rearranging my practice has been terrific for me, and seems to offer a lot of value to those patients who have sought me out (and, of course, are willing and able to pay). Over the next year or two, I hope to learn more about how to use technology to better leverage my geriatric expertise.

And who knows, if my personal experiment in geriatrics continues to go well, perhaps more geriatricians will end up being outpatient consultants, rather than primary care doctors as they customarily are in the U.S. And perhaps Medicare and the other insurers will find a way to cover the kind of service I’m now providing.

 Leslie Kernisan, M.D. M.P.H., 36, is a practicing outpatient geriatrician in San Francisco. She blogs about geriatrics and technology at GeriTech.