Why You Should Choose an Independent Doctor

Find out how choosing an independent practice can save you up to 50% on medical costs.

Recent changes to medical plans have made high deductible plans almost ubiquitous. With Obamacare rollbacks, we are also seeing a lot of people opting to forgo medical insurance and not have any at all. These situations have found many people in a place where they need to seek the most cost effective care they can receive. Independent doctors are uniquely positioned to provide this. There are a few reasons why this is so.

Why Independent Practices offer Low-Priced Quality Care

First, independent practices have decreased overhead. Compared to a large multi-physician foundation that employs a larger staff, an independent practice can keep its personnel to a minimum to support fewer doctors. This savings can be passed on to the patient.

Second, small private practices have decreased bargaining power. This is unfortunate for us, but you, the consumer, can benefit from it. Even with the discounted rates from insurance, services are going be cheaper through an independent practice. Unfortunately, small private practices do not have much negotiating power when dealing with insurance companies and often will be reimbursed less for similar services and therefore have a much greater discount for patients. Larger foundations and corporations can negotiate high rates and this translates to higher patient shares on high deductible plans and for cash payers. I have seen the EOBs (explanation of benefits) of large medical groups versus smaller independent practices and the difference can be staggering.

Third, supportive care can be more personal. When you call a private practice, you will often have a live person pick up the phone, as is the case at our practice. Bigger foundation practices often route you through a phone tree. When calling a large medical group, I had to dial 3 numbers to get where I wanted and then was on hold for 4 minutes. Unfortunately when I did talk to a person, he was unable to help me because he only knew scheduling and knew nothing about billing. He pointed me to a website where I could look up prices.



Some Examples

To prove my point I decided to do my own cost comparison. For the large medical foundation, I used their online cost estimation tool for a typical office visit for a cash pay patient and was quoted $138 discounted from the billed amount of $197 (cash pay is often given a discount to bring down the price closer to the negotiated rate from insurances). At our independent office, a similar visit will cost a person without insurance $66.50 discounted from the billed amount of $105. That is less than half the cost!

This cost savings also extends to ancillary services such as physical therapy and x-rays. For the large medical group I researched, a basic physical therapy initial evaluation will cost you $192 (discounted from $274) out the door. American River Rehab (a local independent PT) is cheaper at $100 for the initial evaluation if you are cash pay (and $75 for follow up). Again, almost half the price!

For radiology, I looked up the large medical foundation radiology services and inquired how much a screening mammogram would cost. I was quoted $337 discounted from the billed amount of $482. I compared this to Insight Imaging (a private radiology office in Grass Valley, a nearby town) where it is $192.50 discounted from the billed $293. This savings is significant. Here I only mention PT and radiology but this extends to skilled nursing facilities, labs, hospitals, home health and all other medical services.

Obviously I’m a little biased as I work at an independent practice. However, it is hard to argue with the numbers I present above. This is nothing against the doctors at these bigger groups. They are all very capable and comparable to independent doctors, but when it comes to value for services rendered, independent physicians come out on top. If you are happy with your doctor and the cost you pay, please stay with your current physician. But, if you are looking for a better value, do your own cost comparison and call around to your local big groups and small independent physicians. I believe your findings will be similar to mine.

This has huge implications in today’s medical field where spending continues to rise and doctors are being blamed. A recent study shows that by 2026, health spending in the US will rise to $5.7 trillion! To be good stewards of money flowing through the medical community it is our duty to take cost into consideration while still providing excellent care. ACOs (Affordable Care Organizations) have this as their primary goal and are where medicine is migrating. These organizations band practices together with the goal of providing superb care while keeping costs low and referring to low cost entities to save Medicare money. We recently joined National ACO with this in mind.

So, when you are looking for a new doctor or any ancillary services, take into consideration the cost. If you are outraged about the rising cost of healthcare, do some research. An independent practice will most likely offer you more value in your medical care. You can also choose a doctor affiliated with an ACO. As an independent doctor, I join with other independent practices and make the commitment to you and the community to provide excellent medical care while keeping the costs down.



Worrisome Skin Spots and Growths: A Primer

Here you can find a brief guide to worrisome skin spots and growths and when they should be evaluated.

“My wife saw this new spot on my back and wanted it checked out.” “Doc, there’s this new growth on my arm.” These are phrases I often hear when somebody comes into my office with a skin concern. They often wonder if it is something that needs to be removed. Is it worrisome and possibly cancerous? Should it be biopsied or can it be left alone? Below I want to go over some of the things to look out for with worrisome skin spots and growths.

First, there are three main types of skin cancer. These cancers include squamous cell cancer, basal cell cancer and melanoma. These names are given based on the type of skin cell from which the cancer derives. The most worrisome of these is melanoma. This one can travel to other parts of the body. The other ones are concerning as well and all of them need to be removed.

Squamous Cell and Basal Cell Cancers

Squamous cell cancer (SCC) comes from the squamous cells in surface of the skin. They typically look like a crusty red spot. At times they will ulcerate and start to bleed.  They are persistent and do not go away on their own. A basal cell cancer (BCC) comes from the basal cells at the base of the epidermis.   Typically, they look like a round domed pearly growth but can also appear as open sores, red patches, or pink shiny growths. They too are persistent and will not go away on their own. A skilled doctor can determine if a growth is concerning for an SCC or BCC and requires biopsy.

ABCDE of Melanoma

Melanoma is the most concerning of the skin cancers. For these we have a very specific way of evaluating whether or not an unusual spot needs to be biopsied. The acronym that is easy to remember is ABCDE. Each of these stands for a characteristic of the spot that can be concerning. A stands for asymmetry. If the spot is not perfectly round but is more irregular it is more concerning. B stands for borders. If the lesion does not have definite borders where you can clearly see where the spot ends and normal skin begins and it is more hazy or irregular, then it is more concerning. C stands for color. Blacks, blues and purples are more concerning than browns and tans. If there are multiple colors then it is more concerning as well. D stands for diameter. Anything bigger than 5 mm in diameter or the size of the eraser tip on a pencil is more concerning. Lastly, E stands for enlarging or evolving. If the spot has been changing rapidly over time or getting bigger than it is more concerning.


Biopsy techniques

Of the five criteria above if the spot meets two or more and is concerning to the evaluating doctor, then it should be biopsied to see what it is. There are a few different ways to biopsy a spot or growth. If the growth is elevated then a shave biopsy can be done where a curved blade is used to take the elevated area of the growth to send it to the pathologist.  A punch biopsy can also be done which takes a plug of skin through all the layers. Lastly, an excisional biopsy can be done to completely remove the growth. If there is suspicion for melanoma we try to either completely excised the spot or take a punch biopsy of the most representative area of the spot. For basal and squamous cell cancer any of these biopsy techniques are reasonable. See below for links to video examples of these techniques.

If the biopsy comes back showing a cancer, than that cancer must be completely removed. Sometimes we remove the cancer completely on the first try. Other times we need to go back in and remove the rest of it. If the biopsy shows melanoma, it is much more concerning and needs to be referred to a skin surgeon for extensive removal and lymph node biopsy since these do travel (metastasize). Often times cancer doctors (oncologists) are involved as well.

I hope the above information has given you more insight into what is more concerning for unusual skin spots and growths. If you have any concerns about a spot or growth, you should consult your doctor and have him or her evaluate it completely to see if it needs to be biopsied and if there is concern for cancer. A doctor’s experience in evaluating skin spots is very valuable and a doctor can make the right decision about whether or not something needs to be biopsied.

To view videos of the above procedures on the Auburn Medical Group YouTube channel, click on the links below:
Shave Biopsy
Punch Biopsy
Excisional Biopsy
Malignant Melanoma Example

Photo Credit Mark Vaughan, MD



The Value of Physician Extenders

PAs and Nurse Practitioners are a great addition to the medical team. See why.

We were sitting around the table at our monthly office meeting. Our new Physician Assistant (PA) brought up an encounter she had with a patient. The patient was unsatisfied with seeing her because he felt he was getting poor care. He wanted to see the doctor for his care. This led me to think about the value of PAs and nurse practitioners. The new term “physician extenders” has been put into place to try to convey the value of these practitioners. A physician extender includes any healthcare provider who is not a physician but is able to perform the typical activities of a physician. This includes PAs and nurse practitioners (NPs) who work in collaboration with an overseeing physician.

These practitioners used to be referred to as “mid levels,” however this conveys an inferiority which is not the case. PAs and nurse practitioners are a valuable part of the medical team. Many offices (ours included) are moving towards having a combination of physicians and physician extenders to provide care given the value and quality of care they provide.  Physician extenders can do just about anything a doctor can.  They can take medical histories, perform physical examinations, order diagnostic tests and studies, diagnose medical conditions, and implement a treatment plan in consultation with a supervising physician.  They can prescribe medications in all states and counsel patients on health promotion.

I must admit that I didn’t use to have such fond feelings of physician extenders. Mostly this was jealousy because they were able to perform the same activities as me as a physician with less training. This changed after I worked more closely with them. My experience showed me that they were very capable primary care providers. They were experienced and competent and were able to function independently in a primary care roll to provide excellent care.



PAs are the first type of physician extender.  PAs were only recently recognized as primary care providers with the Affordable Care Act. They can work as generalists such as in Family Medicine or they can specialize.  Their training is similar to that of a doctor including in classroom didactics and hands on clinicals.  It typically takes 2 years to complete and is broad covering all areas of medicine making them ideal primary care providers. They have a rigorous certification system consisting of completing a PA program and passing a national certification exam.  They must also complete continuing education courses throughout their career to maintain their certification. They work closely with physicians as a collaborative team.  

Nurse Practitioners are the second type of physician extender and they are very similar.  NPs are initially trained as registered nurses and then complete a advanced master’s or doctoral degree program. These programs can take 1 to 3 years to complete.  They undergo similar didactic and clinical courses to medical school for a physician. Their education is extensive and prepares them well to participate in primary care and specialty care. They have to complete their program and undergo national certification.  They too need to complete continuing medical education courses throughout their career and work closely with physicians as a team.

As you can see, Physician Extenders are capable medical care practitioners and are a valuable member of any medical team. Medical care that used to be confined to only a physician has now extended to include these providers. There will always be those who want to see a physician. In today’s medical world, this will not always be possible.  You will likely find yourself being seen by a physician extender at your doctor’s office or in the hospital at some point. Do not see this as a decrease in your care. To the contrary, this is allowing doctors to extend their reach in caring for more patients.  PA’s and nurse practitioners are a wonderful addition to the medical team and are able to function in a collaborative and independent role to provide excellent care.  If you currently see a physician extender make sure you thank them for their great care.



How to Hack Your New Year’s Resolution

A list of ways to make your resolution stick this year.

Happy New Year!  By now you have probably already made some resolutions.  Often these include changes that affect one’s health including losing weight, working out more and quitting smoking.  Unfortunately, we are all too unsuccessful at achieving these goals.  According to Statistic Brain Research Institute, only 9.2 % of people who made a resolution felt they were successful. This is dreary, but if you have made a resolution, take heart!  Below I have compiled a list of “hacks” that can make your chances of success much greater.

Understand Habits

First, we must understand habits and how to form or break them.  According to The Power of Habit: Why We Do What We Do in Life and Business by Charles Duhigg, every habit consists of a cue, a routine and a reward. This loop starts with a trigger that tells your brain to go on autopilot through a routine and is then rewarded at the end. For example, a person wakes in the morning and brews some coffee (the cue) which then triggers them to smoke a cigarette (routine) and they feel calm and ready for the day (reward).  Duhigg also has a “Golden Rule of Habit Change” that will help people stop their addictive habits.  It states that if a person keeps the initial cue and reward but replaces the routine, change will occur.  Lastly, he states you need to believe in wanting to change and be properly motivated for it to occur. This can’t be understated.  You need to buy in to the change or it will not happen.

To develop a habit, you just need to institute the habit loop around your goal.  Develop a cue and reward for what you want to start doing and eventually it will become habit.  If you want to start working out, then first get a cue such as hearing your alarm clock or something as basic as lacing up your tennis shoes.  The reward can be as simple as the feeling you get after working out or you can set an external reward such as a punch card to treat yourself to something every 5 or 10 sessions. Once you understand the habit loop and see it in your life, you can use it to your advantage.

Focus on the Process not the Outcome (Be Specific)

Often when we make our resolution for the year, we make general statements such as “I want to lose weight” or “I want more money.”  These unfortunately are too broad and will easily fall by the wayside.  You need to be more specific (and realistic) and not just state the end goal.  Determine the the process by which you are going to attain that goal and make that your objective.  So, instead of saying “I want to lose weight,” you should say, “ I plan on getting cardiovascular exercise for an hour 3 times a week” or “I am going to increase my fruit and vegetable intake to 50% of what I eat.”  These are specific and attainable processes.  In doing this you are making yourself go through the process which you have more control over.  You can’t always control the outcome but by controlling the process you can make the outcome much more likely.



Focus on One Small Attainable Goal at a Time

All to often when we are making our New Year’s Resolution(s), we get very excited and shoot for the stars.  While the intentions are admirable, this unfortunately sets us up for failure.  We make the resolution too lofty or we make multiple resolutions which we cannot handle.  First, you need to start small.  Make a resolution which you will keep.  If the hour 3 times a week of exercise is something you cannot see yourself doing, then start smaller at 15 minutes three times a week.  After 1-2 months of success, you can increase the amount.  If the 50% of fruits and vegetables frightens you, then scale it down to something you feel is attainable and slowly increase it later.

You should also avoid making multiple resolutions and focus on one goal at a time.  The brain can become overwhelmed from the increase in stress from working on resolutions.  Following through with resolutions requires multiple decisions a week (sometimes a day) and this can cause decision fatigue if there are multiple resolutions being pursued.  Decision fatigue causes you to eventually make a poor decision which will be the downfall of the resolution.  So pick one behavior you want to modify and focus on it. Don’t try to quit smoking, decrease your alcohol, start exercising and eat right all at once. Pick one and focus on it, when you have conquered that one goal, then you can move on to the next (even if it’s not New Year’s Day).

Write it Down

Once you have decided on the one, small, attainable goal that focuses on the process, you need to write it down.  Putting pen to paper solidifies your commitment to the task. Seeing it in black and white can also be a reminder when things get tough.  You can go back to this notation and read back your goal. This can be done in a journal or something as simple as a sticky note.  Lastly, once you have written it down, put it somewhere to remind you of your commitment (Hint: this can be the cue in your habit cycle).

Tell Someone

After you have done all the above “hacks,” make sure you tell someone about your resolution.  The benefits of this are twofold.  First, it will again solidify the goal in your head as it is verbalized and secondly, it will create accountability.  Once another person hears your resolution, they can check up on you to see how you are doing.  This will also motivate you more because you will then have an external standard to live up to.  This can also be done through joining a group such as a running club or alcoholics anonymous.

Roll with the Punches

This last part will be tough to hear.  You WILL have a moment of failure with your resolution.  This is normal!  When (not if) this happens, you need to see it as a bump in the road and not a roadblock.  Roll with it, it’s okay.  When you hit a bump in the road, you get over it and keep going.  You don’t need to start over.  You pick it up where you left off and resume your new routine.



In light of the above , I’ll tell you my resolution.  I plan on reading at least a chapter of a book every night before going to bed (see how this is small and specific).  As above, I plan on hacking the habit loop to make this stick.  My cue will be plugging in my phone which will start the routine of picking up a book and reading.  My reward will be internal as I mostly read non-fiction and self improvement is a big motivation for me.  

With that, I hope that you have success in your New Year’s Resolution. By taking your resolution and running it through the hacks laid out above you will definitely increase your chances of success. Let me know what your resolution is for the new year in the comments below.  Feel free to pass this on to any friends who need it through any of the social media links below. Good luck and keep me posted!



Wait! Coffee is good for me?

A new study shows that coffee has many health benefits.

For some, coffee is the most refreshing part of their day.  For others it is the only way to get going in the morning.  A new study now tells us it has health benefits as well.  With the growth of Starbucks and their success in making coffee a mainstream addiction, just about everyone enjoys a cup of coffee on occasion, if not daily.  Keurig has also now made making a single cup of coffee easier than checking email (yes, even I have succumb to this as that is my Keurig pictured below). What used to be relegated to the likes of construction workers and shift workers such as nurses, is now seen in every profession.  Historically, coffee became more common in the United States after the Boston Tea Party when drinking tea was seen as “unpatriotic” (apparently even coffee can be political).  Furthermore, most would state they are more productive when they have some coffee.

Coffee has often been used for its short term benefits such as increased awareness, productivity and cognition.  This is due to the caffeine it contains.  Each cup of coffee contains about 95 mg of caffeine. Caffeine is a stimulant that works on the brain.  It blocks adenosine and its drowsy effects and also directly stimulates the autonomic nervous system to heighten alertness. Caffeine has generally been considered safe by the FDA.  It would take about 10,000 mg to be lethal or about 100 cups of coffee.  Its half life is about 6 hours, so that morning cup of joe should last you all day.

In 1991, the World Health Organization (WHO) labeled coffee as “possibly carcinogenic” and linked it to bladder cancer.  In June 2016, this decision was reversed and the WHO stated it may actually be helpful in protecting against uterine and liver cancer. They stated it has other health benefits as well including decreased heart disease, diabetes and neurologic disorders. Strangely, the WHO still hedged and said that consuming “hot” beverages may still possibly cause esophageal cancer.  All of this was based on a review of over a thousand epidemiological studies.  This information from the WHO did not receive as much fanfare and press as a new article that came out last week.

The new study done on coffee was reported in the British Medical Journal (BMJ) on November 22, 2017.  The authors did a large meta-analysis and concluded that coffee intake in amounts of about 3-5 cups a day was associated with many health benefits.  This was thought to be due to anti-oxidant and anti-inflammatory compounds instead of the caffeine.  These benefits include living longer, decreased heart disease, decreased cancer, decreased liver disease and decreased diabetes.  Wow! Does this mean we’ve had the wonder drug right under our nose this whole time? Unfortunately, we cannot be so quick to make this assumption.  



Based on these results, every doctor should start recommending every person take in 3-5 cups of coffee a day, right? Well, no.  Sorry to burst your bubble.  Those currently drinking coffee can continue though with a new clear conscience in regard to it affecting their health.  Remember that these studies were meta-analyses of observational data.  This tells us there is a link between coffee and the health benefits but it is only correlation not causation.  We cannot say for sure that drinking 3-5 cups of coffee will cause you to live longer or have decreased disease processes.  Coffee drinking is a complex social behavior associated with other behaviors that may be linked with the general decreases in illness and improved health.

In certain cases, drinking coffee can have negative health consequences as well. If pregnant, it can cause lower birth weights.  It can increase anxiety if predisposed and, if sensitive, it can cause irregular or rapid heart rhythms. It can increase your blood pressure and it has been linked with increased fractures in women.  So, unfortunately coffee is not all gumdrops and candy canes.  Which brings me to the next point: Most of the coffee we drink today has way too much fat and sugar.

While the BMJ study states that coffee can decrease the rates of diabetes, it obviously isn’t referring to my venti white chocolate mocha frappuccino.  Yeah, I said it.  That fancy “fru fru” coffee in your hand is not doing you any favors. At upwards of 500 calories in 1 cup, daily consumption of these drinks will definitely tip the scales (pun intended) towards type 2 diabetes, not away from it.  If you want to get the health benefits of coffee without going up 2 (or more) notches on the waist, it needs to be black or very low calorie.  Don’t get me wrong, I enjoy a nice frappuccino, but it is a rare occurrence due to the calories it contains.

So what’s the takeaway?  In short: Coffee is safe!  Go ahead and enjoy it without worrying about your health.  Use it for its benefits such as increased awareness and cognition. If you’re taking a test today, have a cup or 2 of coffee to help improve your scores.  As for the long term health benefits, I would say the jury is still out.  I am definitely not going to start recommending it to my patients who do not already consume it based on this study just for the health benefits.  But if you are one of the 83 percent of adults who already consume coffee and don’t have any of the health conditions adversely affected by caffeine, go ahead and have another cup today (as long as it’s not over 5 cups).  You can rest assured your health will not be negatively affected and in fact, you may be doing yourself a favor in the long run.  Enjoy! (unless it’s a high calorie blended drink, then JUST SAY NO!)