Why I See Only Nursing Home Patients: A Doctor's Manifesto

You are listening to ReachMD radio on XM160, The Channel For Medical Professionals.  Welcome to Advances In Long-Term Care Medicine produced in cooperation with AMDA.  Your host is Dr. Eric G. Tangalos, Professor Of Medicine at the Mayo Clinic in Rochester, Minnesota, and a Certified Medical Director.

Many physicians considering a career in long-term care medicine have concerns about getting started.  What are the realities and the myths about working in geriatrics and long-term care medicine?  Joining us to discuss his article on the subject, Why I Only See Nursing Home Patients is Dr. Gregory Zydiak, Medical Director of a skilled nursing facility in Saint Louis, Missouri.  Dr. Zydiak has focused much of his 23-year-practice on geriatric medicine and has created a practical guide website for physicians considering careers in long-term care medicine.

DR. ERIC TANGALOS:

Greg, welcome to the program.

DR. GREGORY ZYDIAK:

Hi! Thanks for having me.

DR. ERIC TANGALOS:

Now, why do you think geriatrics and long-term care medicine is less appealing to many young physicians?

DR. GREGORY ZYDIAK:

Well, that is a good point and I think a lot of it has to do with a lost of misconceptions about long-term care and I think a lot of that is just not really knowing firsthand what long-term care and geriatric medicine is really about?

DR. ERIC TANGALOS:

Now, you wrote an article and it really is called "Tens reasons:  I only see nursing home patients."  You want to tell us about that article and the 10 reasons?

DR. GREGORY ZYDIAK:

Actually, I can put 1000 reasons why.  The article started out to write about something that you love and know and long-term care in nursing home practice is what I love and know.  The 10 reasons there are, basically it is a perfect storm of opportunity with the population of seniors rising and expected to reach over 70 million the next couple of decades, in that also there is also a shortage of physicians interested in that, formally trained or otherwise, and that's just 2 of the main reasons why I think this is a perfect opportunity people should be trying to enter it, not avoid it.

DR. ERIC TANGALOS:

You have the ball field all to yourself.  Is that what this is?

DR. GREGORY ZYDIAK:

Pretty much, and I think that I, maybe, had a scoop here and I think that how come no one else sees this as a wonderful opportunity, it's a perfect storm.

DR. ERIC TANGALOS:

There must be something wrong.  What pushes people away right now?

DR. GREGORY ZYDIAK:

Some of other misconceptions are that it is hard to make a living.  There is no money in it, but actually if the practice is properly structured, it actually has a very low overhead 20-25%.  My personal practice has only had 24% for the past several years.  It is very easy to make a very good living in long-term care.

DR. ERIC TANGALOS:

Well, go ahead and explain this to our listeners a little bit more.  I have gotten a pretty good idea of why such low overhead, but tell the audience.

DR. GREGORY ZYDIAK:

Well, it is interesting because long-term care and geriatric medicine is open to so many different practice models and the one model that I have developed over the years is actually to have no outpatient practice whatsoever and strictly go from nursing homes to skilled facilities, even house calls and this involves no office overhead.  Right there, you cut your overhead literally in half, the typical outpatient practice, which has 50%-60% overhead.  So, without that it's a no-brainer.

DR. ERIC TANGALOS:

Now, do you rent any space for offices at the nursing home or do they let you just use the place because you are the only game in town.

DR. GREGORY ZYDIAK:

Well, actually you don't need an office.  You are actually making rounds in the facilities.  Now one of the models could be opening an outpatient practice at a facility.  I have not personally done that, but again long-term care is open to any of those kind of different practice models.  It is a just a matter of how creative you are.

DR. ERIC TANGALOS:

Now, your primary billing sources, what Medicare, Medicaid, or ManageCare.  What is it?

DR. GREGORY ZYDIAK:

Well, the primary source in long-term care is MediCare of course, and one another bonuses about long-term care is you don't have to belong to ManageCare or deal with any of that hassle if you don't want to.  I don't particularly want to and I haven't throughout my career and petty much the reason for that is that ManageCare really has a hard time making a living in long-term care, the penetration is even in California is around 50%, so there is a lot of room for people to deal with Medicare Primary and that not deal with the ManageCare hassles.

DR. ERIC TANGALOS:

Now, I have read you article "Ten reasons why I only see nursing home patients."  You had a bonus that you haven't covered yet.  Tell us about the colorful patients?

DR. GREGORY ZYDIAK:

Well, I tell you what, when was the last time and you probably have because you are in long-term care, but when was the last time a patient hugged you and kissed you.  I get that all the time and another reason is the patients there are a lot more appreciative and they are lot more respectful of the physicians.  The time they grew up in were different times than now, and it is a pleasure, and another secret, the 11th secret is they are a wealth of wisdom and I don't hesitate to pick their brains until they tell me and scream to stop because they are wonderful bunch and you can learn a lot from them.

DR. ERIC TANGALOS:

That is what they always say about geriatrics is that we are in it because of the stories people tell.

DR. GREGORY ZYDIAK:

That is correct.

DR. ERIC TANGALOS:

You also did a publication "The Secret of My Success" that kind of dovetails on to some of these things.  Anything else you would like to add from that particular article and how it fits in.

DR. GREGORY ZYDIAK:

Well, it does and in part of things that I review in my long-term care practice manual is a lot of the problems with long-term care that the physicians see are not so much clinical as basic customer service and it sounds kind of trite, but a lot of the facilities, the nursing homes are hungering for doctors that actually do right by their patients and treat them with respect and that's just good costumer service.  So, that article just tried to review some of that, that I think anyone can benefit, not just long-term care physicians.

DR. ERIC TANGALOS:

You've pretty creative in the things that you've done with your practices and the work that you've done in long-term care.  Any examples you would like to share where you have been allowed to be creative because you have been on site.

DR. GREGORY ZYDIAK:

Well, I tell you a lot of it and I wish I could take credit for it, a lot of the creativity was not so much creative, but out of necessity and I started to see a lot of patients in an outpatient setting and they gradually became more frail and actually couldn't come to the office and then I just followed them.  I followed them and made house calls, and then that led to an opportunity.  People would say well we have a lot of patients here who can't get out to see their doctor, would you mind seeing them, no one seems to want to see them and I said sure.  Then, they became more frail, went to the long-term care setting, and I said sure, I will be more than happy to follow them there and it just one thing led to the other and there is an ocean of patients waiting to be seen.

DR. ERIC TANGALOS:

So, your definition of long-term care doesn't have the same physical constraints of a nursing home.

DR. GREGORY ZYDIAK:

Oh, absolutely not.  That's one portion of it, but there are many different levels of care in the skilled units which is the inpatient care of 10-20 years ago are now the skilled units.  The postop orthopedic patients with their hips and knee replacements that is a large part of the long-term care practice of today.  House calls as we already talked about is a huge area that some people are taking an advantage of and that is not to mention the administrative and leadership roles, medical directorships that are required under our regulations to have as an additional sources of income, so there is just a wealth of practice models available.

DR. ERIC TANGALOS:

What other changes have you seen in the field over the past 2 decades?

DR. GREGORY ZYDIAK:

Well, unfortunately, I have seen as you are well aware and a lot of our listeners are that it is not as popular as it was, that the physicians seem to be turning away, and that is to me is very distressing and I am really not sure what the reason for that is, that I have seen and I have also seen our patients becoming much more complicated, much more complex, and really in need of interdisciplinary care that is just not readily available sometimes.

DR. ERIC TANGALOS:

If you are just tuning in, you are listening to Advances in Long-Term Care Medicine on ReachMD, The Channel For Medical Professionals.  I am your host, Dr. Eric Tangalos and joining us to discuss his article on the Subject "Why I Only See Nursing Home Patients" is Dr. Gregory Zydiak.  Dr. Zydiak has focused much of his 23-year private practice on geriatric medicine and has created a practical guide website for physicians considering careers in long-term care medicine.

Now, let's continue discussing some of the benefits you found in working with long-term care medicine.

DR. GREGORY ZYDIAK:

Sure, that would be fine.  The other thing that we alluded to a little bit was the conduit that long-term care offers to a lot of different opportunities, again it is just a matter of your creativity.  One of the ones that I think that is actually a kind of a nice change of pace from clinical is medical direction and the facilities require by federal regulations to have a medical director and this to me was something new and I was not in administration, but actually was a lot of fun and gives you a lot of power to direct your facility and to try new things and new ideas.

DR. ERIC TANGALOS:

One of the issues that we face is physician burn-out.  It has come back to the forefront.  Just taking with you these past few minutes doesn't sound like you got any burn-out going for yourself.  Tell us about the variety of your day and how it all fits together?

DR. GREGORY ZYDIAK:

I think I am very lucky, almost I kind of pinch myself and think I am almost too lucky.  My day does not start until I want it to and I typically take my kids to school in the morning and have an extra cup of coffee and if it is a nice day, I will sit out in the porch with my wife and will look at the traffic go by for a while, I may start my date 10 or 11 o'clock in the morning or I can start early and finish early, I mean I have, the day is up to me.  Contrast that to an outpatient practice where you are double and triple booked and you start to fall behind and you look in the waiting room and you have 20 angry patients and the ones you do get to see, you have to push out faster and faster.  I don't think that any one wants to practice medicine that way.

DR. ERIC TANGALOS:

There have got to be some drawbacks to the practice in the style that you have taken on.  So, let us know what you think those might be?

DR. GREGORY ZYDIAK:

The only drawback and the major one for people who are new to long-term care and it is a real potential, is the number of phone calls and we do, do a lot of our communication by telephone and unfortunately a lot of doctors do not control that and they end up having a problem, but there are systems that are possible and protocols to follow to make the phone calls very manageable and really it is not an issue.

DR. ERIC TANGALOS:

Yeah, most people that do this full-time really do have a lot of protocol-driven opportunities.  You want to talk a little bit about that.

DR. GREGORY ZYDIAK:

Well, I try to keep things as simple and as organized as I can.  My personal one and there is a variety, but for phone calls, I pretty much like as of right now while we are doing this interview my calls are being held unless there is an emergency and that emergency is being held by a coverage doctor.  During the day, I pick up my calls on the hour, every hour, and make the calls in a flurry and then continue working uninterrupted, that works for me.  Some doctors use the fax machine, which I personally don't like a whole lot, but it saves a lot of time in aggravation.

DR. ERIC TANGALOS:

Do you share this practice with others and how many people are in your team that work together.

DR. GREGORY ZYDIAK:

Well, I am actually one of the real dinosaur.  I am a solo practitioner, but I hook up with 2 other doctors who are also solo practitioners in long-term care and that is how I started.  I got hold of a doctor who was established, who needed coverage, and we started.  We have our own separate practices, but we share call every third weekend, and I typically think that 3 is the magic number, 4 gets to be kind of problematic with the number of calls and the number of patients too.  I think you can do better than every other weekend off.

DR. ERIC TANGALOS:

Yeah you can always have an hung jury with an even number, so I would have to agree 3 or 5 would be the way to go.  Now, do you work with any nurse practitioners.

DR. GREGORY ZYDIAK:

I personally don't and I think that is more of paranoia and I go to bed worrying at night, what I forgot, let alone what somebody else forgot working under me.  So that is the model though and nurse practitioners really work well in long-term care if they are used appropriately and used for the benefit of the patients as opposed to benefit of the business of medicine.

DR. ERIC TANGALOS:

But you know, sharing this time with you, we really do get to see the opportunities are there, we get a pretty good glimpse of your personality and we see how the practice has been able to fit for you and I think that is the lesson to be learnt here.

DR. GREGORY ZYDIAK:

And I couldn't agree more, I mean I just love what I do and it is always changing and is always something new and you can go as far with it as you want, you can build an empire with 10 different doctors or you can go solo and enjoy a little bit leisurely lifestyle, which I think is the biggest asset and one last point which I think I'd be remiss if I didn't say.  According to 2002 Annals of Internal Medicine, internal medicine geriatric practice was not one of the most, but the #1 highest practiced job satisfaction of any other practice type, including surgical and all the high-tech invasive cardiology, etc. that is a pretty amazing feat.

DR. ERIC TANGALOS:

Yeah pretty happy docs for not such great salaries.  So, I would have to agree with you there too.  So as we wind down, give us that wisdom of 23 years and tells us what you do again and tell us what you wouldn't do again.

DR. GREGORY ZYDIAK:

Well, what I wouldn't do, I wouldn't wait as long as I did to get into long-term care.  I would investigate it as soon as I possibly can and the best way is to talk to some of your long-term care doctors that every body knows, that would be what I would avoid, and thinks to do now particularly to the younger doctors, I think 10 or 20 years from now what you really want to be doing and lot of times, I see physicians after 5 years of outpatient practice or 5 years of their high powered field of specialty they absolutely hate it.  So, I think a little bit down the road as to how you want to live your life professionally and privately and then looking in to geriatrics and long-term care, it is absolutely a perfect fit for stability and for not having ManageCare, job security, and job satisfaction, it really can't be beat, I just can't say enough good things about it.

DR. ERIC TANGALOS:

I would like to thank my guest, practicing geriatrician and medical director, Dr. Gregory Zydiak.  Dr. Zydiak, thank you very much for being our guest this week on Advances In Long-Term Care Medicine.

DR. GREGORY ZYDIAK:

My pleasure.  Thanks for having me, sir.

You have been listening to Advances in Long-Term Care Medicine from ReachMD Radio on XM160, The Channel For Medical Professionals.  Advances in Long-Term Care Medicine is produced in cooperation with AMDA.  For more information about this or any other show, please visit reachmd.com which now features on-demand podcasts.

The American Medical Directors Association, AMDA was founded in 1975 and today is the only national organization representing long-term care, LTC physicians and professionals.  Our members are physicians and other professionals who care for patients in long-term care settings including nursing homes, assisted living, hospice, and home care.  AMDA has distinguished itself nationally with evidence-based pragmatic solutions for effective practice in long-term care settings.  The 2009 AMDA Annual Symposium takes place in Charlotte, North Carolina, March 5 through March 8, 2009.  AMDA members are experts in the long-term care field who will address today's most relevant clinical and practice management issue.  To learn more and register for the AMDA Annual Symposium and core curriculum meeting, visit www.amda.comand be sure to listen each week for Advances In Long-Term Care Medicine, a weekly series exploring the latest clinical issues, trends, and technologies in long-term care medicine practice exclusively on ReachMD.