Dropping Out

Dropping Out

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After 18 years in private practice, many good, some not, I am making a very big change.  I am leaving my practice.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job.  The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve.  The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk.  I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

I must confess that there are still a lot of details I need to work out, and plan on sharing the process of working these details with colleagues, consultants, and most importantly, my future patients.

Here are my main frustrations with the health care system that drove me to this big change:

  1. I don’t feel like I can offer the level of care I want for my patients. I am far too busy during the day to slow down and give people the time they deserve.  I have over 3000 patients in my practice, and most of them only come to me when there are problems, which bothers me because I’d rather work with them to prevent the problems in the first place.
  2. There’s a disconnect between my business and my mission.  I want to be a good doctor, but I also want to pay for my kids’ college tuition (and maybe get the windshield on the car fixed).  But the only way to make enough money is to see more patients in my office, making it hard to spend time with people in the office, or to handle problems on the phone.  I have done my best to walk the line between good care and good business, but I’ve grown weary under the burden of having to make this choice patient after patient.  Why is it that I would make more money if I was a bad doctor?  Why am I penalized for caring?
  3. The increased burden of non-patient issues added to the already difficult situation.  I have to comply with E/M coding for all of my notes.  I have to comply with “Meaningful Use” criteria for my EMR.  I have to practice defensive medicine to avoid lawsuits.  I have more and more paperwork, more drug formulary problems, more patients frustrated with consultants, and less time to do it all.  My previous post about burn-out was a prelude to this one; it was time to do something about my burn out: to drop out.

Here are some things that are not reasons for my big change:

  1. I am not angry with my partners.  I have been frustrated that they didn’t see things as I did, but I realize that they are not restless for change like I am.  They do believe in me (and are doing their best to help me on this new venture), but they don’t want to ride shotgun while I drive to a location yet undisclosed.
  2. I am not upset about the ACA (Obamacare).  In truth, the changes primary care has seen have been more positive than negative.  The ACA also favors the type of practice I am planning on building, allowing businesses to contract directly with direct care practices along with a high-deductible insurance to meet the requirement to provide insurance.  Now, if I did think the government could fix healthcare I would probably not be making the changes I am.  But it’s the overall dysfunctional nature of Washington that quenches my hope for significant change, not the ACA.

What will my practice look like?  Here are the cornerstones on which I hope to build a new kind of practice.

  1. I want the cost to be reasonable.  Direct Care practices generally charge between $50 and $100 per patient per month for full access.  I don’t want to limit my care to the wealthy.  I want my practice to be part of a solution that will be able to expand around the country (as it has been doing).
  2. I want to keep my patient volume manageable.  I will limit the number of patients I have (1000 being the maximum, at the present time).  I want to go home each day feeling that I’ve done what I can to help all of my patients to be healthy.
  3. I want to keep people away from health care.  As strange as this may sound, the goal of most people is to spend lesstime dealing with their health, not more. I don’t want to make people wait in my office, I don’t want them to go to the ER when they don’t need to.  I also don’t want them going to specialists who don’t know why they were sent, getting duplicate tests they don’t need, being put on medications that don’t help, or getting sick from illnesses they were afraid to address.  I will use phones, online forms, text messages, house calls, or whatever other means I can use to keep people as people, not health care consumers.
  4. People need access to me.  I want them to be able to call me, text me, or send an email when they have questions, not afraid that I will withhold an answer and force them to come in to see me.  If someone is thinking about going to the ER, they should be able to see what I think.  Preventing a single ER visit will save thousands of dollars, and many unnecessary tests.
  5. Patients should own their medical records.  It is ridiculous (and horrible) how we treat patient records as the property of doctors and hospitals.  It’s like a bank saying they own your money, and will give you access to it for a fee.  I should be asking my patients for access to their records, not the reverse!  This means that patients will be maintaining these records, and I am working on a way to give incentive to do so.  Why should I always have to ask for people information to update my records, when I could just look at theirs?
  6. I want this to be a project built as a cooperative between me and my patients.  Do they have better ideas on how to do things?  They should tell me what works and what does not.  Perhaps I can meet my diabetics at a grocery store and have a dietician talk about buying food.  Perhaps I can bring a child psychologist in to talk about parenting.  I don’t know, and I don’t want to answer those questions until I hear from my patients.

This is the first of a whole bunch of posts on this subject.  My hope is that the dialog started by my big change (and those of other doctors) will have bigger effects on the whole health care scene.  Even if it doesn’t, however, I plan on having a practice where I can take better care of my patients while not getting burned out in the process.

Is this scary?  Heck yeah, it’s terrifying in many ways.  But the relief to be changing from being a nail, constantly pounded by an unreasonable system, to a hammer is enormous.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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111 Comments on "Dropping Out"


Guest
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clara
Jan 21, 2013

Superb write-up!!!! Your article shows how hard you have worked to pen down this wonderful post…

Guest
Greta
Sep 17, 2012

You are writing the future! I’ll be rooting for you and your patients.

Guest
Sep 13, 2012

My comments are on http://healthtrain.blogspot.com

Go where we used to be…..great move, hard to improve on evolution.

Guest
Oct 23, 2012

Love the article…this is what I have been harping on for years. I posted reposted it on http://www.facebook.com/healthcareforless for everyone to see…hope you comment there too…….:)

Guest
Marie
Sep 13, 2012

First, I want to congratulate you Dr. Rob on your willingness to step out of your comfort zone. I would love to work for a practice like this. I am a NP in a primary care practice and even I feel pressure to see x number of patients per day. Second, I have a high deductible insurance plan so that I am covered for something catastrophic, everything else I pay for out of pocket or through a HSA. I am healthy, get regular screenings and take a few medications that are generics. My impression of the ACA is that Congress took a sledgehammer to the healthcare system when a scalpel might have been a better choice. The system is a mess but the solutions should be collaborative not forced.

Guest
Rob
Sep 12, 2012

I am amazed at how someone can, with pretense of sincerity, suggest it is my civic duty to stay in a failing system and burn myself out. The good news is that I will be able to prove myself right while Ms C tries to spin it on her direction. I guess this is how actors feel about newspaper critics or athletes about TV analysts. I will now do my civic duty and start ignoring the hot air in hopes to stem their effects on our global climate.

Guest
DeterminedMD
Sep 12, 2012

By the way, let’s have a moment of brutal candor here, neither party honestly promotes autonomy and independence in their deeds, justs says it in campaigns and then write and pass laws to further suppress real independence. Patriot Act? Gimme a break! PPACA, a covert military action by slow and insidious process.

Choose your own doctor, and premiums go down. Do you hear laughter in the alleyways and at the tops of those tall buildings in the financial districts across America? Their biggest belly busting laugh is they got the president to do the bidding. Who that is not a partisan hack would argue otherwise?

The Lamberts of this process are frightening to PPACA proponents, because if enough doctors follow suit, who does this care you all claim will come? Oh yeah, and be ready my fellow invested and skeptical colleagues, if the democrats do regain full control of the legislative branch, they will amend PPACA to make Dr L’s choice illegal. Just an opinion, based on the history of power gone mad.

Guest
catherine
Sep 12, 2012

ACA provides money to boost primary care, but then again, you might be required to actually look into the facts behind the law to know what I’m talking about.

I’m done (and I was speaking to YOU not Liz in this comment. catherine says:
September 12, 2012 at 3:42 pm

Guest
Sep 12, 2012

I wish every Doctor thinks the way you do.

It seems that you want to change complete health system of America. You want to get out the system and want to start your own. That’s really appreciable. However, it will be very difficult. But someone has TO start for the change. I believe you may be the one…

Wishing you all the best…

Guest
Barry Carol
Sep 11, 2012

Rob –

I’ll be interested to hear if this idea gains any traction with employers. I’ve been told that in any given year, 25% of the population incurs no healthcare costs at all. Even within Medicare, the healthiest 50% of beneficiaries account for only 4% of program costs. It seems that a small employer already paying a high price for health insurance in the small group market would perceive a service like the one you propose as a high cost add-on and I question how many middle income employees would be willing to pay for it themselves. I view it as a more attractive option for someone who already has significant medical issues like heart disease, diabetes, asthma, hypertension, etc. and for more affluent people who simply want a higher level of service than a conventional PCP practice can offer.

I don’t know if employers could offer to pay for it for only those employees who want it unless it can be offered as an optional add-on beyond the regular health insurance policy and as part of a cafeteria benefits plan.

Guest
catherine
Sep 11, 2012

Liz says:
September 11, 2012 at 5:34 pm

Irregardless, DeterminedMD used a legitimate word…

For reference:
http://dictionary.reference.com/browse/irregardless

@Liz

Did you read the cite you link to? It says it’s a “non-standard” word, meaning not legitimate.

Word Origin & History

irregardless
an erroneous word that, etymologically, means the exact opposite of what it is used to express, attested in non-standard writing from at least 1870s..

John Ballard says:
September 11, 2012 at 5:50 pm

@Liz.
Is that anything like “legitimate” rape?
#JustAsking

Good one, John Ballard!

Guest
Sep 12, 2012

Thanks.
Twitter has taught me much about brevity, the soul of wit.
Too bad it’s not contagious. This thread has become too long now for recommended reading. Sad, because there is an unusually rich variety of ideas and opinion here, mostly well articulated. It would be a good piece for a seminar.

Guest
Sep 12, 2012

Thanks.
Twitter has taught me much about brevity, the soul of wit.
Too bad it’s not contagious. This thread has become too long now for recommended reading. Sad, because there is an unusually rich variety of ideas and opinion here, mostly well articulated. It would be a good piece for a seminar.

Guest
DeterminedMD
Sep 12, 2012

Irregardless of your efforts to diminish my earlier comment, I am a doctor and just trying to use a “racist type” ploy to distract was lame.

As are the ongoing efforts of PPACA advocates who do NOT want people to know the specifics and possible consequences of PPACA and further deterioration of medical care. Wow, Dr Lambert’s post really did stir a nest as said by another here! Can’t let people find out truth, eh?

Guest
catherine
Sep 12, 2012

“Racist-type ploy.” Wonder what that’s supposed to mean. Too bad the “Democraps” are not only going to keep the White House and Senate, they just might pick up more seats in the House. You want people to know the truth, so one wonders why you keep lying.

Guest
Liz
Sep 12, 2012

@catherine

Irregardless, you expect people to take you seriously even though you don’t even capitalize your first name.

Guest
DeterminedMD
Sep 12, 2012

Nice of you to insult the writer of the post for taking a stand about quality and integrity of care that, by your inferring you speak for PPACA to stand as us, seeking quality and integrity of care is inconsequential to the purpose of the legislation.

Thank you for highlighting that perspective per my interpretation. I guess I capitalized on the opportunity, irregardless of what others might think.

This partisan shrill by both parties had got to stop. Maybe public unions can cripple the democraps and the same for the Tea Party and repugnocants. Well, we can hope anyway.

Last sentence from me dangling from the thread, do what is right Dr Lamberts, just don’t wait for the masses to thank you.

Guest
catherine
Sep 12, 2012

You’re right. That’s a great move to deflect from your failure to provide the “specifics and consequences” you predict from the ACA, nor debate on facts, acknowledge facts, recognize corrections I provided to HSA numbers and other wrong statements, etc. Feel free to continue raging and engaging in barely literate and shrill fear mongering (such as the usual empty smear of the IPAB, which, to date, has done very little). Solo practices are closing up every day. I fail to see how this one will succeed, and it certainly will not be able of provide the range of services and continuity of care that patients deserve and has been show to improve outcomes. Most importantly, by “dropping out” Dr. Lamberts’ services will only be available to those who can afford what he wants to charge and whether he actually improves the health of his patient base will be a secret as he won’t be reporting to anyone. National public health goals be damned, I guess. But let’s not pretend this is noble or ground-breaking and it’s certainly NOT the Qliance model.

Guest
DeterminedMD
Sep 12, 2012

Your partisan agenda only serves you and your cronies. Nice projection about the lies, what have I “lied” about? Most of what I write is opinion and conjecture, when I state facts I usually include a link to show it is not my only opinion or position but someone of some level of authority notes prior or concurrently.

You are a Ms Mahar clone. Just spouting democrat rhetoric and when challenged basically retort “it is law so it is true”.

Hmm, wasn’t there once a law that denied women and African Americans the right to vote? That law was shown to be wrong, and wasn’t it Democrats who used to suppress black rights, until they conveniently changed course just to get their votes?

Enslave and then maintain dependency, now there is a campaign slogan for the Left. Oh, don’t feel I am picking on your party alone, I’ve got a slogan for the Right too, “if you’re not with us, you’re against us”.

Oh yeah, that could apply to democraps too. How about “middle class, we’re too above that crowd”, so the Right is about abandonment.

Wow, this is what 2012 politics had to offer, enslavement or abandonment. Goes along with the PPACA agenda for me. And again, that is not a lie, catherine, an astute observation.

Irregardless of what you think.

Guest
DeterminedMD
Sep 12, 2012

Yeah, instability is based on a point of reference, we just don’t all share and bow to yours, catherine. People said Ghandi was unstable, and yes it was not his followers. To me “racist type” accusations can be applied to comments you make, because I argue against you, I can’t be a doctor or I am unstable. Just like your party has said over and over, “if you don’t agree with Obama, then your are a racist”.

Care to defend that one, ma’am? Biden was right, people are goin’ to be back ‘n’ chains, but it won’t be just if Republicans win. Another moment of projection by politicians.

All this man said at the top of this post is he is going to provide care more on his terms. That really frightens you and your party’s agenda, doesn’t it?

Guest
catherine
Sep 12, 2012

I honestly hope you’re not a doctor because your comments reveal a highly unstable person.

Guest
Rob
Sep 11, 2012

This is not a workplace clinic. I would have an independent practice and would just contract with the business for the care of their employees and give the benefit of better care and fewer absences to the employer. Instead of the employee paying me per month I get it from the business to whom it has most value.

Guest
Barry Carol
Sep 11, 2012

Rob –

Workplace clinics are a fine idea for employers large enough to afford and support them. They could also work for groups of smaller employers located in close proximity to each other. As I understand it, there are roughly 8,000 of these in the United States today. Some are staffed by doctors and some by NP’s. Walgreen is a market leader in this segment as a result of a couple of acquisitions it made a few years back. Employers generally pay for them on a cost plus basis. They vary greatly in both physical size and the scope of services offered. Employers expect the cost of the clinics to be more than offset by lower healthcare costs for their employees and family members. Convenience for employees is generally not enough to justify the expense.

By the way, the workplace clinics are a separate business from small clinics located within retail stores and staffed by NP’s. Walgreen and CVS are co-leaders in that segment. People who use them generally like them.

Guest
Rebecca Coelius, MD
Sep 11, 2012

I think the family docs and general internists who have been practicing for decades and still are supportive of NPs and PAs joining the primary care workforce have a pretty good idea of what goes into medical care.

You are making this far too binary. Substitute or nothing. There are many tasks done by the average primary care physician, or any physician, that people without a lick of medical training could do. I’d love to see that waste quantified in all of these IOM estimates of the money we dump down the drain in healthcare.

Then there is a bunch in the middle that could be done by NPs/PAs, especially if aided by clinical decision support and good working relationships with a doctor.

And then there is a small amount in the average primary care clinic that could only be done by someone with the depth and breadth of clinical training held by an MD. Ideally we have physicians doing more of what they alone do best (ie less referring and more management and time spent on medical decision making in complex patients) and less of this “only a doctor can do all of that” mentality with no evidence whatsoever behind the claim.

The role of the primary care physician, and primary care itself, needs to evolve with the needs and capabilities of the wider medical system. I despise that any person who suggests that is attacked for undermining primary care.