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Publication Date: Wednesday, May 22, 2002
Guest opinion: Is there room for the old-fashioned medicine?
Guest opinion: Is there room for the old-fashioned medicine?
(May 22, 2002)
By Anne Hillman
Early this month, a young pediatrician got the surprise of his life. He walked into a Bay Area meeting hall and was greeted by several hundred patients and their parents. "Yay, yay, yay!" The cheers echoed from voices young and old for several minutes. The doctor ducked his head and laughed in delight.
It was a sight that would have delighted anyone. The air was filled with bright balloons trailing ribbons, and so many families crowded the hall, there was barely room to walk between the long rows of wall-to-wall tables. There were children everywhere: children standing, children nursing, children scrambling; children playing with endlessly patient fathers. Not a one crying.
Families from all walks of life were eating from a simple deli buffet, drinking fruit punch and eyeing the decorated cake. Mothers with strollers chatted, adjusting their babies' bonnets. Fathers lined the walls, carrying infants on their backs. All shouting "Yay, yay, yay!"
The hand-lettered red and yellow banner on the wall proclaimed, "Farewell and Thank You, DR. GILL!" The families were there to say goodbye, not because this pediatrician was ill or leaving, but because he had closed his practice at the age of 36. Not because it was not successful -- for it obviously was -- and not because he wanted to.
Jeff Gill, Stanford '87, said it had been his dream "since I was 9 years old, hanging upside-down on the monkey bars at school and thinking about becoming a doctor. I counted the years it would take: four more in grade school, four in high school, four in college, four in med school, and more for a residency. Maybe 20 in all."
Subtracting years as he went, his dream took shape before he chose his pediatric residency. He imagined offering the kind of care that allowed for house calls when needed, and for office visits with plenty of time to listen, to teach and to collaborate with parents. He'd limit the size of his practice so he'd have that time, and get to know his patients, their families and their environments well.
The motto for his practice was Time to Care. It was inspired by his recognition that managed care was "a lot of momentum in the wrong direction." He knew he didn't want to practice "assembly-line medicine" with long delays for appointments, crowded waiting rooms and rushed visits with a doctor running well behind schedule. "Physicians are frustrated too," he commented, "pressured by insurance company constraints to see more patients per hour. They want to practice great medicine, but feel they can't always do what they think is best for their patients." He hoped to "provide a welcome diversion from larger-scale, less personal health care delivery systems and offer parents an opportunity to break free from restricting insurance contracts."
He developed and tested a business plan that included neither HMO options nor their cumbersome paperwork. Then he borrowed money, built his own examining table and hung out his shingle. In the first three months, he saw only one patient. The long rows of medical records folders sat empty. As they gradually filled, he answered phones, practiced medicine, did the bookkeeping, cleaned the offices, scrubbed the bathrooms.
Eventually, word spread among parents as far as a hundred miles in all directions. Not only was this doctor taking a risk. The parents were gambling as well, in hopes of qualitatively different medical care for their children. Dr. Gill was neither an HMO "preferred provider," assuring a lower rate, nor was he offering "two-tier medicine" with a hefty annual fee, serving the wealthy.
His charges were comparable to patients' costs under managed care. Without an HMO's expenses and overhead costs, however, his earnings compared favorably with those of his more harried peers working under intense HMO pressure to produce. His practice grew. Within three years he'd taken a partner, added hospital privileges and a satellite office, and restricted new patients to newborns. In the fifth year, true to his plan to keep the practice small, he stopped accepting any new families.
When Dr. Gill walked into the hall, he never made it to a table. He stood for two hours as lines of parents and children formed to speak with him. Everyone embraced the man they'd come to honor. Children brought crayon drawings, and reached up to hug him as flashbulbs popped continuously. It was like photos with Santa, only better, because this man was their friend.
A local pediatrician said, "I've never seen anything like this in all my years of practice." One mother cried. "He came to our house on Christmas Eve to set our daughter's wrist." Another added, "We're all devastated -- there's no one else in the world like him! Our daughter was hospitalized three times, and he always got there before we did."
"The families presented him with a white doctor's coat covered with tiny red, blue and green handprints, still damp. They'd sent in so many letters and photographs, the bulging scrapbook he received barely held a quarter of them. A mother volunteered to make three more.
Why close such a successful practice? His partner moved away a year ago to accommodate his wife's job. Despite a competitive salary guarantee and a two-year patient waiting list, Dr. Gill couldn't find a pediatrician to replace him. "I've explained it to my patients this way: I love my practice. Everything about it lets me be the kind of doctor I want to be and give the care I want to give. But I just can't do it alone any longer. And I can't find anyone else to come work with me."
While Dr. Gill practices in Pleasanton, the same phenomena exist in Menlo Park and Palo Alto. A prominent internist on the Stanford clinical faculty who has practiced in Menlo Park for 35 years describes the dilemma.
Housing costs are prohibitive here. Moreover, there is enormous frustration with a managed care system that's worse in California than anywhere in the country -- we have the highest percentage of patients in HMOs and the lowest reimbursement figures for medical doctors of any state.
Still, only a handful of local physicians have left the managed care fold and started a small practice, charging a premium for "access." Others are leaving medicine altogether or retiring early. Countless have moved to the East or Midwest, seeking more traditional practices.
San Mateo County has had a net loss of physicians. The demand is ferocious. However, half the medical graduates today are women, many wanting half-time practices. And another substantial percentage of graduates leave the medical field entirely or combine it with law or business.
These factors make California applicants cautious. While some may hunger for smaller practices, the unfamiliarity feeds uncertainty. The Stanford physician muses, "Gill's practice offers the elements that most doctors want -- closeness and time with patients. But graduating doctors are concerned with lifestyle issues. The weight of responsibility, the time demands may have sounded too much."
Jeff Gill also wonders aloud, "I know a small practice without an up-front fee sounds risky. Yet the two of us had good incomes and two long weekends off a month. Because we had half the 'normal' patient load by choice, our pace was easy by comparison, and most times on call, the phone never rang." And then he almost whispers to himself, "Maybe they thought it sounded too good to be true."
Anne Hillman lives in Portola Valley and is a member of the Almanac's Panel of Contributors. She is the author of "The Dancing Animal Woman -- A Celebration of Life," and can be reached at firstname.lastname@example.org.
Anne Hillman Almanac May '02 A Doctor's Farewell