CLINICAL DIABETES These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. PRACTICE PROFILES Surviving the Medical Meltdown in California Claresa Levetan, MD Editor's note: In the "Practice Profiles" department of Clinical Diabetes, we spotlight clinicians who have chosen to dedicate a significant portion of their time to the care of patients with diabetes. We welcome suggestions for future interviews.
Did you always know that you were going to be a
doctor? When I went to the University of Washington, I started out in the honors math program, but the material was so esoteric and boring that I decided to switch majors. Next came physics, then chemistry, and although I did well, I couldn't see myself spending the rest of my life in these fields. In these classes, I began to bump into the pre-med students, although they usually just took the basic nonmajor science classes, and they seemed to have the clearest idea of where they were going. And unlike the physics and engineering majors, they didn't wear their slide rules on their belts. (I kept mine hidden when I was in public.) In addition, I had a huge amount of respect for my long-standing family doctor, although I never felt I could fill his shoes. At the end of my junior year, I suddenly made my decision, and I have never regretted it. What led
you to initially become an infectious disease consultant? In my final year, I was recruited to join a group in Sacramento, Calif., aptly named Consulting Internists (this name was later to be our undoing). The physicians I joined in that group were superbly trained in nephrology, endocrinology, rheumatology, noninvasive cardiology, and critical care medicine (although that term had not yet been coined). I often felt I was in a continuing postgraduate program. We spent most of our time doing hospital consults and gradually acquired large consulting office practices that covered all aspects of nonprocedural internal medicine. I successfully treated the first toxic shock case in our area (before the disease was described) but was not so fortunate with a growing number of bizarre infections I began seeing in early 1980 (more than a year before AIDS was defined). You were
in practice in California as the health care system underwent drastic changes in that
state. What was your experience? Additionally, our hospitals' implementation of the COBRA laws of 1987 was onerous to internal medicine. We were mandated to take all unassigned medicine admissions (often more than five in a night). Most of the family medicine physicians dropped off staff, and the specialists, such as the cardiologists, refused any case that did not require a cauterization. Most of our cases were nonreinbursed. My office-based practice was similarly affected as managed care decided to pay me on a capitated basis. My large number of complex patients acquired during my consulting years in Sacramento were now a noose around my neck. We changed our name to Internal Medicine Associates and refused consultations. I went for 2 years without a vacation and moved to a smaller home as my income dropped by more than half. I was seeing more than 30 patients a day and had no opening for even a simple follow-up for months. During this period in the late 1980s, we merged our 10-man group into a large multispeciality "group without walls" of more than 100 physicians to negotiate with insurance carriers and hospitals for contracts to help give us some control in this increasingly complex environment. Unfortunately, reimbursements continued to tumble, and our overhead skyrocketed. At one point, we had a deficit of more than $1 million, and I often felt like I was working to keep out of debt. Being in this larger group allowed us access to the salaries of other members. Although I was the highest-paid salaried internist, I made less than half of what my children's pediatrician earned and one-third as much as a starting anesthesiologist. However, in 1990 two white knights appeared to save the day. Sutter Community Hospital began active negotiations to buy our foundering group. Leaving my old group would have been financially disastrous to my remaining colleagues, who had been my closest friends for more than 14 years. The Sutter offer suddenly solved this dilemma. At this same time I received an unsolicited offer to set up a solo practice next to Capital Medical Center, a small hospital in Olympia, Wash. The offer and timing seemed too good to be true. My remaining original partners are still working for Sutter Health Systems but have quit their specialties of nephrology, rheumatology, and endocrinology and do primarily geriatric general internal medicine. My only regrets were the loss of my collegial associates and friends and my old patients. How did
you come to change your specialty from infectious diseases to diabetes?
She called me at the office in tears. A blood glucose reading of 650 mg/dl confirmed our worst fears. I was in shock and felt I must be in the middle of a bad dream. My perfect little girl had a disease whose terrible complications seemed to dominate my practice. Our group ran the Sutter Hospital dialysis unit, where half the patients had diabetes. That afternoon, my wife, daughter, and I were in the office of the pediatric endocrinologist. My wife and I were tearful, and I still remember my daughter asking if we were sick. We started her on insulin at that time. We took her home and began our journey to learn and treat our daughter's disease. We first took home the four glucose monitors available at that time and practiced until we found our favorite. I devoted all of my educational time to diabetes and went to every available conference that I could. As a general internist, I thought I had a good understanding of the disease, but I soon found out I had a lot to learn. It reminded me of taking a foreign language course in college and then going to a country where that language is spoken and discovering how inadequate course work was compared to living the language. The details are important! Fortunately, my daughter went into a honeymoon period for 9 months requiring only one shot a day so we could learn the details when things became more challenging later on. My work schedule was extremely hectic. On my on-call day, I would work all day and all night. On my other days, I would work all day in the office and would usually get several infectious disease consults requiring me to go to the hospital for several extra hours. I seldom got home before 8:00 p.m. One day in 1988, I decided I needed to quit my infectious disease practice and wrote letters to all of my referral doctors. We had a large number of both new and old patients with diabetes in our group, and I naturally began to acquire more of them in my practice. One of my partners was an excellent endocrinologist, and I would try to learn as much as I could from him. However, the lessons learned at home while treating my daughter were more practical and many times more helpful to my patients. When I moved to Olympia, I had an opportunity to start over and avoid some of the mistakes that had occurred in Sacramento. I was determined to do no more consulting and hoped to acquire a large panel of representative internal medicine patients. At the time I arrived, there was a shortage of internal medicine physicians. There had been three endocrinologists in Olympia for years, but shortly before I arrived two of them left practice. I became active in the local American Diabetes Association, and my wife became a nurse at the local summer camp for children with diabetes. I also gave lectures at diabetes education classes. Before I knew it, I was swamped with new diabetes patients. One of the endocrinologists who left practice had contracted cancer, and I acquired most of his patients. Although I never met him, it seemed uncanny how similar our insulin regimens were. On early visits with his former patients, I would stress the value of frequent testing. I would teach them pattern recognition and how to prospectively manage their blood glucose levels. (During my early years, I once thought that people with diabetes could be managed with the perfect personal sliding scale. Now I realize that this is retrospective care leading to recurrent highs and lows.) After 6 months, the patients I had acquired from the endocrinologist had improved their HbA1c levels by an average of 1 point with only minor insulin adjustments. But they were all now checking their glucose levels at least 3 times a day. My practice is now so busy it is hard to see new patients, and I have taken on a new associate who does general internal medicine. My next new patient opening is more than 4 months away. I will still try to work in new patients with diabetes as soon as possible, usually after hours. I usually spend 60–90 minutes with new diabetes patients. Depending on the case, I will usually see them back frequently at first and then less often depending on their needs. When stable, they return to my office every 3 months. I do most of the diabetes education myself, especially insulin starts. I believe that patients can only learn so much at one sitting, and I will have them back within a week to review how they have done and continue their education. Some patients are quick learners, and some are very slow. I bill the subsequent follow-ups as office visits. In almost all cases, I become the patient's primary care doctor. I emphasize the importance of tight control of blood pressure and lipids, as well as glucose control. What has
been the biggest breakthrough that you have seen in diabetes? Are you
doing many diabetes clinical trials in your office? What do
you find rewarding about treating patients with diabetes? At this time, there is no severe penalty for doctors caring for patients with diabetes in Olympia. This was not true in Sacramento. Treatment for diabetes can be very expensive, but treating the complications is much more expensive. The trend of putting physicians at risk for the cost of care I find very frightening, especially when it comes to diabetes. Having less frequent monitoring, using older insulin schedules, and prescribing only sulfonyureas may save money in the short run, but these practices will hurt in the long haul. Claresa Levetan, MD, is director of diabetes education at Medlantic Research Institute in Washington, D.C. She is an associate editor of Clinical Diabetes. Copyright © 1999 American Diabetes
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