“I’ve been getting winded lately.”
He’s a middle-aged man with diabetes. This kind of thing is a “red flag” on certain patients. He’s one of those patients.
“When does it happen?” I ask.
“Just when I do things. If I rest for a few minutes, I feel better.”
Now the red flag is waving vigorously. It sounds like it could be exertional angina. In a diabetic, the symptoms of ischemia (the heart not getting enough blood) are atypical. It’s the pattern of symptoms that is the most important, and to have exertional shortness of breath which goes away with rest is a pattern I don’t like to hear.
What he needs is a stress test – more specifically in his case, a nuclear stress test (because his baseline EKG is abnormal). But there’s a problem: he has no insurance. A nuclear stress test will cost thousands of dollars.
I can refer him to the hospital, but I know the financial situation he and his wife face. They have no money because of a chronic pain problem he has. He hasn’t worked in several years, but hasn’t ever been able to get disability either (“I tried, but was denied three times”). Without insurance he’s not able to get his problem fixed, so he’s disabled. But he can’t get disability, so he can’t get insurance to get his problem fixed and no longer be disabled.
But the problem on hand is this: he needs a test he can’t afford.
There are many folks out there in this same situation. It may not just be the people with no insurance, and it may not even be people who don’t have money. In fact, my own family is facing this same problem. Multiple family members (myself included) need dental work done. Some need it done badly, yet we don’t yet have the money to pay for it. So we wait for the money to show up while the problems gets worse.
Continue reading “One of Those Patients”
Filed Under: Patients, THCB
Tagged: Rob Lamberts
Mar 5, 2015
Dear ACO General Hospital:
Thanks for contacting me about my most recent blog post. I’m sorry to scare your administration about HIPAA information, but I am equally concerned about that and will always do my best to respect the privacy of my patients. At your request I hid even more of that information.
I know it’s kind of embarrassing to have that kind of thing made public, and I am overall grateful that you did not take it personally that I put the “transition of care” documents for all to see. My goal was not to embarrass or ridicule, it was to point out what our healthcare system is driving us all toward: replacing patient care with documentation. You are being encouraged by the system to produce those ridiculous documents, as they are part of the deal you accepted when you became “ACO General” in the first place.
Continue reading “Dear ACO General Hospital”
Filed Under: THCB
Tagged: Accountable Care Organizations, HIPAA, Rob Lamberts, Transition of Care
Nov 4, 2014
My 87 year-old father broke his hip this past weekend. He was in Michigan for a party for his 101 year-old sister, and fell as he tried to put away her wheelchair. The good news is that he’s otherwise pretty healthy, so he should do fine.
Still, getting old sucks.
During the whole situation around his injury, surgery, and upcoming recovery, one thing became very clear: technology can really make things much easier:
- I communicated with all of my siblings about what was going on and gave my “doctor’s perspective” to them via email.
- I updated friends and other family members via Facebook.
- I have used social media to communicate cousins about what is going to happen after he’s discharged from the hospital and coordinate our plans.
All in all, tech has really made things much easier.
This reality is in stark contrast to the recent headline I read on Medscape: “Doctors are Talking: EHRs Destroy the Patient Encounter.” The article talks about the use of scribes (a clerical person in the exam room, not a pal of the Pharisee) to compensate for the inefficiencies of the computer in the exam room. Physician reaction is predictable: most see electronic records as an intrusion of “big brother” into the exam room.
To me, the suggestion to use a scribe (increasing overhead by one FTE) to make the system profitable is ample evidence of EMR being anti-efficient.
Despite this, I continue to beat the drum for the use of technology as a positive force for health care improvement. In fact, I think that an increased use of tech is needed to truly make care better. Why do I do so, in face of the mounting frustrations of physicians with computerized records? Am I wrong, or are they?
Neither. The problem with electronic records is not with the tech itself, it is with the purpose of the medical record. Records are not for patient care or communication, they are the goods doctors give to the payors in exchange for money. They are the end-product of patient care, the product we sell. Doctors aren’t paid to give care, they are paid to document it. Electronic records simply make it so doctors can produce more documents in less time, complying with ever-increasingly complex rules for documentation.
Continue reading “Personal Tech”
Filed Under: Tech, THCB
Tagged: Connecting Tech, EHR Design, EHRs, Organizer Tech, Rob Lamberts, Social Media, Twistle
May 29, 2014
I’m back. I’m recovering right now from trauma related to the Affordable Care Act. I’m OK, but probably a few months until fully recovered.
Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me. Those folks may be right in how it directly impacts my practice (since I don’t know the actual impact on other doctors, it’s not easy to compare), but there has been a significant impact. I’ve got plenty of ACA stories.
But that’s not what I am going to discuss in this post.
My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient). It has been quite a ride — one that has not yet reached its destination.
CHAPTER 1: December 9, 2013
Being the adventurous guy I am, I thought I’d give the Healthcare.gov website a whirl. Expecting the worst, I set aside a lot of time for the experience. It was actually quite a bit easier than advertised. My family is as follows:
- Me – Age 51, healthy
- Wife – Around my age, but actual age disclosed only for legal reasons.
- Child 1: Son, 21 years. College grad but living at home for now.
- Child 2: Daughter, 20 years. In college
- Child 3: Son, 18 years at time of application. In college. Birthday later in December.
- Child 4: Daughter, 14 years.
I submitted the information about whether any of us smoke (no), any of us are pregnant (no), and how much money we earn (not much, as I am starting a new business). I immediately got the following eligibility notice.
Continue reading “Adventures in Caring and Acting Affordable”
Filed Under: THCB
Tagged: Healthcare.gov, Rob Lamberts, The ACA, The ACA Navigator
May 6, 2014
The janitor approached my office manager with a very worried expression. ”Uh, Brenda…” he said, hesitantly.
“Yes?” she replied, wondering what janitorial emergency was looming in her near future.
“Uh…well…I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer….” He cleared his throat nervously, “Uh…his computer had something on it.”
“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.
“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.
Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.
Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.
The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”
The Fatal Error in Health Care
Yeah, this makes me nervous too.
We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.
It’s a problem with something that is starts at the very beginning of health care itself.
The health care system is not about health.
Continue reading “Fatal Error”
Filed Under: Physicians, THCB
Tagged: Coding, Coding Errors, Costs, culture of health, ICD-10, payors, practice management, Providers, Rob Lamberts, sick care system
Apr 7, 2014
Thank you, my patients for all you have done for me. Thank you for the encouragement and support. Thank you for believing in me enough to join me in this crazy new way to do health care. Thank you for giving me the honor of being the one you call “my doctor.”
Your trust motivates me to work harder to justify that faith in me – a faith I often don’t have and, one I certainly wouldn’t have without you. I hope and pray this holiday season is a blessing to you. May you find peace in this time of year so often without peace.
May you also have a happy and healthy new year. May you stay out of the ER, away from the hospital and, yes, away from doctors. May you have no need for lab tests, procedures, x-rays and medications (and if you must have medications may they be very cheap.)
If, however, you do get sick, remember that I am here to help you get well, feel better or avoid getting any worse. And if I cannot do any of these, I will still be there to stand by your side through the hard times, and to offer whatever comfort I can give. Doing these things is what it means to me when you call me “my doctor.” It is why that is such an honor.
Again, thank you for all you do for me. God bless you.
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 an earlier version of this post first appeared.
Filed Under: Physicians, THCB
Tagged: Patients, Physicians, practice of medicine, primary care, Rob Lamberts
Dec 8, 2013
By ROB LAMBERTS, MD
My older brother is also a doctor, but not a PCP like me. He’s a specialist: a limnologist. If you have problems with blue-green algae in your lake, he’s the man to see. Limnology is the study of lakes, and fittingly, Bill works in the “Land of a Thousand Lakes” as a professor in fresh-water ecology.
I’m not sure he’s thinking of switching over to direct-care limnology. I’ve been afraid to bring it up.
We do have a lot in common in our professions, as we both see a mindless assault on the things we are trying to save (patients for me, lakes for Bill). My frustration with our health care system is matched by his anger toward those who deny global warming and the harm humans are causing on our world.
Just as he can get my blood pressure up by asking if his child will get autism from the immunizations, I simply have to suggest this week’s cold weather as proof against global warming to raise his systolic pressure.
So it was notable when I heard a rant against an unexpected target: “You know the Gaia hypothesis?” he asked. ”They think the world is a ‘living organism’ that works toward a ‘balance’ to maintain life. They believe that humans act against nature, and so are responsible for everything that’s wrong with ‘mother earth.’”
“It’s total bullshit,” he went on to explain, not waiting to hear if I knew what he was talking about. ”Do you know that when trees appeared on the earth, they caused a mass extinction (called the Permian Extinction)! Trees! There’s no mystical ‘balance of nature;’ it’s always in a constant state of flux, of imbalance.”
Let me make this clear: Bill is not saying that it’s OK that we are harming the earth, nor is he trying to absolve us of our responsibility for what we are doing. His beef was with the notion that there is some kind of ‘balance’ of nature, when the evidence clearly points to the contrary. The result of this belief is that that there is somehow an imputed moral goodness from this ‘balance’ (resulting in the idea of ‘mother earth’), and a subsequent implied immorality to any assault on our mother’s sacred ‘balance’.
This has come to mind as I have had significant changes to my thinking about giving good care my patients, especially as it applies to the area of “wellness”. Since leaving my old practice, which was immersed in a world of ICD (problem) codes and CPT (procedure) codes, I have shifted my thinking away from a medical world where every problem demands a solution. I have moved my thinking away from reacting to every thing that is going on at the moment, and toward the bigger picture. I am focusing less on problems and more on risk. I am focusing less on solutions, and more on responsibility.
Continue reading “The Purpose-Driven Doctor”
Filed Under: Physicians, THCB
Tagged: Gaian Medicine, Problem-based Medicine, Reward, risk, Rob Lamberts
Nov 30, 2013
I have felt from the start that this practice model is far better than the one I had in my former life, including:
- Better experience for the doctor
- Better experience for the patient
- Better care quality
- Savings for the patient and for the system.
The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice. This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against).
Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get. This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model). I realize that this does not constitute a proof of concept, but it is not without meaning.
PATIENT 1. MEDICARE. AGE: 90+
Pt had a head injury and came to my office wondering if they should go to the ER. I assessed the mental status did an exam, determining that this was not necessary. Set up imaging study that day (CT without contrast) which came back negative.
In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this.
Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price.
Savings: Avoided ER with head injury work-up. Cost: ? (More than $300 by far).
Continue reading “The Doctor Returns Bearing Data.”
Filed Under: Physicians, THCB
Tagged: direct primary care, practice management, Rob Lamberts
Oct 22, 2013
He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.
He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here. He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like. First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits. Then there is my guitar just behind me. He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music. Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person. He seems intrigued.
He owns a business, which is a service type business like mine. Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it. I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine.
He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report. Spin happens. But as we talk, there is much to find in common, and he warms up. His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.
Continue reading “Target Demographic”
Filed Under: Physicians
Tagged: direct primary care, doctor/ patient relationship, Patient-centered care, Patients, practice management, primary care, Rob Lamberts, Small Business
Oct 11, 2013
My worst night as a doctor was during my residency. I was working the pediatric ICU and admitted a young teenager who had tried to kill herself. Well, she didn’t really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.
On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning. We did everything we could to keep her alive, but without a liver there is no chance of survival.
Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests. I told the ER doctor to check an acetaminophen level and, sadly, it was elevated. She too had taken a handful of acetaminophen at an earlier time. She too was lucid and scared at the start of the evening. The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant. I got the call later that next day with the bad news: she died.
The saddest thing about both of these kids is that they both thought they were safe. The handful of pills was a gesture, not meant to harm themselves. They were like most people; they didn’t know that this medication that is ubiquitous and reportedly safe can be so deadly. But when they finally learned this, it was too late. They are both dead. Suicides? Technically, but not in reality.
For these children the problem was that symptoms of toxicity may not show up until it is too late. People often get nausea and vomiting with acute overdose, but if the treatment isn’t initiated within 8-10 hours, the risk of going to liver failure is high. Once enough time passes, it is rare that the person can be cured without liver transplant.
According to a recent ProPublica investigation, acetaminophen overdose is the #1 cause of liver failure in the US. And between years of 2001 and 2010, 1567 people in the U.S. were reported to have died by accidentally overdosing.
Continue reading “My Worst Night as a Doctor”
Filed Under: Physicians, THCB
Tagged: acetaminophen, painkillers, Patient Safety, Rob Lamberts, Tylenol
Oct 2, 2013