I was furious. I went to the office on Sunday to see what work the electrician had done (and to discuss decor issues with my wife), and my office was deserted. The inspection was supposed to happen on Monday, allowing me to get furniture in the office and see patients on Tuesday. A text message back from my contractor said that the electrician would be in on Monday and the inspection would happen on Tuesday. Apparently he didn’t realize I was so ambitious (read: crazy) to see patients so soon after construction was completed. Apparently my panic wasn’t obvious to him.
On Sunday I broke with my usually placid demeanor (read: codependent) and expressed my emotions on the issue quite clearly. Many panicked calls from supervisors and electricians later (read: effusive apologies and promises to fix things), and the reality had not changed: inspectors would not be coming until Tuesday, and so my opening, already a month after I planned, would wait one more day. What a terrible way to start my new practice: canceling appointments on my first day.
Then I realized something: I don’t need an office to do my job. One of the things I am trying to overturn is the practice of requiring all care to be conducted in the exam room. Why can’t people talk to their doctor on the phone? Why can’t they email questions? Why not videoconferencing for visits? Why not texting me a picture of the rash (depending on the location, of course)? Why hold my expertise hostage to the ransom of an office visit? So then what’s the big deal of not having an office?
So on Tuesday morning, Jamie my nurse and I set out for our first office visit, grabbing whatever we thought we’d need in the boxes of supplies we ordered, climbing in the Rob-Mobile (a 2000 Mazda Protege called “Zippy” which has 160,000 miles on it) and driving to the homes of my first two patients. What a wonderful way to start my new practice: not having to cancel appointments for the triviality of having no office, instead doing something very old-fashioned: house calls. Both couples (Medicare patients who couldn’t stand losing their doctor) greeted me with warm hugs and expressions of disbelief that a doctor would come to their home. It turned out that being at home gave me a much better chance to look at medication lists, for them to run get hospital discharge summaries, and to have these lovely people be completely at their ease while seeing the doctor – something that doesn’t happen much in our wonderful health care system.
I spent about an hour with each of them, straightening out confusion on medications and agreeing to work on getting things straightened out. One husband showed a spreadsheet he printed out with his wife’s blood pressure and daily weight. I suggested he email this to us daily, which he did the first day, but then we decided to use a Google Doc spreadsheet that would alert us whenever he added new information. He did that today and it worked great (although the Google Doc website strongly encouraged him to install Chrome, which confused him). We will probably set up spreadsheets like this for more of our patients, perhaps for diabetics to input their blood sugars and whatever else we think will help.
So, what started out as another in the string delays making me miserable (read: wallowing in self-doubt and whining), ended up as a delightful day opening my new practice by abandoning the “normal” way of doing things for a way that worked better. It’s a perfect symbol to what I want to do in this practice. I told Jamie (when I was trying to convince her to join me) that we have the chance to ask the question: “wouldn’t it be great if we could….” and then do it.
The days that have followed in the office have been a delight, spending time with people and getting the system figured out. We haven’t over-scheduled ourselves, so we have time to figure out solutions to problems we run across. There are still huge problems we need to solve, but given our first day, I think we are firmly situated outside of the box, a place where it seems a lot of good ideas live.
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.
R u back to using paper, or simply using word documents? I am glad to see that your approach to meaningfully useful care is different than that of the ONC braintrust.
An IT person sounds like a fantastic idea. Maybe even some med students/health professionals in training could help-might be a good way for them to keep this in perspective as they undergo training. Just a thought.
How do you transport your meaningfully useful EMR? Orrrr, are meaningfully usefule electronic records less meaningful for your meaningful face to face visits and hands on examinations?
You do realize that (as I have written before) I have abandoned “meaningful use” and have been quite critical of it (to the point that I got a call from ONC to discuss my thoughts). I am not sure why you are taking this up with me, but in doing so you undermine any point you are trying to make.
Yes, I will do it when it seems the right thing. Another cool idea I had was to hire a geek to go around to people’s homes and troubleshoot their computer problems. The problem with tech is that it confuses people, and having someone making sure their computers are set up properly with easy-to-find shortcuts would be real helpful.
Great idea. A little coaching goes a long way.
Tell him to look around while he’s there to insure they actually know what they are doing. I have seen daily questions as part of the “MedBuddy” monitoring regimen (designed to track progressive dementia, weight and vital signs) being answered by the spouse, which defeating the purpose. As Yogi Berra said, You can see a lot by observing.
**Applause, applause, applause….**
**Sustained cheering…. yelling “You GO, Doc!!!”**
Idea/ suggestion: even after you get into your address, occasional house calls might be a good way to keep your batteries charged, not to mention the happy surprise of the lucky patients.
In another post Dr. Kernisan tells about her geriatric house visits. Very impressive.