Volume 60, Number 3 - Summer 2009

 

By Steve Osborn

A: During my freshman year at Stanford, I settled on two options: either to be an English teacher or a physician. I kept them open all the way through college until graduation, and then I decided that I would probably be able to do more good for more people as a doctor. I had some teachers who really influenced my life, but I realized that a teacher only does that with a few people each year. As a physician I would have a lot more opportunities to help people.

Stanford had a five-year medical school, and they allowed you to do research, so I went for a master’s degree in medical sociology. My project was at Stanford’s Children’s Hospital, looking at the influence of children’s chronic disease on families. My conclusion was that the family is so overwhelmed with the child’s disease that you have to treat the whole family in order to heal the child. That is how I got interested in family practice. Medicine is so much more than caring for the isolated patient in front of you. The whole outcome depends on taking care of the family as a unit. 

A: That is so true. Our opportunity in family practice is to see that. I have had some five-generation families. Only a few of the families were all patients at the same time, but I have cared for five generations of several families.

A: After I graduated, I went into the Air Force for two years, so I wasn’t actually in this group practice until 1975. We moved to this building in 1980, and I have been here ever since.

A: Right here. We were part of a group that built this office complex. I chose this spot next to the emergency room because I go back and forth to Palm Drive Hospital about five times a day. 

A: We got to design this particular building. Dr. Nancy Davidson was already with me, and we had an interesting parade of doctors who joined us. Some are still in town, but there are quite a few others who have moved on to other places.

A: Since 1978. In August, it will be 31 years. We may be the oldest medical partnership in the county as far as two people still practicing together. 

A: We are doing quite a bit more in preventive care. I like to call it “health improvement,” instead of saying “health maintenance,” which is the standard term for what physicians do routinely for people. Health improvement is more working on life changes, such as weight loss, better exercise, better diet, rather than just updating their Pap smears and immunizations, or prescribing their blood-pressure medicine and telling them that they need to avoid sugar and fat in their diet. Health improvement is a more active effort to get people to live in a healthy fashion.

A: In the process of converting to electronic medical records, doctors can get caught up in their recordkeeping and not pay attention to their patient. Staying focused on your patient is a big challenge. The system wants to make everything automated so that the patient comes in and the doctors have a list of things that the schedule says they are supposed to do, rather than sit down and ask the patient what’s been happening, what they would like to talk about today. 

I have never had less than 20-minute appointments, and the doctors who have briefer appointments don’t have time, I think, to really talk to their patient, especially if they are trying to complete the checkboxes on their preventive care list. I think the danger to family practice is getting so caught up in meeting all the guidelines that you forget to take care of the patient. 

A: Fortunately, I don’t have a computer yet, so I don’t have this challenge. I sit there and look my patient in the eye and get to talk to them. I don’t interrupt my patients after 11 seconds, as the standard says. They get to talk for several minutes and tell me what they’re thinking about. A lot of times, it’s something that is not especially important to their medical care today, but it has to do with their life and their family and other people. I learn a lot about my patients from their family, from crises that are happening at home.

A: Exactly. At Palm Drive ER, where I work, we have a template that is disease-specific, and I have great difficulty because the sequence of questions in the template doesn’t fit my sequence. My question leads from the person’s answer to the prior question. It’s really hard for me to use those templates because they don’t allow you to change the flow. It’s someone else’s structure, it’s not my own. It’s just really hard for me to follow that pattern.

A: I think that’s true, and everybody’s style is different. Gaining that information at the patient’s pace rather than in a stock set of questions works better for me. Some doctors have a pretty organized list of things they are going to ask, and it doesn’t matter what the patient answers, the next question is the next question. 

A: No. What I recommend to my colleagues is that they don’t pay more attention to their notepad or their computer than to the patient. I just think that really looking at the patient and listening to the patient is so important, that the tremendous pressure to do the electronic medical record and try to do your recordkeeping concurrent with your visit is really a harm to that relationship. 

A: Yes, I think we always have, but the additional feature of it is the completeness of preventive care. Part of the reason that the Sonoma County Primary Care IPA has been so successful is that they are all family docs, and they all do a really broad spectrum of care. We are also older. The training today doesn’t include anesthesia and surgery nearly to the extent that we had. 

We don’t get to assist in the operating room nearly as much as we used to, and we don’t do anesthesia. We still do a lot of skin surgery, casting and other simple orthopedic things. Most of us have given up obstetrics. Almost every day my “dessert” is to perform some kind of skin surgery. That’s one of my favorite things. You actually get to be hands-on and see a permanent result from something you do in the office.

A: I have really strong feelings about that! HMOs intentionally pitted the primary docs against the specialists. The HMOs told us, “You’re the gatekeeper. Don’t let patients go to specialists unless you have to.” They cut down the income of the specialists, and also reduced the cost of medical care. That was the only time that costs went down, but the process pitted the primary docs against the specialists. 

That’s the rift I hope to heal during my term as president of SCMA. I want to bring doctors back together again and realize we’re all doctors, all trying to take care of our patients. The economic issues really shouldn’t divide us the way they have.

A: I’d say 70% are Medicare. I have a lot of people who are Medicare and Medi-Cal, which means I write off the 20% Medi-Cal portion, but that’s okay. My primary Medi-Cal is probably down to 1%. The uninsured are climbing up toward maybe 5%. These are regular people who pay their bill to see me, and my bills are not very high. Most visits are below $100. People go to the vet all the time and pay that amount without question. The rest of my patients have regular insurance, not Medicare.

A: Because I won’t schedule less than 20 minutes, I have increased my hours. Basically what I have done is to take more middle- and end-of-the-day patients so that my skin surgery starts at six o’clock on most days.

A: That’s a long office day, but my real day begins at six in the morning to do charts and rounds and the rest of it. My day is from around six in the morning until about midnight. That’s how I make a great living being a family doctor. We are underpaid, but it does fine if you work those hours!

A: I have a very special wife. She is very tolerant of that, and she brings dinner over here, and we have dinner around six-thirty or seven many evenings. That’s generally about the only time we get to be together. 

A: I do phone calls mostly, from seven until nine. Nine to ten is rounds at Palm Drive because I usually have quite a few people in the hospital. And then keeping the records, and going through the lab, and doing all the paperwork, is what takes the rest of the night.

A: Five days a week. I also work weekends. I do a 12-hour ER shift at Palm Drive two to four times a month. 

A: Yes, I do! I think it’s crazy! 

A: Several of us have taken additional classes and then taken a test sponsored by the Internal Medicine Board called “Added Qualification in Geriatrics.” It’s a full-day exam. It’s like the boards that are done for family practice, but it’s geriatric-focused. 

A: It sort of evolved with the patients in our practice. Our longest-term patient has been with us since 1926. He was delivered by Dr. Chester Marsh, who was a predecessor of our practice. Geriatrics just evolved because of our old established practice, and I love it. I have many 90-year-olds, but I only have a couple of 100-year-olds. 

A: They do have more cumulative illnesses, although the ones who make it to 90 are often pretty healthy. The people who die in their 70s or 80s are the ones who have lots of diseases and all kinds of conflict between the treatment of one disease and the other diseases. 

A: When Howard Dean spoke at the recent CMA Leadership Academy, he was very optimistic that President Obama’s plan could be enacted this year. The plan includes the idea of a public option, where you could buy something like Medicare. I think that’s by far the best solution. 

The insurance companies take 30% off the top, and because they do that, the cost of our medical care is incredibly high. If we didn’t have all the options that the insurance companies provide, if we had only six options, like Medicare supplements do, we could simplify the administration, and we would know what a patient is entitled to. We wouldn’t have to spend so much effort finding out whether this is a covered benefit, or whether they would allow it. 

The cost of this whole system would be incredibly reduced if we eliminated the insurance companies, and I think they will be eliminated if we give Obama’s plan a chance, because nobody’s going to pay that 30% extra, compared to the 6% that Medicare administration costs. 

A: I’m extremely happy with my career. I could not imagine anything I would rather do. Being a teacher would be wonderful, but it wouldn’t compare with what I get to do here. And I think, really, being with people at the beginning and the end of their life, being with them in the room when things are really important to them, and helping them get through hard times, has been the most rewarding part of being a doctor. Just the relationship with so many people, and a really intense kind of trust and being with people at a time when big things are happening to them. 

A: There are several. One of them was a patient that we have taken care of for a long time. He was the patriarch of the family, and he had a heart condition that he wasn’t going to have anything done about, so he knew he was going to die. He told his family that he wasn’t afraid of dying, he didn’t mind going at all, he was just sad to leave all these good people, his family. The way he was able to say that was really a lesson, a good instruction on the best way to die. 

It’s the geriatric people that I learn the most from. That’s what I like best about my practice. They have a great deal to teach me.

A: Forever!