By ROB LAMBERTS, MD
I was planning on leaving behind the seriousness of the past few posts and going back to my usual inane writing, but some of the comments have made it too hard for me to keep quiet. The response has been largely positive, and overall it has been overwhelming. More people have read or commented on my letter to patients with chronic disease than any in recent history. I am grateful that it is circulating around the web for others to contemplate, perhaps understanding the intent of what I wrote and improving their relationship with their doctors in the process.
The purpose of the letter was to give some helpful insight into the emotion on the other side of the equation. I can’t understand what it is like to have a chronic illness without having the disease, but it is still fruitful for me to try to figure this out. In the same way, patients with chronic illnesses benefit from a better understanding of the doctors they see so frequently and depend on so greatly. I can sympathize, but I can’t feel the pain. Still, I do need to listen closely to patients so I can have the best relationship possible.
Some folks felt that I was saying that doctors need their egos stroked and to be treated special, but that is not what I meant to say. Each person needs to be understood and treated as their situation dictates. People with chronic illness want to be understood (as witnessed by the incredible response to my letter!) and treated based on that understanding. Doctors want to be understood as well. So let me tell you my side of the story. What is it like to sit in my chair? I don’t say this for sympathy or pats on the back, I say it to be understood. If I am better understood by my patients (and readers), my relationship with them is better, which is good for both of us. I think I represent a fair percentage of primary care docs in these ways.
1. I care about my patients – As hard as I try to “just do the job,” and not expend the emotion I do during the day, I couldn’t live with myself if I let my patients down. They depend on me for a lot, they pay for my service, and they deserve my best. I’ve been told I do this to a pathological degree (along with my llama obsession), but it is there. I want to help them. I get frustrated at my powerlessness and am genuinely happy when they do well.
2. I am tired – Each day demands an emotional price. Some days the demand is not so high, others suck the life out of me. Being “needed” cuts two ways; on one side it is nice to truly help people when they need the most help, it’s satisfying to see your life making a difference. On the other side, it is a never-ending river of need, pain, and crises to be handled. Being patted on the back (or patting myself) is nice, but it doesn’t mean anything for the future. Each day brings new hands to hold, needs to meet, problems to be solved. Each day is as much a burden as it is an opportunity. That burden won’t leave me until I take down my shingle, yet the opportunities to make a difference will make it hard to take that shingle down.
3. I also run a business – In terms of priorities, I need to pay my staff, pay the rent, and pay my personal bills to even have the chance to take care of patients. I get frustrated when patients insinuate that I value money too much. I get very frustrated by that, actually. People seem more willing to pay for cable TV, cigarettes, or eating out than to pay me for what I do. I earn less than most other medical specialists, yet some people resent my income. The mess of a system we have works against primary care and works against complex patients. If I spend 30 minutes with a complex patients (I do spend 30 minutes with people regularly), I am paid about 50% more than if I see a 5 minute ear infection visit. Doing the math says that my mind is not valued and that I should see more ear infections and less chronic patients. All of this adds to my daily stress.
4. I am actually a person, not just a doctor – I have four children and a wife, and being a dad and a husband isn’t easy when I come from work with the emotional life sucked out of me. I struggle with my own emotions and I get sick. I worry a lot about money, and I feel insecure about the fact that despite being a doctor, I am not saving enough. Hence I also struggle with working too much. Life’s not easy for anyone, and despite my title I am not exempt.
5. I hate bad doctors – Many of the comments to the letter I wrote were lamentations about doctors who suck. Unfortunately, doctors who take bad care of their patients make my life miserable too. I have to clean up their messes, I have to re-teach their patients on what medicine should look like. I have to wean their patients off of addictive drugs that they didn’t have the guts to deny. I am personally frustrated when I send a person to a specialist and they don’t do anything or upset my patient, and I hate the fact that they almost never communicate with me. It makes my already hard job even harder.
6. My blog is a refuge and a tool – I am thankful that I have this blog as a means to vent, to use another part of my brain (some may argue that point on some of my posts), and to make a difference. I actually have a voice in the whole healthcare reform debate. I actually can reach a large number of people and make their medical experience better (which was the most gratifying thing to hear in the comments to my letter). I’ve made practically no money doing this, but I’ve gotten a whole lot out of it.
That’s my story. Like it or not, it is what it is. I am just a guy who happens to be a doctor – the same as the rest of the doctors out there. There will always be angry people and idiots on both sides of the doctor/patient relationship, but no matter what, the doctor-patient encounter is a human thing. Love is human, war is human, murder is human, and so is childbirth. You can’t put humanity into a bottle, you can’t throw a single label on it. The highest calling is to enter into another’s life, to see things from their perspective, and to add good to it.
That goes for all of us, regardless of letters behind our names.
Thanks for listening.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, 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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I was a Respiratory Therapist for 28 years.I contracted a resistant staph infection.As a result I lost my leg,my job ,my house and everything I worked for! Now I get letters every week,t get threat letters if I can’t pay them! .Don’t you think it is time for Doctors to decide whose side they are on?
Thanks, Rob, but I don’t want to see my point misconstrued by anyone reading the empty spaces between our letters, so, a little clarification:
I’m not saying you should hide the business side of what you do. I’m saying something far more radical. I don’t think doctors should be running businesses. In his 2007 work, Better, Atul Gawande discusses the 1970s experiment of internist Harris Berman and a few enterprising doctors,all of whom agreed to take a reasonable salary and work for the betterment of the health of their clientele. The system worked until they found that they needed an orthopedist and couldn’t find one who would work for the same amount as everyone else. At that point, the system fell apart. The Mayo clinics have been a little bit luckier in this respect, but I don’t know how they determine the salary levels of their doctors.
Sorry, Rob. I know this seems a bit much to lay at the feet of just one family doctor–especially when the real source of trouble seems to be the other guys–the specialists. The conversation has to start somewhere, though.
As for hidden costs, I have one question for you–how much does an MRI cost? Do you tell your patients how much such procedures cost? I realize the insurance companies cut deals with everyone, making setting prices difficult, but everyone has a starting price–the price the patient would pay if she weren’t insured. I think every patient (or parent, for minors) should know those prices before they make any decisions. When I was ten years old, my tonsils were removed. I asked my parents: no one ever told them how much my surgery was going to cost. How about you, Rob, do you tell Mom how much Junior’s tonsilectomy will cost? Like I said, every process has to start somewhere.
Great points. I don’t like to talk about money much because people don’t like to hear well-paid professionals complain.
Regarding the business side of things, I think the issue needs to be understood, not brushed under the table. People are uncomfortable with the fact that a medical practice is a business, but this is a fact. Hiding from the fact of it makes it no less true. I would love to be able to up-front price what I do so that people could judge the value of what I do based on the quality and the cost, but insurance makes that impossible (unless I go boutique, which I won’t do). We worry about being overcharged in any business transaction, but medicine is different for two reasons. First, because of the nature of the transaction – it involves a person’s health. Second, because the costs are hidden. I firmly believe that until we figure out a way to hold people accountable for what they charge (including hospitals, labs, pharmaceutical companies, and doctors), we will never solve our problems in healthcare.
We can’t hide the business aspect of things. I learned early (when I went months without pay) that a medical practice has to be financially solvent for care to be given at all. I must first pay rent, staff, and for supplies before I can get a dime, and if I can’t do that I won’t see patients for very long.
Thanks, Rob. I appreciate your candor. You sound like a fine man. I’m sure you’re an excellent primary care physician.
I’d also like to say that I’m sorry you’re tired. I think everyone deserves a break now and then. Maybe you should look into some kind of break-sharing system with a group of other doctors. Say, five of you agree to take over all of one member’s patients while that one goes off to dive Rangiroa or fish Scotland or ski Stowe for two weeks. Everyone gets two fortnights per year. Or something like that. With a group of five, no one man has to take on an entire colleague’s custom at any given time. Just a thought.
As for the money, I understand some of the reasons your patients worry that you’ve become too concerned with the bottom line. To be sure, part of it isn’t you. The latest study I could find says that GPs average $175K/yr. That’s salary, not profit. So, that’s after paying the staff and the office and equipment rents. In my best year, I made $100K while my wife was pulling down $60K. Even with my outrageous student loan burden (far worse than the average med student’s—long story) and mortgages, we thought we were in pretty fine shape at that income level. So, perhaps you can see where many of us feel little sympathy for someone who makes that much more than the rest of us and still laments not making as much as a specialist.
I’m speaking generally, here, Rob, not specifically.
Speaking specifically, I’ve been in serious straits. I have been hungry and wondering where the next meal would come from. I’ve been broke just as one child was approaching college age. I understand that financial troubles can hit anyone at any income level—especially someone with four kids growing up and heading for college. So, for your specific situation, you have my sympathy. I hope you find a way to put some money aside for your future.
I also understand the inherent stupidity in the current piecework mechanism by which physicians are paid. I’ve been all through the CPT and HCPCS. It’s all based on paying for surgery. Even the name of your primary pay code—Current Procedural Terminology—tells the tale. Aside from the fact that the name sounds more like a glossary than a guide to what deserves payment, the onus is on Procedure. I think the GPs, Pediatricians, and OB/GYNs should break away from the AMA and form their own group.
The real killer, though, for an outsider, is hearing a physician say, “I run a business.” That’s where you worry us. Patients hear that and wonder, will his next decision be based on what’s best for me or what’s best for his bottom line? Do I need that blood test or does his cash flow need another procedure? Doctors who own their own imaging services, laboratories, infusion centers, or hospitals compound that concern, twenty-fold. Every doctor claims this is not a problem–not a dilemma–that he knows when and where to draw the line. I’m sorry, but some of us really don’t know you very well. How do we know to trust you? On Twitter this past week, I’ve been following the posts of a frequently snide gent who calls himself BurbDoc. He’s angry because his patients are giving him grief about paying their bills. Some, apparently, are angry about copays. You yourself say, “People seem more willing to pay for cable TV, cigarettes, or eating out than to pay me for what I do.” Well, perhaps, but most of those patients have already paid quite a bit. We have a hefty chunk of our paychecks going toward health insurance, which is supposed to pay for your services, but the insurance companies have this idiotic idea that we’ll avoid frivolous visits if we have to pay the first $500 worth ourselves and then have to drop thirty bucks every time we walk into a doctor’s office. Aside from your indigent patients (if you have any), maybe you should remember, we’ve already paid for your services. It’s nothing personal, Rob. It’s the insurance companies who have us all in a vice.
Anyway, again, thanks for sharing. I admire your writing, and I really do wish you were in my area. But take a vacation. You sound like you need it.
What a nice and inspiring story..thanks for sharing your story..really cool!