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Dropping Out

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By ROB LAMBERTS, MD

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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  7. “Not sure I understand this argument. Insurers and government are still the payers in ACOs, so what if its physician led?”

    It wasn’t an argument, it was just a question about what other options Dr. Lamberts had explored, such an an ACO, which is designed to give doctors more control. Not saying it does or will–but that’s what he said he lacks.

    Also, you are not correct about an ACO. Insurers are not the payers, CMS is, and if you see Medicare benes, who else is the payer?

    ww.dwt.com/advisories/Final_ACO_Regulations_Legal_Structure_and_Governance_11_08_2011/

  8. Not sure I understand this argument. Insurers and government are still the payers in ACOs, so what if its physician led? There are many physician led hospitals in the current system that have primary care docs on the hamster wheel. I think what’s more interesting is joining an ACO that already understands the ROI of primary care since they are actually paid to keep people healthy instead of serving as referral centers for lucrative subspecialty reimbursements. Though I’m not so sure there is enough upside in keeping people healthy to negate the money to be made in heart caths and major orthopedic procedures, the ACOs whose high level conversations I’ve been privvy to are still pretty focused on volume for these services.

    While I realize this is not a popular opinion- I would also remind everyone that these are million to billion dollar entities you are asking physicians to run. I think the clinical/frontline counterpoint to business perspectives are essential in any delivery system, and should be an equally powerful voice in all decisions. But its idiotic to regulate that 70% of an ACO governing board be physicians. Healthcare delivery is a very different beast from clinical medicine. How many doctors know anything at all about the financing of healthcare, policy any deeper than what about it pisses them off, informatics, systems analysis and improvement beyond the baby steps taking place through QI research projects, etc? We see articles all the time on this blog bemoaning the lack of business training in medical school and residency and how people are fleeing private practice because they don’t have the business interest or chops to make it. Something here doesn’t add up.

    If you have to regulate governance, why not also insist a certain percentage also be patients? Nurses or other front line staff? Frankly I think it would be interesting to have these staff also share in the risk and rewards of high quality, efficient care. Its often the safety and efficiency of the system in which you receive care that most affects your outcomes as a patient, not the doctor. I think the GroupHealth governance model is interesting for this reason. Its recognizes that health care delivery systems are teams.

  9. @Chase
    No one who has followed the sausage-making has any illusions that ACA will reduce costs in any real way. That may have been the inspiration that got the process into the legislative process, but by the time all the “interested parties” had input cost savings took a place in line over behind the ponies for Christmas.

    There is an old saying that a camel is a horse designed by a committee. ACOs are a crude legislative effort to replicate the efficiencies and outcomes of the few places in US health care that DO achieve better outcomes at lower costs. Dr. Gawande’s articles in the New Yorker and the exemplary operations like Mayo, Geisinger, Cleveland and others were the jumping off place. Unfortunately the end results have been a rather tortured effigy.

    That said, the reality is a step toward either (pick one) reducing costs or rationing scarce tax dollars. The alternative was doing nothing.

  10. My comments have never referenced reducing costs. However, that is one goal of ACOs, that and improve outcomes for chronicle ill Medicare recipients. What I said was if he wanted greater control, why didn’t he explore being part of the ACO, which are designed to be physican-led, rather than insurance-company led?

  11. Not trying to speak for Rob, but like many burned out physicians, this is his plan to continue practicing medicine. The alternative would be to retire and find different employment, making the issue worse.

    So, this is not selfishness, this is his way to maintain sanity and continue practicing medicine to help others.

  12. Catherine- your hopes will surely be dashed if you think ACO’s will reduce costs. ACO’s break-even at best- all of the impact studies focus on ‘cost-savings’ but do not factor in the tremendous costs and resources required to obtain those cost savings. So, although they’ve been proven to reduce costs, they never mention the ROI because in order to reap those benefits, it costs A LOT of money.

    Secondly, you’re not really understanding what this physician is saying- none of the issues that the ACA or ACO’s will address fix his problems. They will continue, and one might argue, they will be magnified as 32 million Americans become insured.

    I wish this physician the very best- good for him to take the plunge and make his career satisfactory to his liking.

  13. Ah yes, Gregg, you always read the fine details. Once again my mind has been changed..Obamacare seems to cover it all. Maybe not so bad if folks read the finer print. Thank you for edifying me

  15. 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.

  16. 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

  17. 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.

  18. 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.

  19. 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.

  20. 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.

  21. 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.

  22. @catherine

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

  23. 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?

  24. 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.

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

  26. 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.

  27. “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.

  28. 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?

  29. 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…

  31. 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.

  32. 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!

  33. @JohnBallard

    “Legitimate rape” doesn’t exist, unlike the word “irregardless,” which is an actual word.

  36. 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.

  37. 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.

  38. 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.

  39. Good luck thinking NPs and PAs will fill what will be a fairly large void with physicians dropping out of the system. Only those who minimize the needs, or more likely just have no clue what goes into medical care think people doing less training can deliver the same services.

    These other professionals are adjuncts, not substitutes!

  40. She’s right. Doctors don’t make grammatical errors. She’s the one whose right about that.

  41. My hope is that getting a system to do this type of thing efficiently (building systems is my main strength that has earned awards and acclaim), adding additional patients using either extenders (PA’s NP’s) or even using nurses who are well trained in the system, then the overall number could be brought up. The goal would be to then lower the cost (sorry to Cathy who thinks I am greedy), so more patients could access the system without making me hop back on the hamster wheel. The main application of this, however, would be to reach out to businesses who want to offer something for their employees without breaking the bank. The benefits of having a system that allowed people to get care without leaving work are obvious: less absenteeism and healthier employees. The value to businesses would be huge, and it is a place where the cost for individuals could be offset by charging businesses more ($100/employee would be worth it if I can deliver the goods).

    Alas, big dreams.

  42. Re the NP question, I do agree that bringing in other allied health professionals is key. However these individuals respond to the exact same work environment and income pressures that MDs do. I have many friends going the NP route, and 9/10 have chosen to do a subspeciality (derm NP, NICU NP, etc) rather than primary care, and all of the reasons sound just like those given by my medical school classmates when we made our decisions. Interestingly some of my NP friends actually say that they feel more competent to take on a subspeciality than primary care since the breadth of knowledge required is less extreme. Lets also not forget that there is also a shortage of nurses to do traditional nursing jobs, we are draining one pond to fill another.

    Its worth mentioning the importance of creating an expedited system for getting foreign providers fully up and running in the United States. Obviously there needs to be some quality assurance, but requiring another round of indentured servitude (residency) in an American hospital is ridiculous. I remember scrubbing into a cardiothoracic surgery alongside a 40 something Asian man just beginning training to be a PA. The attending surgeon needed only ten minutes to realize that this guy had been a skilled surgeon back in his own country. Such an enormous waste.

  43. Irregardless? There’s no way you’re a doctor. And there’s no government take-over.

  44. Regarding the issue of a potential shortage of primary care doctors which could be exacerbated by more docs moving to the direct practice model, it’s worth noting that we already make more extensive use of NP’s in rural areas than in more populated areas out of necessity. Moreover, I’m told that in Europe, most well child care is provided by pediatric nurses instead of pediatricians. Historically, most of the opposition to allowing NP’s to practice at the top of their license came from the physician lobby because they don’t appreciate competition from outside the guild.

    At the end of the day, though, if new payment models and efforts to use more NP’s to satisfy some of the demand for primary care still leaves us with a shortage of PCP’s and access problems for patients, we can always resort to the tried and true market based solution – just pay them more. It would be easier to justify paying them more if the doctors practicing the way Dr. Lamberts would like to in the future can demonstrate that the patients they care for actually cost the healthcare system less on a risk adjusted basis than patients treated by primary care docs practicing in the traditional way.

    Complicating the equation is the fact that Japan only spends about 8% of GDP on healthcare vs. 17%-18% in the U.S. while they enjoy long life expectancy. A typical primary care visit in Japan lasts all of about thee to five minutes on average. This seems to support the contention that the quality of healthcare one has access to accounts for only about 10% of a given individual’s health status. 40% is attributable to personal behavior (diet, exercise, smoking, drinking, etc.), 30% relates to genetics and 20% to socioeconomic status and environmental factors. As former manager Tony LaRussa once said about successfully managing a major league baseball team: “A lotta stuff goes on.” The same is true in spades for managing the health of a large diverse population like we have in the United States.

  46. Congrats and respect for taking a risk to practice medicine in a way that fulfills you.

    I entirely agree lanierbrian that its not up to individual physicians to slave on the hamster wheel just to ensure there are enough primary care doctors out there. A great deal of nonsense is put up with by doctors because its so easy to play to our commitment to patients. We are all just people who need to find the work environment and problems to solve that make us come alive.

    Yet its naive to think that DPC will recruit enough physicians fast enough to primary care to not only address the existing access issues, but make up for the fact that DPC docs have panels that are 25-50% of the average primary care office. I don’t think “med students will see how fun it is and it will solve all of our problems” is a good enough argument for society to be reassured. The income and respect disparity is still huge, it takes years to train a primary care physician while the access gap grows every day, and again and again surveys of medical students indicate that there is rapidly dying (some would argue long dead) interest in dealing with the business side of medicine/owning an independent practice.

    I’m far more interested in asking how we scale all the parts of primary care that don’t necessarily need a clinician’s training using technology, other types of people, (I love diagnosis and demographic concordant health coaches), and even stand alone companies like Teladoc that answer the simple health questions and diagnosis, or Omada Health for group chronic disease management. What I don’t think works is just shifting a bunch of administrative tasks and algorithmic triage down to expensive RNs or unqualified MAs, while the doc’s role is basically whipping into the room for for a few minutes and running the whole complex show and all of the staff, the latter all skills that we receive zero training in during residency.

    Again- this is not a moral argument about what individual doctors should or shouldn’t do with their practices. Its just pointing out that there are significant problems and opportunities out there for the people who would solve them in primary care, and we shouldn’t let the hubbub around DPC or PCMH blind us to this fact.

  47. Ok, it’s been over 2 years since this legislation has been passed, and irregardless of what the partisan press and crony clinicians monotonally retort in reply to legitimate concerns raised by doubters and skeptics, there is still a sizeable percentage of physicians who do not trust nor want to participate in this government takeover.

    It is not a good law, because truth and honest intent would shine through by now. So, if you as a concerned patient don’t like reading about the Lamberts trying to maintain their sanity and commitment to what are the appropriate boundaries and expectations to health care, enjoy the allied health professional takeover to come as substitutes.

    Responsible and invested people don’t like their autonomy and independence messed with. Deal with that reality!