The New Physician
Earlier this year, Dr. Michele A. Romano opened the doors of her solo family practice in Fairfax, Virginia, to The New Physician. Thousands of practices like this operate throughout the United States. Dr. Romano says the week we visited hers—during the height of Northern Virginia’s flu season and patients’ health-insurance changes—was typical. While many physicians today leave their practices for a life with fewer managed-care headaches, Dr. Romano heralds success. Her practice, located just 20 miles west of Washington, D.C., has around 9,000 patients on its books and is making a profit.
Want to know what it’s like? Spend a week in her life.
8 a.m. -- It’s a gray and drizzly morning, with dark skies and heavy fog blocking out all chances of anyone seeing the sun today. Most people would want to sleep in on a day like this. Not Dr. Romano. She awakened at 5 a.m. and was in the office by 6:15. It’s her normal routine for workdays. These early hours are a time she cherishes. They’re quiet—a silence and beauty similar to the calm before a storm.
Dr. Romano’s office is nestled in the back of the practice, almost at the heart of where all the action takes place. The scale where nurses weigh patients is just outside her door. The largest of the six exam rooms is across from her office; the others are down the hall to the right. The offices of Dr. Kathleen Curtis and Marie, a nurse practitioner, can be found down the hall as well. They work full time with Dr. Romano and allow for the practice to care for a greater number of patients than was ever possible when she first started flying solo seven years ago. “I don’t know how we survived those early days,” Dr. Romano says, thinking back to the time when it was just her and her office manager, Carole.
Tucked between Marie’s and Dr. Curtis’ offices are a sample medication closet and a nurses’ station. Four nurses—Kathy, Mary, Revelle and part-timer Vicki—work for Dr. Romano as well.
Down the hall to the left of Dr. Romano’s office are rooms used by Dr. Patricia Sue Inman. She leases space from Dr. Romano to run her own practice. The two offices share a tiny kitchen, break room, X-ray room and waiting area.
Dr. Romano uses this early time to her advantage. Sitting at her paper-covered, dark wood desk, this former ICU nurse reviews patients’ charts, returns phone messages and attends to the myriad of things she never has time to do once the clock strikes 8:30 a.m. and patient No. 1 walks through the door.
“This is my down time,” she says, looking up from a patient’s chart. “As soon as the office opens, it’s going to be rock ’n’ roll.”
And it’s a busy day at that. Her patient schedule is booked with 15-minute appointments until 4:45 p.m., with a two-hour working lunch blocked off from noon until 2 p.m. But no scheduled times are sacred or set in stone. Lunch and quitting times tend to get pushed back as patient visits collide with one another. “They’re usually not 15-minute exams,” she explains. “One thing becomes many.” She expects she won’t get home until 7:30 p.m.
Winter is the more difficult time of year for her schedule, she says. That’s not because the practice is inundated with flus and colds. It’s because of the darkness. It’s dark in the morning when she leaves for the office and dark at night when she leaves for home. “That’s why I have this jar of chocolates,” she jokes, pointing to the plastic jar filled with foil-covered goodies on her desk.
8:10 a.m. -- Dr. Romano slips a white coat over her petite frame. Only 20 minutes remain before her patient visits begin—enough time to visit with the administrative staff.
To reach their work area, she has to slip through the narrow hall that doubles as a lab, being careful not to run into one of the nurses or anyone else who is using the small space. The business office—with its thousands of charts lining the walls at one end and the front desk check-in/check-out windows at the other—marks the practice’s frontlines. There, we find Carole and three medical receptionists: Pam, Kim and Cami.
“They have an incredibly difficult job up here because every phone call could be a disaster,” Dr. Romano says, nodding her graying-blonde head. Carole and the front desk staff provide protection. “The patients will come in a bad mood, and they will just be arrogant, snotty and terrible up front,” Dr. Romano says. “But by the time they get to us, they’re absolute angels.… And that’s not [completely] fair. Most patients are absolutely wonderful—but we all have our bad days.”
8:27 a.m. -- A nurse weighs the first patient of the day and brings her into an exam room while Dr. Romano returns a patient’s phone call. There’s no answer, so she leaves a message.
8:30 a.m. -- Rock ’n’ roll. As Dr. Romano heads to meet with Kristin,* a 47-year-old patient with hyperlipidemia, she asks nurse Revelle about the 8:45 a.m. patient, “Has she given a urine yet?”
“Yes,” Revelle says.
“Oh, good,” Dr. Romano says, then disappears in the exam room. So far, things are getting off to a good start.
8:40 a.m. -- All exam rooms are occupied—with Dr. Curtis’, Marie’s and Dr. Romano’s patients. The morning has picked up speed, and at least five patients are in the waiting room.
9:35 a.m. -- Dr. Romano is in her office jotting down a few notes on a patient’s chart.
Nothing too out of the ordinary has happened so far this morning, she says. She’s had to give the usual “exercise, eat healthy and quit smoking” lecture to Rachel, her 9 a.m. patient. She’s about to meet with her 9:15, when Cami comes in. She asks if Dr. Romano has time to take a look at one of the medical receptionists who isn’t feeling well.
“No, I just can’t,” Dr. Romano says. She says she is too busy today, what with being out with the flu last Friday and a full patient load ahead of her. She suggests they try one of the other caregivers at the practice to see if they have time. Cami nods and leaves.
“Of course, they all want to see Dr. Romano,” Dr. Romano says, chuckling a bit at how by simply being the leader of the practice, she’s constantly in demand. But, she’s not really complaining. “I wouldn’t do anything else,” she says. “I love it.”
9:40 a.m. -- Dr. Romano meets with her 9:15 a.m. She describes her patient as a “wonderful young mother,” but one who has some stress and denial issues—mainly involving caring for her two young children—and they’re affecting her health. Tonia, 40, brought her 18-month-old son with her today. She tells Dr. Romano that he doesn’t sleep through the night, and she complains about her headaches. She’s sure she has a brain tumor.
“‘No, you don’t have a brain tumor,’” Dr. Romano tells her. “‘We’re going to rule that out. You’re stressed to the gills.’”
Denying she’s stressed, Tonia says she doesn’t know what to do when the baby can’t sleep. She says she’s bringing him to bed with her. Dr. Romano thinks that’s one of the problems and suggests she talk with her pediatrician and a child therapist. Tonia says she sees no reason to do that; she’s going to take the baby to a sleep center, and she’s thinking about going back to work.
Dr. Romano tries several times to get Tonia to recognize how she’s attempting to escape from her children and the stress. But in the end, Tonia refuses and asks for a referral to get a computed tomography (CT) scan.
“She doesn’t want help,” Dr. Romano explains. “So, we’ll keep going through this and going through this, and eventually she’ll come around. But, she’s too close to it [right now].”
9:52 a.m. -- Dr. Romano’s husband, Don, enters the practice carrying a computer. He says hello to the staff up front and then swiftly moves down the halls to the break room. Dr. Romano uses a couple computers there to do billing work. Don runs a consulting business for health-care companies and has created a system for his wife that will allow her office to track all of its billing. “It’s wonderful,” Dr. Romano says.
Her husband—who’s regularly in the office on Mondays, Wednesdays and Fridays—has been a strong asset to this practice from the beginning. Dr. Romano says it’s necessary to have people with you who know what they’re doing on the business end. When she was starting out, she had two key advisers to help her with this area—an accountant who was well-versed in the mechanics of medical practices, and her husband, who had been a hospital administrator for 25 years. “So, between the two of them, they walked me through everything.” Plus, she had Carole, who knew exactly what sort of supplies the office would need and could guide them through the management of that end. “Whenever you start out,” Dr. Romano says, “you have to have a good office manager, a good accountant and a good biller. Otherwise, you’re not going to make it…. Everything else you can probably blunder your way through. It’s going to take you a while, but eventually you catch on.”
10:50 a.m. -- The hallway has become a game of dodge ball. Fortunately, newborn Colleen and her parents are already safely inside exam room No. 3.
The parents have placed a soft yellow blanket on the exam room chair for the baby to rest on. They stand close to their first child, hands cupping the baby’s head protectively.
Dr. Romano greets the two-week-old girl’s parents with a gush of support.
“This woman just goes and does it,” she says to the mom, telling her she heard stories about how well the delivery went. She caresses the baby’s legs and stomach and notices a little redness on the skin. “That’s just a little rash. That’s normal. That’s normal…. How’s she doing for you?”
“Last night was a little rough,” the mom says. Colleen was awake most of the time.
Dr. Romano listens to her, looking at both parents directly and nodding her head. They laugh about the first few sleepless weeks. Then, Dr. Romano says, “She’s perfect,” and pats Colleen. The baby coughs and lets out a little cry. “Beautiful baby,” Dr. Romano says to the parents again and again. “Beautiful baby…. You all are doing a great job with her,” she says and hands them two brochures. The first is baby-care information she compiled for new parents. The second is on car seats. “You’re perfect,” she tells Colleen one more time. The parents will bring her back in two weeks. And if they have any questions before then, “Call us—anything that comes up—that’s what we’re here for.”
Noon -- finished with this morning’s patients, Dr. Romano works on charts in her office. Marie pops her head in, needing advice on a medication for a patient with heart trouble.
12:15 p.m. -- Dr. Romano examines a patient’s chest X-ray that Revelle took this morning. All of the nurses are X-ray licensed.
12:20 p.m. -- It’s lunchtime for most of the staff, so the halls are quiet again. Today’s lunch is special. Christy, a pharmaceutical representative, brought Chinese food and sodas for the office. Dr. Romano meets her in the small kitchen, where several staff members are already eating.
The two women chat warmly, then Dr. Romano announces she only has about five minutes before she has to get back to paperwork. Christy comes to the point. She wants to hear Dr. Romano reaffirm her commitment this year to prescribing a medication aimed at preventing osteoporosis in postmenopausal women. Dr. Romano says she’s behind it “100 percent.”
Satisfied, Christy asks Dr. Romano to play a word game. “I’m going to say the name of a drug and you tell me what comes to your mind,” she says.
“Ok,” agrees Dr. Romano.
“Depression,” Dr. Romano says.
“Interesting….” Christy responds. This odd game goes on for about another minute. Then sensing she’s given Christy enough time, Dr. Romano takes some sesame chicken and rice and heads back to her office. Christy stays to eat lunch with the staff.
Back in her office, Dr. Romano plays the never-ending game of completing charts and clearing them off her desk just as new ones are brought in. Throughout the day, files get piled onto her desk and spread from there to the side table near the door. Dr. Romano compares it all to the lines at Disney World. Just when you begin to make progress, you realize you’re behind.
The rest of the afternoon moves similarly to the morning. Dr. Romano finishes with her last patient—50-year-old Erica, who suffers from severe headaches—at 5:17 p.m. Dr. Romano says she saw a more needy and depressed group of patients today and blames the grungy weather. Sunshine, she says, tends to make people forget about their worries.
After finishing the day’s charts, going through a stack of mail and peeking at what’s going to come at her on Tuesday, Dr. Romano heads home around 7:30 p.m.
1 p.m. -- It’s sunny outside and looking out Dr. Romano’s office windows, one can see the Blue Ridge Mountains in the distance. Perhaps it’s the sun, or the fact that everyone survived Monday’s craziness, but the practice is clearly under a different mood today.
It’s lunchtime and Dr. Romano is in her office as usual. She never goes out. She’s lunching on a plate of macaroni ’n’ cheese while listening to an oldies radio station and reviewing charts.
“Today is physical exam day, where we’re kind of getting caught up on everything,” she says. Tuesdays, in general, are less hectic days in the office. Only Marie and Dr. Romano are in to see patients today. Dr. Curtis is off after working long hours on Monday and being on call last night.
Most of Dr. Romano’s patients today are in for complete physicals, a 30-minute whole-body work-up many insurance companies don’t pay for anymore. Patients get an EKG, chest X-ray, hemoccult test and full lab work done. Dr. Romano calls the visits “executive physicals.” Two weeks after the exam, the patients come back and meet with her to discuss the results. The other majority of patients today are in for gynecological exams and PAP smears. One patient with possible uterine cancer undergoes an endometrial biopsy, and a few others need help with depression.
2 p.m. -- Nurse Kathy announces to the front desk staff, “Don’t schedule anymore flu shots.” The office only has enough supplies left to give two shots outside of those already scheduled, she says. They’ll save them for patients who happen to come in and request a vaccination. They’ve gone through 1,000 shots already this winter season, and it’s normally half that number.
3:30 p.m. -- Dr. Romano’s next patient, 60-year-old Gary, suffers from multiple medical problems, including colon cancer. He came in with his wife to discuss ways the family can support him. Dr. Romano says Gary hasn’t been responding to antibiotics and has no appetite. It’s a very difficult time. She says the visit acts mainly as “a cheerleading session.”
5 p.m. -- Dr. Romano still visits with patients. Her last one was scheduled for 4:30—a follow-up visit for a blood pressure recheck. She’s done with her at 5:10 p.m. and has just sat down at her desk when Marie comes in and says, “What a day!” She hands her charts over to Dr. Romano to review. Marie was booked solid today with colds and flus; normally she has more flexibility in her schedule. She jokes to Dr. Romano that all of their well patients who need routine physicals should stay at home. “Don’t come here, the germs are here,” she says.
Dr. Romano goes through her daily ritual of looking over her charts and all of Marie’s (since Dr. Curtis is out), opening mail and signing the day sheets.
Today is the day her staff tried to kill her, Dr. Romano jokes. Wednesdays are always her longest days, but this one especially so. She normally sees patients from 9:30 a.m. until 7:30 p.m., allowing for a two-hour lunch and a 15-minute “dinner.” Then, she’s on call. Except this week, someone slipped up and began her Wednesday patient visits at 9 a.m. “Then we just hit the deck running,” she says. It’s a good thing she allowed herself to “sleep in” until 5:15 a.m.
Dr. Romano’s most complex patient of the day is 57-year-old Caroline. “[She’s] one of my favorite people in the whole world,” Dr. Romano says. “[She’s] always trying to be so sweet.”
Caroline has a virilizing ovarian tumor. “She’s known about this for two to three years now and is scared to death to do anything about it...even to the point where I’ve come right out and said, ‘Honey, this is cancer. You have got to do something about this.’ [But], no, she just doesn’t want to,” Dr. Romano says. She says Caroline mainly doesn’t want to be a bother to anyone. “She never makes it back to her appointments right on time, so she keeps running out of medicine.... [But] it’s hard to be mad at her, because she’s just so sweet.
“She’s going to try harder, and we hope it works this time, but we’re not getting through here. She will die of ovarian cancer,” Dr. Romano says. “She will die. It’s a slow-growing tumor. She will die.... [And] it’s so frustrating. It’s so frustrating when we can save somebody. Some of these things are so treatable, if you just do something about them. But, you know, people have got to live their own lives.”
The rest of Dr. Romano’s day moves quickly as she goes from one appointment to the next. One patient suffers from neck pain. Another has polycystic kidney disease. A few need treatment for stress and depression. Two women come in for the weight-loss program. And 87-year-old Lucille—who as Dr. Romano describes, “has all of the little old lady things” like arthritis, hypothyroidism, high blood pressure and low-back pain and can’t afford the medications—goes home with a bag filled from the sample medication closet.
A little after 6 p.m., Dr. Romano can finally take a deep breath and go to the bathroom during her 15-minute “dinner” break. Then she sees five more patients, catches up on the daily paperwork and drives to the local hospital at 9:15 p.m. It’s her turn to be on call. Dr. Romano has to go see a patient who was admitted this morning with chest pains. She spends an hour or so at the hospital and arrives home around 11 p.m. She has some pizza and goes to bed.
During the night, several patients telephone her, most of them suffering from the flu. None of the calls require her to leave home.
Dr. Romano wears her businesswoman hat today. It’s her day off from seeing patients, so she allows herself to sleep an extra hour this morning. Then, she takes the Metro into Washington, D.C., to meet with her brokerage firm. This is the time of year she makes deposits to fund her and her employees’ profit-sharing retirement plan.
“I’ve decided that if we work hard, we all work hard,” Dr. Romano says. “So, our [retirement plan] is strictly profit-sharing. We can put in anywhere from zero, if we have no money left over, up to a maximum of 15 percent for everybody. And we were very fortunate this year. Everybody worked themselves to death, and we were able to put in 15 percent on everybody’s plan.”
Next, she spends a few hours reviewing checks and papers left by the practice’s biller, depositing the week’s payroll and counting out day sheets.
Not all Thursdays involve doing so much business work, she says. Sometimes she attends a lecture or a conference. She may just go to D.C. and visit a few museums. Or, she does something for the executive committees she’s involved with at the hospital. “And I enjoy that,” she says. “That’s fun stuff for me.”
10 a.m. -- This final day of the week is a stark contrast to Monday’s dreariness. The sun shines through the blinds in Dr. Romano’s office, and everyone looks forward to the weekend.
Dr. Romano spends the morning in her office doing work, to the incessant hum of the bubble-jet printer on the table behind her desk. It jams once or twice, and Dr. Romano handles it with her usual “so, what?” attitude. Not much ruffles her feathers.
As Dr. Romano does paperwork in the morning, Dr. Curtis and Marie see patients. A couple of times they stop in Dr. Romano’s office to discuss a patient. Dr. Romano’s first appointment on Fridays isn’t until 2 p.m., allowing her to catch up with the business side of things. Dr. Romano says this is where her work is very different from the other two caregivers at the practice.
Some Fridays, when she has time, Dr. Romano will visit with Carole. It’s “state of the nation stuff,” she says. This is their chance to catch up with one another on office issues. The big project this month is how to update the computer system.
1 p.m. -- Marie is finished seeing patients for the day and stops in Dr. Romano’s office to say goodbye.
2 p.m. -- Dr. Romano sees her first patient for the day—51-year-old Jackie, who has hyperlipidemia and needs her cholesterol checked.
3:15 p.m. -- Dr. Romano is in her office between patient visits when Dr. Curtis comes to talk to her. She tells Dr. Romano recent developments about a patient with a stomach abscess. The patient was at the hospital earlier today getting a CT scan when Dr. Curtis learned about the abscess. The patient needs to get care immediately, so the hospital is trying to track her down to tell her to stay. Dr. Curtis wants her patient to be admitted to the emergency room so she can get on some antibiotics and wait there until a bed opens up. Hospital staff assured Dr. Curtis that by the end of the day four beds will be free.
Dr. Romano congratulates her colleague on identifying the problem so quickly. She says that usually this type of thing happens at 5 p.m. on Fridays, when there’s less time to get things done.
4:21 p.m. -- Almost a half-hour from quitting time, a bleak cloud settles on the practice. Dr. Romano takes an urgent phone call from Cassie, a 57-year-old patient. Cassie had breast cancer 10 1/2 years ago and fears there’s a recurrence. She just got a phone call from an ear, nose and throat specialist who told her to contact Dr. Romano. There are problems with Cassie’s CT scan. Knowing there’s something terribly wrong, Cassie tells Dr. Romano that she’ll be right over. A few minutes later, the specialist calls Dr. Romano and gives her a summary of what he’s found. Cassie has a huge mass in her chest.
“I hate those calls. Cancer on a Friday afternoon just makes one’s day,” Dr. Romano says sarcastically.
5:20 p.m. -- Dr. Romano is finished seeing her scheduled patients, and Cassie has arrived. She waits in an exam room. “This is one scared lady,” Dr. Romano says. “She’s gonna need some lovin’.” She goes to meet with Cassie. Ten minutes later Dr. Romano returns, her face is slightly flushed and she’s sniffling.
Sitting at her desk, Dr. Romano writes down several names of specialists that Cassie needs to call first thing on Monday morning. She also gives her a list of vitamins and supplements to start taking. Dr. Romano is extra concerned about Cassie, because it’s late on a Friday afternoon. The offices she needs to call won’t be open over the weekend. Dr. Romano needs to give Cassie an agenda. She needs to make Cassie feel as if she’s accomplishing something. So, she hands a “to-do” list to her, telling her to call the office if she has any problems—especially if she can’t reach any of the specialists on Monday. If that happens, Dr. Romano will make the calls. Nodding her head, Cassie takes the information, thanks Dr. Romano and steps into the hall.
“Are you OK?” Dr. Romano calls to her a couple of times, then quickly moves to the hall to give her another hug. She comes back to her office in silence. Several minutes pass. Then she says, “We’re done.”
After a couple of hours of the usual paperwork, Dr. Romano goes home. It’s a weekend, and she’s not on call. So, there’s plenty of time for her and her husband to enjoy two free days together.
She says this has been a pretty normal week in her life, with its usual ups and downs. And although there can be many headaches, she wouldn’t trade the work for anything else in the world.
Rebecca Sernett is an associate editor of The New Physician.