Probably the hardest part of making the change from a traditional to a direct-care practice is the effect it has on relationships. I am only taking a maximum of 1000 patients (less at the start) and will be no longer accepting insurance. These changes make it impossible for me to continue in a doctor-patient relationship with most of my patients.
For some, this transition will be more hassle than anything. Some people do everything they can to avoid my office, and so are not going to be greatly affected by my absence. They will simply choose another provider in our office and continue avoidance as always. There are others who see me as their doctor, but they haven’t built a strong bond with me (despite my charm), so the change may even be a welcome relief, or a chance to avoid initiating the change to another doctor.
But there are many people, some of which have already expressed this, for whom my departure will be traumatic. ”Nobody else knows me or understands me like you do,” one person told me this week. ”I’ve seen you for so many years, you just know so much more about me than any other doctor,” said another. I’ve seen tears, have gotten hugs, and get frequent demands for a clearer explanation as to what I am doing and why. It’s been a rough week for me, as I don’t feel I can cut off these relationships without some sort of closure. Fore someone who sometimes goes overboard in the importance of others not being mad, it’s been hell.
In truth, the depth of the response I’ve seen underlines the main reason I am going to this new kind of practice: I care too much. I have always run behind because I talk to people, joke with them, tickle the kids, and ask open-ended questions. When I am running behind (I try to keep it under an hour), I don’t let that stop me from giving my full attention to the next person in the exam room. Despite my chronic lateness, people don’t complain much. They know that I will give them the time they need when I am in with them; I can’t cheat them of the time they need (and are paying for).
I’ve always been puzzled when people say things like, “you are the first doctor who’s really listened to me,” or “you always give me your time and attention when I come in.” Isn’t this what being a doctor is about? Aren’t they paying for my attention, for explanations, for listening? Isn’t it dangerous as a doctor to not listen? If those doctors don’t talk, what are they doing? Singing? Doing sign language? Using their psychic powers to probe the patients’ minds? Whatever the case, I see from these statements (which are frequent from new patients) that I either care more than many doctors, or I just love to talk. The last one is definitely true, but the burn-out has occurred because of my inability to not care.
The most gratifying thing that has happened since my announcement is that patients have almost universally expressed their happiness for me in making this change. They aren’t surprised that I burned out, and they are pretty fed up with the system, so they don’t question why that would happen. But the genuine happiness for me as a person has really touched me. The relationship really does go both ways. Many of them have observed my increasing signs of burn-out over the past few years, while others have heard me voice my frustration with a system that tries to push me away from them.
For those I’ve taken care of for many years (some of them nearly 18 years), there is a bond that is hard to explain. I’ve walked through life with them, and for many, that life has been very hard. I’ve been through sickness, sorrow, death, pain, and despair with them, and not just as a bystander; I have taken an active role in their pain and hurt. I knew the husband or child who died 10 years ago, and remember how crazy their parents were. I’ve been through good things as well, and have felt joy when they came back with good news. I recently saw a patient I hadn’t seen for 5 years who, when I last saw them, had been using drugs and getting into very bad relationships as a teenager. I was thrilled when I saw how much they had changed, not letting bad choices ruin their life, and I told them how happy I was.
This is one of the reasons it is a huge advantage to have a primary care doctor who you trust. When I walk into a room with one of my patients, I know more of the back-story in their life than most, if not all other people. I remember how anxious they used to be, and see the little bit of anxiety they still have as a dramatic improvement. Any other doctor would see it as a problem, not a victory. I recently walked into the room of a mother with her newborn child and was struck by how much about this child’s legacy I knew. I knew about her grandparents, who went through very difficult times and have since died. I knew about the uncle with lung problems and the aunt with anxiety. I took care of the mother as a child and knew some “interesting” things about her past as well. When I was looking at this child I thought about all of the other people in that legacy and was struck by my privilege to have been witness to both the good and bad.
My decision to leave my current practice didn’t involve money. I am paid just fine for what I do (although I wouldn’t mind a little more help on college tuition), and haven’t seen a drop in salary, despite the mess our system is in. My decision was largely driven by relationship. I’ve watched as my ability to draw close to my patients has been slowly taken away. Some (on other blogs that will remain nameless) have suggested that I have been selfish in this decision, bolting from the sinking ship instead of trying to fix it. This, of course, is beyond crazy; I have been obsessed with fixing the system – first through use of computers to improve the process, and then through my voice on the Internet through writing. I have done all I can to change the system from within; now it’s time to be real disruptive, and change it by stepping out.
To those patients who follow me on this “adventure:” thanks. Thanks for trusting me enough to follow me to a different planet. I had a patient grin at me yesterday and tell me, “this is just you. I am not at all surprised at this because it’s just the way you do things.” I guess I’ve always been a little subversive. Maybe it was the sandals. Maybe it’s the computers.
No, I just cared for them in a system erroneously labeled as “health care,” and they cared back at me because I did.
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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It sounds like you have joined up with MDVIP. I, as a patient, have signed up via MDVIP with my own established internist when he joined MDVIP. I rationalized the quarterly “surcharge” by saying that it was less than I paid for cable, My primary care internist is happier, and that is worth it, but I am not sure I have received any real extra value because of it.
No, not MDVIP. Trying to keep costs lower for patients and maximizing accessibility. Go to http://more-distractible.org to read about what I am doing (or http://doctorlamberts.org )
Trying to be “friends” with your patients is a recipe for disaster and is not what docs are talking about here. Actually, that’s more a problem (IMHO) with NPs, who can sometimes get confused about the proper roles and boundaries.
What docs like is to know their patients over time, so when they do show very sick (which happens to most of them), we’re not starting from ground zero.
“not starting from ground zero”… That makes a lot of sense to me. That’s a symptom of our defragmented, silo’d system. It is a sad truth that the patient has the responsibility to defrag the environment -to carry test results and re-paint history for the healthcare pros they engage because they changed jobs or moved to a new city. I find it obscene that most of us track car maintenance records but not health records. Car maint recs equates to better resale value but it is the doctors job to track my health over time? If we can start to pivot the responsibility, along with some share of the financial rewards to the patient… That would change everything.
Sorry for taking the tangent on the theme of the post, but it’s interesting how overlapping these topics are.
I just don’t see it. A typical patient sees their doctor once a year. Maybe twice for 20 minutes or so. Do we really need this relationship to be one of the pivotal, lastIng, meaningful relationships in our lives?
Are we looking to our doctor for advice and medical expertise or are we looking for a best friend who really “gets me” all while our insurance com
sorry, trying to write that on my iphone, hit submit by accident… but to continue…
Are we looking to our doctor for advice and medical expertise or are we looking for a best friend who really “gets me”…on our insurance companies dime?
For me, I need a mechanic, not a best friend. It is up to me to take ownership of my health, my wellness, my fitness, my nutrition, my lifestyle and then when the acute health issues arise, I need a mechanic, not a best friend.
It is not up to my doctor to be my best friend and inspire me to take care of me.
my perspective: i’m relatively healthy, i was not born with a chronic condition and therefore didn’t create a bond with my doctor, so I don’t really feel personally get that bond that some folks may have with their doctor.. but I am quite sick of hearing about how everyone needs/expects their doctor to be their friend who spends time with them and calls them to make sure they are taking their meds and reaches out when they hear that you were in the ER with a dog bite… and if their doctor is not doing those things than that is a bad doctor.
Nonsense, it is up to each and every one of us to take responsibility for our own health, the doctor is but one resource in a vast array to assist with that responsibility
The nutritionist should be your best friend, not the doctor.
ok.. end of rant.
smile, be happy, be healthy.
I can’t disagree with you on this, and am not suggesting this is a “friendship” in most cases. There are a few patients I truly like and would go out for a beer with if given the chance. There are others who I have strong affection toward (particularly my elderly patients). The thing the non-frequent fliers (80-90% of my patients) want is access. They want to be able to get to me when I am needed and not have to wait forever to get an appointment or to wait in the office for a long time.
Yet my role is different than a friendship in that I dwell on them, not me. I have to be willing to have compassion, but to say the things people don’t want to hear. It’s something that has taken 18 years to learn, and a reality that is being sorely tested as I am breaking this relationship for “selfish” reasons (not wanting to burn-out). It is hell for the people-pleaser that lurks under my skin.
Personally, I think the “mechanic” comment prior to your reply was not frivolous but on the mark. Patients do now regard doctors as Jiffy Lube type shops, yet, why are we not surprised many of the same “in & out” patients bitch when they change expectations on a dime and demand more time when they suddenly have more issues.
Just curious of the “mechanic” crowd out there, do you tell your true mechanic what parts to use and challenge their assessment of problems the way some patients act in our offices? Gotta love what Jiffy Lube had done to expectations in the auto repair world, eh?
That’s funny, I was just thinking that my recent doctor visits have been like going to Jiffy Lube, but from the other perspective: I go in for one thing, and she tries to “up-sell” me on Vitamin D testing, bone density scan (conveniently performed in her office), mood meds, metformin (because I’m a few points away from being pre-diabetic, which I guess makes me pre-pre diabetic), etc etc.
I think Jiffy Lube is an interesting metaphor to take a bit further. Jiffy lube is cheap, convenient, efficient, they get the job done and get you on your way. I don’t have to schedule an appt weeks in advance, I don’t have to get out of my car. That’s what I call patient centered!
I would not go to jiffy lube to have the charging system in my hybrid tested and worked on, for that ill go to the dealer/hybrid system experts and ill probably make an appt and wait in the waiting room.
Lets add a Jiffy Lube-like option or 2 to the wellness and disease care network that my insurance company will pay for, give me some options beyond my 12 minutes with “my” doctor.
Great post Dr! Change will start with the Doctors taking a stand! Best of luck to you, your patients and your practice.
This is my comment on Gawande’s article on efficiency, etc. I think he’s right, but that he misses the most important thing.
Really, I have spoken to some doctors who do not see Kaiser as some deity as described above. Monolithic entities eventually lose their souls and the focus is on “the organization” and not the people that compose it. We are learning that a bit with some big name businesses, and this near lust by entrepreneurs who used to be doctors just shows that profit margins do expose the less than stellar clinical care abilities that should drive practiced.
And evidence based medicine has been effectively corrupted by pharma and medical device industries, so I think this rote commentary to just embrace models to force PPACA agendas is, well, disingenuous to say it as nicely ad possible. But, it is not about what is best for people, but party.
Keep letting politicians, bureaucrats, and academicians set the bar for health care needs. Good luck finding the Lamberts to provide you compassionate, personable care. Hey , these nurse practitioner clinics can be named Jiffy Rube, for Rube Goldberg type applications.
Yeah, a harsh ending, but dumbing down the value of doctors does not deserve pleasant rebuttals. Some people make a living because they earn it. Just because others live on the same street does not mean these others deserve a share. This Democrat message that all are equal and entitled is as damaging as their counterparts believing “whoever has the most toys wins”.
Sheesh, we are doomed being pounded with these failed dogmas!
Man, typing on iPods is nuts, keep missing some “s” for “d” instead. Sorry.
Rob, you make a lot of sense in this and most all your blogs I’ve read. Like you, as a fellow primary care doc who also tends to spend a bit too much time to be practical, I see both the grave need to change the current system – but also the need to preserve its core values. I was surprised to read in Captain Sullenberger’s bio his value in the traditional autonomy and highly trained professionalism of the pilots – not just the standardization and recent safety measures which make commercial flight safer. I’m not sure any of us knows exactly how to remake the system yet; but I’m cautiously optimistic that things are getting there. I do think that the kind of role you have strived to serve – as well as your proposed new role – will both be preserved in the emerging system–much as the nuclear family persists in modern culture. I for one continue to hold out that hope; because there are some things I, like you, cannot do; but thankfully, many things we still can do.
Thank you. I agree that we need systems in place and that standardization is important. Yet just as the “no child left behind” was meant to do good, the tyranny of being measured can outweigh the benefit. I do think you need to attack a problem from both sides: from the systems approach which looks to make change gradual, and then the disruptive innovators need to look at things from a different perspective. I think medicine has resisted the latter too much and so stands to see a bigger disruption than it wants in the near-term, since the technology (i.e. The Internet) has been there to disrupt, but the payment system and communication tools have totally resisted this disruption, clinging to legacy ideas.
I’m very glad to hear that you plan to use PA’s and NPs so that you can extend your practice (seeing more of the patients who very much want to be part of that practice.)
As you say, “continuing care” needs a team.
I’m not sure why you are so skeptical about integrated delivery networks (IDNs) like Geisinger. “Integrated” usually leads to co-ordinated care. I know doctors who work in INDs, and they defintely don’t see patients as “data points.”
Unfortunately in Manhtattan (where I live) some doctors in solo or small
practices see patients not as data points, but as dollar ($$$$) signs.
I hope you’ll read (or very likely have read) Dr. Atul Gawande’s recent article
titled “The Cheesecake Factory.” http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande
If you haven’t read it, I think you would like it. Gawande is as sensitive to the needs of patients as you are. (He is one of the most patient-centered and humble doctors who I have ever met.)
At the same time, he realizes that in order to change our dysfunctional
system (which, as you say, kills some patients) we need large centers of excellence where doctors practice “evidence-based medicine.”
He makes a strong argument for “Big Medicine”–i.e. larger entities delivering
higher quality care.
Primary care docs in these places have their own patients that they see over a period of years (plus the parents and children or those patients.) At Kaiser in Northern California, several generations of patients have been on Kaiser,.
“Big Medicine”‘ does not have to be anything like profit-driven “big business”.
‘Unfortunately in Manhtattan (where I live) some doctors in solo or small
practices see patients not as data points, but as dollar ($$$$) signs . . . “Big Medicine”‘ does not have to be anything like profit-driven “big business”.’
Have you ever seen an EOB on a non-Medicare patient from Mayo? It’s big business like I’ve never seen anywhere else in medicine.
Your prejeudices are so enormous as to really undermine the good points you make.
I do think that the Kaisers and the Mayos have a role in this, but they can only reach a limited population just as the folks doing what I am doing are not going to reach everyone. I do think that as my practice grows, my intent is to service as many patients as possible (reasonable) using just me and a few nurses, moving on to PA’s and NP’s once I’ve extended myself as much as is appropriate. I don’t think that the need for physicians is that high, and that my model actually is best if done in a team approach (since care is done on the continuum, not just at encounters), not by just docs. I am not a big fan of IDN’s – especially ones that seem to control the market on multiple levels (as I said in a comment on a different post) as they remind me of Wal-Mart and how it takes over a market, eliminating competition. It does sound odd to have those monolithic institutions be held up by folks I know to be generally anti big-business. They can do a lot of good, but they have a bit too much power for my liking, and they view people a bit too much as data points.
Still, as long as the system is being challenged and is being pushed toward change, I don’t really care who does it. People I know have died from our system and its dysfunction. My decision to leave traditional care was not a financial one; I simply could not stomach the system I was taking part in.
Nationwide, more and more states are letting nurse practioners open community heatlh centers. It”s likely that this will happen in your state in the next couple of years. See http://centerforhealthreporting.org/blog/nurse-led-clinics-may-not-be-new-they-may-be-future972
(Health Reform legislation provides new funding for nurse practioners and for community health centers.)
All of the research shows that nurse practioners offer excellent care. (See
I realize that many primary care physicians are underpaid and over-worked. I believe that we should pay them more–and offer them more support.
But half earn over $176,000 a year (median income for primary care physicians) . Some earn as much as $300,000 or more. So while I totally sympathize with those on the bottom half of the PCP income ladder (some of whom earn just $100,000 have med schools loans, or take Medicaid patients) I can’t feel as badly for those on the top half, earning over $176,000.
Also, those who work for hospitals or larger organizations like Kaiser or the
Mayo Clinic have good support. Doctors at Mayo don’t make as much money as the best-paid primary care doctors in private practice (though they are pretty well paid), but at Mayo & Kaiser other people do the billing and run the business (hiring and firing, worrying about the cost of the real estate, malpractice insurance, etc. )
These doctors just practice medicine. This is why Kaiser has many more doctors applying for positions than it has slots.
Loving your first person reporting Rob. Best of luck!
What relationship? I’ve never had a doctor who even gave the impression of a quick chart review before entering the room. But then, I’d be one of the “avoiders,” or as I call it, not a frequent flyer. Not a worried well. Not a bundle of anxieties.
And the things I DO want to know, most doctors aren’t even trained in, like nutrition. Talking micronutrients here, not the macros.
Good on you, then, and wish there were more like you, for those who need it.
I hear you Kilroy! Every time I go it seems like the doctors walk into the office not knowing anything about me. Very frustrating! and the last time I was there, a communication error resulted in me getting charged an extra $300 in lab fees – and they just laughed it off like it is no big deal.
Michael Pollen (Food Inc.) says that only 10% of practicing doctors in the US have any education in nutrition. I don’t know how accurate that number is, but I like Mike and his books and movies.
While the burnout among primary care physicians is understandable (I’ve discussed it with my own doctor), what is most worrisome to me as a patient and parent is the trending inability to find primary care physicians who will take new patients. Combine this with the fact that I live in a state where the physician lobby has pushed the legislature to forbid nurse practitioners to open clinics that provide many of the same services offered by GPs, and it truly looks as if those who control the industry are set on leaving patients out sick in the cold.
GOOD. Out of the way “healing arts” and make way for “industrialized medicine” in the best possible sense of the word. I don’t want smiles, hunches, and haphazard experimentation. I want a consistent, high quality service delivered at a reasonable price for a change. Advance the science…
Sucks, doesn’t it? It’s the reason I held on at my previous as long as I did. And I still miss my patients, a year later. Depending upon your metaphysics, people are the only real, eternal entities we encounter in this world.