A day in the life of a physician

A Day in the Life of a Physician: Part 4

Posted in A day in the life of a physician, Primary Care on August 23rd, 2010 by MMS – 2 Comments

By Robin Dasilva and Therese Fitzgerald

This is the final in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass.

Read Part 1, Part 2 and Part 3.

Devotion to Patients – From Physician and Staff

Mid Afternoon

DSCN0688Dr. Izenstein’s office staff manages the front office as he continues seeing patients. The office staff is very dedicated to the practice. It is readily apparent that they enjoy their jobs and love working with the physicians and patients in the practice. The atmosphere is more like a family than a workplace.

The office transcends its designation as a place for medical care to a place of caring, similar to a home for patients. For example, one of Dr. Izenstein’s patients, who is mentally challenged, came in for a scheduled appointment. The staff was very attentive to her needs and made sure she was comfortable during her stay. They also ensured that she had her medication and a ride home. The staff often arranges rides for her and takes the saying “give you the shirt off your back” to a new level, with one staff member giving the patient her own coat when the woman arrived in inclement weather without one. On her way home that night, the staffer stopped by to retrieve the coat and check on the patient.

The familial feelings of home fall away and we’re brought back to reality when we ask the office staff about their typical day’s activities. We discover that staff spends most of its time dealing with administrative procedures pertaining to insurance companies. Most of the issues involved prior authorizations, lack of reimbursement, and billing issues related to coding.

According to Dr. Izenstein, insurance companies are not adequately covering medications and turning down prior authorizations. Dr. Izenstein was frustrated that as a physician he was spending so much time getting a prior authorization for patient care. He noted that insurance companies continue to add many hours to both the physician and staff’s days due to administrative burdens.

According to the staff, prior authorizations, referrals, and billing issues take up much of their time. Prior authorizations seem to be needed for everything, especially for primary care. Staff spends numerous hours getting prior authorizations. Nine out of ten times they are approved after phone calls to the insurance companies and nearly 100 percent of the time they are approved after peer conferences. When billing, staff estimates receiving only 50 percent of reimbursements. Billing issues mainly are due to coding errors, adding additional time on the phone with insurance companies.

Even when he successfully navigates the system of administrative procedures to provide the prescribed care, Dr. Izenstein faces further barriers of an administrative nature. Specifically, due to the high costs of prescriptions, many of Dr. Izenstein’s patients can’t afford their prescribed medications.

Late Afternoon

As the afternoon wears on, Dr. Izenstein continues to tend to his patients and return phone calls. As he works, we learn from the staff that Dr. Izenstein was greatly influenced by his father, a man who is also seen as an inspiration to many people in Springfield.

The staff was excited to tell us about the upcoming annual grand rounds at the Bay State Medical Center dedicated to the elder Dr. Izenstein’s memory. The Dr. Louis A. Izenstein Visiting Professorship and Lectures in Diabetes, Obesity and Metabolism was started by Dr. Izenstein and his siblings upon the death of their father in 1996. The lectures were developed by the Division of Endocrinology, Diabetes and Metabolism to honor the memory of Dr. Izenstein “who is considered a pioneer and visionary in his native Springfield”.

Dr. Izenstein’s father returned to the Springfield area upon finishing his training to develop an Academic Department of Medicine with a special focus on the development of high-level faculty and to bring the “state of the art” to the management of diabetes. From all accounts, the younger Dr. Izenstein is following in his father’s well-regarded footsteps and is beloved by his patients and staff for his dedication to his patients.

Evening

It is 5:00 p.m. and Dr. Izenstein is still working, seeing patients. He’ll be there late into the evening catching up on the paperwork and phone calls that are necessary but time-consuming to his practice.

Anyone spending the day with Dr. Izenstein can see how dedicated he is to taking care of his patients. And although Dr. Izenstein’s practice may not fit all of the criteria for the “medical home” models being piloted across the state and the nation, this physician’s warmth and caring embodies the true spirit of that model by providing a place where patients are welcomed, supported, and cared for in a nurturing environment.

End of series.

A Day in the Life of a Physician: Part 3

Posted in A day in the life of a physician, Primary Care on August 20th, 2010 by MMS – Comments Off on A Day in the Life of a Physician: Part 3

By Robin Dasilva and Therese Fitzgerald

This is the third in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass. Read Part 1 and Part 2.

Why I Am a Physician

Noon/Lunch

Dr. Barry Izenstein’s dedication and compassion for his patients illustrates his motivation for choosing to practice medicine.

“Medicine was a calling, I thought about going into medicine since high school. I was also influenced by my father, who was a physician, and I wanted to take care of sick patients,” he said. “During my medical training in the 1970s, it was popular to go into a sub-specialty. I wanted to practice internal medicine, but also wanted to be a consultant in endocrinology in order to bring something else to internal medicine. Internal medicine and endocrinology seemed to go hand-and-hand. “

Dr. Izenstein explains that there are important characteristics needed to pursue the specialties he has chosen.

“Internists and endocrinologists must first be good listeners. Patients may arrive with multiple symptoms and signs that the physician must be careful to pay close attention to. They must also have the ability to pull together various facts and diagnoses in order to devise a plan for their patients.  A person doesn’t come in with one condition or diagnosis. Therefore, the physician needs to act like the conductor of the symphony, and the orchestra is the human body.”

Around noon, Dr. Izenstein takes a time out to have lunch. But just because he’s taking a break from seeing a constant stream of patients to eat a salad doesn’t mean he’s not working. Lunchtime consists of checking e-mails and returning phone calls between bites of his salad. Some of the e-mails Dr. Izenstein answers pertain to his work as a governor of the American College of Physicians.

Although Massachusetts consistently ranks high compared to other states for the number of physicians per 1,000 population, Dr. Izenstein’s juggling act reminds us that many of the physicians working in Massachusetts are balancing work and other health care sectors including research, teaching and leadership positions, in addition to — or in lieu of — providing direct patient care.

During lunch, Dr. Izenstein shares his thoughts on the passage of health care reform in Massachusetts and how it has impacted his medical practice.  To summarize his opinions, he refers to an article he had written for a local medical journal outlining the three essential elements he believes are needed in the national health care debate: universal access; fix primary care; and reform the tort system.

Dr. Izenstein believes that no matter what changes occur under health care reform, “My relationship with my patients will never change.” He does hope that ongoing health reform efforts will allow internists to spend “more time, not less, with their patients in the exam room.”

The hospitalist movement has changed the lifestyles of physicians coming into practice. Internal medicine practice is totally different now with not having to care for patients in the hospital. In this new generation you work in a hospital or private practice, not both. This allows for more time to attend soccer games and improve a physician’s lifestyle. Lifestyle is no longer going to be an issue for internal medicine physicians. It is far easier than a cardiologist, for example, who must bear the brunt of working in the emergency room in the middle of the night., although, cardiologists are compensated nicely.

Dr. Izenstein’s salad is almost gone and he has just enough time before his next scheduled patient to run next door to Baystate Medical Center to check on a couple of his patients who have been admitted for inpatient care. Although Dr. Izenstein’s patients are cared for by hospitalists when they are inpatients, Dr. Izenstein takes time to visit with them. Although he is not reimbursed for these visits, he likes to let his patients know that he is still involved and that he is available if they or the hospital staff needs him. Dr. Izenstein’s patients appeared happy to see him, and their family members thanked him for taking the time to visit with him

In Part 4: Dedication from Physician and Staff

A Day in the Life of a Physician: Part 2

Posted in A day in the life of a physician, Primary Care on August 19th, 2010 by MMS – Comments Off on A Day in the Life of a Physician: Part 2

By Robin Dasilva and Therese Fitzgerald

This is the second in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass. Read Part 1 here.

The Challenges of Practicing Medicine in Massachusetts

Mid Morning

DSCN0688Dr. Izenstein’s next patient smiles warmly as he enters the examination room. He asks if Dr. Izenstein enjoyed the coffee he brought back for him from his homeland in Latin America. After asking the patient a number of health-related questions, they discuss the patient’s medications and a recent visit to a specialist. Although the patient has brought his medications with him, Dr. Izenstein does not have any information from the specialist’s office regarding his visit. Without this information, it is difficult for Dr. Izenstein to reconcile the patient’s chart and medications with those of the specialist’s office and has to obtain the necessary information verbally from the patient.

Dr. Izenstein is hoping that these types of issues no longer occur with the implementation of an electronic health record (EHR) system at the office, and his staff is cautiously optimistic about the transition. The staff hopes that the EHR system will make things easier for the practice in the long run. According to the practice manager, an EHR system would help cut out transcription costs to dictate charts. Transcription costs have increased with increased audits by insurance companies. However, the practice does have a system in place for prescribing electronically.

For now, Dr. Izenstein makes do with the information provided by the patient and continues his examination. Dr. Izenstein listens to the patient’s opposition to the surgery Dr. Izenstein has suggested. Together they discuss alternatives to the procedure and agree to continue postponing surgery until further discussion at the patient’s next appointment. The examination continues with Dr. Izenstein checking the diabetic patient’s blood pressure, listening to his heart and lungs, and examining his feet. Dr. Izenstein prescribes new medication for the patient based on their conversation and makes certain he is sending the electronic prescription to the correct pharmacy.

While Dr. Izenstein continues seeing patients, his practice manager discusses her thoughts about maintaining a practice in today’s environment.

“It is more difficult from a cost perspective to maintain a practice today than in past years,” he said. “This year, the practice’s revenue has been impacted largely by increases in premiums for our employees. The premium increases are much higher than in previous years. Also, insurance companies are placing more responsibility on the patient to pay up-front, i.e., increase in co-pays. Many patients cannot afford increased co-pays.

“Therefore, in many cases, the practice waives the co-pays for patients and the practice picks up the cost.  Patients are waiting longer to schedule appointments with physicians due to cost of co-pays.  Physicians have also seen an increase in patient calls. Patients would rather call than come in to see a physician and pay the co-pay.”

In Part 3: Why I Am a Physician

A Day in the Life of a Physician: Part 1

Posted in A day in the life of a physician, Primary Care on August 18th, 2010 by MMS – 1 Comment

By Robin Dasilva and Therese Fitzgerald

This is the first in a series of four posts about a day in the life of Barry Izenstein, MD, an endocrinologist and internal medicine physician who practices in Springfield and Holyoke, Mass.

A Specialty in Crisis

Early Morning

Barry Izenstein, MD, FACP, begins his busy day at 8:00 a.m. the way he has for the past 20 plus years: caring for veterans at the Soldiers’ Home in Holyoke. After consulting with the nursing staff on duty, he performs rounds greeting and examining his patients. Today he is concerned not only with the well-being of his patients, but also with their future care as the threatened closing of the home and its outpatient clinics weighs heavily on his mind.

“These patients have fought for their country and deserve to have their health needs met, “he said. “I worry that they will have great difficulty finding new primary care physicians and the stress they will experience with the transition to a new health care system.”

Dr. Izenstein does more than advocate and care for patients. He served as Governor of the Massachusetts Chapter of the American College of Physicians. In that role, he encourages internists in Massachusetts to provide input and take action on national and local political issues affecting internal medicine. He also hosts local scientific meetings and continuing medical education events, and encourages medical student members and associates to participate in local and national college activities. In addition, Dr. Izenstein educates and mentors young physicians in his role as assistant clinical professor of medicine at Tufts University School of Medicine.

(Note: Thanks to the efforts of Dr. Izenstein and others like him, funding for veterans’ services was restored and care continue to be provided to the veterans at the Soldiers’ Home.)

As a founding partner of Endocrine Associates of Western Massachusetts in Springfield, Dr. Izenstein reports to his practice at 9:00 a.m. for his first of 24 appointments of the day. His first patient has already had his weight checked by the medical assistant and is now waiting in the examination room.

The patient is happy to see Dr. Izenstein and eager to share photos of his new dog. After a short conversation about dogs, Dr. Izenstein begins the visit by examining the patient’s chart and asking him a number of health-related questions, including any changes to his health, medications he is currently taking, and how he is feeling overall.

The patient examination begins with a check of the patient’s blood pressure and pulse, tasks often performed by a medical assistant, but Dr. Izenstein likes to do it himself. As he continues with the examination, Dr. Izenstein talks to the patient about his overall health and well-being and makes suggestions for preventive measures he believes can lead to further improvement.

At the end of the patient’s visit, it becomes apparent that the primary care shortages documented over the past four years in the MMS Physician Workforce Study are all too real. The patient asks Dr. Izenstein if his niece can make a primary care appointment with Dr. Izenstein, but he says his panel is currently closed to new primary care patients.

Later, Dr. Izenstein explains that his biggest challenge as a physician is primary care.

“Caring for the whole patient and responding to all of their needs is a monumental task,” he said. “Likewise, in today’s environment, with the imbalance in paperwork and compensation for time and work, selling primary care to students is a difficult task. Indeed, perhaps that should be health reform’s number one goal.

“A bigger issue is that primary care is undervalued, underpaid. Studies have shown that a system with primary care as its main driver has better outcomes, better quality, and lower costs. Thus, with primary care soon to be in crisis, shouldn’t primary care be the first and foremost concern for the new health overhaul?  With tens of millions of newly insured citizens and only a handful of new primary care physicians.

In Part 2: The Challenges of Practicing Medicine in Massachusetts