A passion returns

I tried capitated primary care, and it reversed my burnout

Here’s how a residency rotation in Denver completely changed my perspective.

In the first week of my residency, despite what I’d heard, I was surprised by the amount of paperwork I was required to complete. Trying to see all my patients, address their concerns, and fill out all the necessary forms within my work-hour limit was truly challenging. “When will I have more time to spend with patients?” I asked myself. I figured that once I adjusted to residency and the health care system, I’d be able to devote more time to patient care.

Eighteen months went by, and the shift I was hoping for never happened. There were just too many demands on my time as a resident. Anxiety started to creep in; I began to wonder whether I would ever be able to have the freedom to practice how I wanted.

Frustrated

I started brainstorming about what else I could do to pay off my loans. Private practice? I knew I could do that, and it would allow me more freedom to spend time with patients, but that I’d be limited to a small number of patients. A hot dog stand? With hard work, I estimated I could make twice my resident salary.

Adil Manzoor, DO

I knew something was wrong when I was ready to leave medicine to start a hot dog stand. I was on the verge of quitting my residency. But then I came across an article in my email from The DO: “The simple appeal of capitated primary care: Practicing without copays, per-visit billing or RVUs.”

Reading the article gave me a glimmer of hope that there might be just a way to practice the way I wanted. I hadn’t been aware of a practice style that allowed physicians the time to comprehend the intricate barriers surrounding patient care and also navigate them to make sure patients received the care they needed.

The article’s author, Laura Selby, introduced me to one of its sources, Cole Zanetti, DO, MPH. Dr. Zanetti helped me arrange to complete a residency rotation at his Iora Health clinic (branded Iora Primary Care) in Denver, and within a few weeks, I was flying to Colorado, ecstatic to experience a different style of caring for patients.

A different way

The two weeks I spent with Iora passed far too quickly. Each day I spent there, I felt more refreshed, enthusiastic about medicine, and convinced that I still wanted to be a physician.

Iora Health contracts with Humana under a Medicare Advantage arrangement, and only accepts patients who are 65 or older. Each Iora clinic has a team: health coaches, a nurse, physician, clinical team manager, patient recruitment team, and a behavioral health specialist.

Staff and I would arrive at the clinic at 8 a.m. From 8:15 to 9 a.m., staff take care of business items and review the patients scheduled for that day; they identify the high-risk patients and discuss their health, their medical conditions, and most important of all, their barriers to health.

Patients are seen from 9 a.m. to 5 p.m. Throughout the day, I worked with the health coaches, who were the connection between the physician and the patient, to identify barriers for a patient, whether they were psychological, social, health literacy, or even distrust of physicians; categorize them in order of the patients’ priorities and come up with a game plan involving the patient. This allowed us to understand what mattered the most to the patients, and what they were willing to work on, so we could meet them there.

This was only doable because we had the time we needed to spend with our patients; many appointments were one hour, and if we went over that one-hour mark, there was no one breathing down our necks.

Toward the end of my rotation, I noted that the goal of most visits was education. I can confidently say that we spent close to 80% of our time educating patients and around 10% doing paperwork and completing medication reconciliations, often removing unnecessary medications. And that last 10% of the time? Doing what our patients needed.

Back to reality

After I finished my rotation at Iora Primary Care, I returned to my residency in New Jersey. The flow of seeing a large number of patients in a limited amount of time has returned. But this time, I know there’s a place that allows the type of practice that we as physicians envision as we enter medical school and our residencies.

I am almost two years into my training and have decided to complete it. My passion for medicine has been re-ignited. What I desire now is to help bring humanity back to health care.

14 comments

  1. Adil! Thank you for taking the effort to write about your experiences. It did shed some light on capitated care.

    However, i believe you are too early in your career to accurately describe what you have as “burnout”.

    Im sorry, but the title of the article is a bit misleading. I think only experienced doctors in practice can give us the wisdom of burnout or non burn out with capitated care. I guess if the article was titled “capiatated care reversed burnout for this resident doctor” ….most doctors in practice would have laughed it off. I feel you cant really give a genuine perspective on the practice of medicine from a residents perspective.

    I have worked in a capiatated and non capitated environement and i have seen some of the worst quality of care in a capitated environment.

    Hope the DO magazine elevates its quality of articles…. :)

    1. You can absolutely have burnout in residency and it is rampant. Depersonalizing your patients? Check. Extremely low sense of personal achievement? Check. Compassion fatigue? Check. Crying every single night when realizing you have work again the next day? Check.

      Burnout can happen fast. I got it halfway through my intern year and it has taken me until now, almost a year out of residency, to see even the first glimmers of hope that things can be better. I too was dreaming of ways to leave medicine in the worst depths of my burnout.

      Still might, once my attorney husband and I dig ourselves out of our $400,000 of debt. We’ll see.

    2. Eyedoctor, thank you for being the first to say what all the practicing physicians who read this article are feeling. The DO, and the AOA in general, have gotten in the habit of only publishing opinions that they believe in, and censor physicians who disagree. No one is actually listening to those of us who are out in practice for decades. No one is paying attention to the fact that we already tried capitation and it failed miserably, and actually in a relatively short period of time. Taking one practice and trying to apply it across the board is similar to taking one patient’s experience with a medicine and assuming everyone will have the same outcome. Most of us in practice would agree that two weeks (or even 4) is not enough time to adequately judge a system of reimbursement, especially when a person’s income was not dependent on it. This entire way of approaching medicine is insane and the fact that we, as a nation, regularly take the advice and opinion of those not in actual practice as a measure of how to practice, indicates one of the deeper issues. I am sorry that you have gotten unnecessarily unprofessional responses to your comment. I thought it was very well written and I appreciated it. Thank you Eyedoctor! And thank you to all the practicing physicians who work to make the system better, not reverse it to already failed ideas.

  2. Nice article, Adil. Thanks for sharing. Fellow med-peds resident here who is exploring some of these options for after residency. Consider looking into direct primary care as another practice model that you may find refreshing.

    1. Thanks Jonathan. Direct Primary Care is definitely​ a good opportunity. I’ve definitely been in touch with quiet a few docs who have based their practice on that concept and are definitely enjoying their lifestyles. Iora gives an opportunity to make a difference in a large scale. I hope they’ll publish their data soon and show how their model has, for example, significantly decreased hospitalizations and is associated with significantly improved quality of life of physicans, which is currently neglected.

  3. Just wanted to say that I am sorry that the system is crushing your enthusiasm but know that life after residency CAN be better than it was. My husband and I have a private rural practice and typically max out at about 20 pts daily. That still gives us time to take care of our patients, our paperwork and ourselves. It certainly isn’t perfect but honestly, I’m better paid than I was when I taught high school and not working huge amounts more than I was then.
    We could obviously double our income by seeing 40 a day but we are doing fine and most of the time, love our life and our practice. Two of our children are adults, one is freshly graduated from med school and the other is an MS III. They have seen the fun and not so fun parts of medicine and still elected to pursue medicine. I think our balanced lifestyle helped them see that medicine can be rewarding. Hang in there! It really can get better.

  4. Lol capitation is an all you can eat hot dog stand and the price is set by the payer. Good luck but I think a cash hotdog stand is a better way to go.

  5. I agree that burnout can occur early in a career due to our intensive training and schedules. The take-away of this article is interesting in that it suggests what some models of care have concluded- that a team-based approach can provide comprehensive care, curtail costs, and increase physician job satisfaction.

  6. I agree that burnout can happen early. I felt burnout within a year out of residency. But this is now the SECOND article (within 5months mind you) the AOA has published about capitated care models. And BOTH are about Iora Health. Which is definitely not the only company doing it. Is Iora paying for these articles??? Where are the articles about other payment models such as direct primary care?

    1. No no, Iora isn’t paying for anything. They didn’t even know that I had planned to publish it. I told them that I was publishing it just prior to doing so

      I agree, there are other companies and physicians doing great things. Atlas MD is an excellent one, doing amazing things with Direct Primary Care and slowly inching towards a national level.

      I don’t full comprehend exactly what they are doing but if you do, I encourage that you write about them and/or the direct Primary Care concept.

      There are so many ways for Physicians to enjoy autonomy and have a good quality of life. Our goal should be to educate each other on such concepts so that we can find ways to get out of this fee for service trap.

      And this article doesn’t do justice as it had a word limit. It’s goal is really to let residents and physicians know that there are other ways to practice medicine​ that is fulfilling.

  7. Adil – If you want to stay in NJ, there may be no better place for support of capitated primary care such as Direct Primary Care. Read the link below for how unions, Democrats & Gov. Christie came together. DPC is one of the relatively few areas of bipartisan agreement.

    https://www.linkedin.com/pulse/why-new-jersey-offering-free-primary-care-over-550000-mason-reiner

    Iora itself is great (my parents are patients in their clinic). There are other innovators out there as well such as ChenMed,CareMore, R-Health, Vera Whole Health and others. Fortunately, there is an explosion of value-based primary care that recognizes primary care has been undermined in this country and must be rethought.

  8. ” I can confidently say that we spent close to 80% of our time educating patients and around 10% doing paperwork and completing medication reconciliations, often removing unnecessary medications. And that last 10% of the time? Doing what our patients needed.”

    As a patient who has chosen osteopaths as my primary care doc for 40 years, here’s my 2 cents worth. For me, OMT has been a life saver. Too many DO’s, by choice or necessity, are choosing to forego what makes the “O” unique and opting to be simply – and I do mean simply – MD’s. Whether that’s because the admission requirements were less stringent than or because of reimbursement for OMT, you who choose to neglect this most sacred art and science of your profession are depriving patients of what may be, in the long run, life saving treatment. Your profession (and association) would do well to learn from the chiropractic “practice management” consultants, who have only a hammer to sell but, through successful marketing strategies, make the whole world of the patient look like a nail. “Make Osteopathy great again,”

  9. 17 years into my career at Kaiser in Northern California and not a regret. Primary care is busy work here like everywhere but without the ownership headaches. It’s good to hear there are more salaried programs like ours out there. Good luck in your future!

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