Tag: primary care

Live From the Garage

Jul 7, 2013• 2

By Rob Lamberts, MD

Hi. It’s me again. No, I’ve been doing fine; my writing slow-down is not due to calamity, catastrophe, apostrophe, or even syndactyly. I’ve been working hard, working like a dog.

So, what’s been so all-consuming that I can’t sit down and write? My computer system. I know it may sound nerdy and lame, but I’ve been putting every ounce of my creative energy into building a system. It’s driven by two main things: trying to give the best care I can, and doing so while avoiding personal bankruptcy. Fear of the latter is strong motivation. So I’ve been pouring myself into this task like nothing I’ve done before. My goal is to build a system that will:

1. Organize information. My care will only be as good as the information I have. It should be presented in a way that gives me just the right amount of information, with the ability to get more when I need it.
2. Cope with the flood of incoming information. Take the piles of communications coming in and route it to the proper storage place, use the information to make decisions, communicate it with the patients, and decide on follow-up. This is an enormously difficult task.
3. Integrate with every communication tool possible. Most doctors don’t do this because they rely on office visits for income, and that hinders the care they give. Communication is care, and I want to have good communication that is enlightened by good information.
4. Create a shared medical record with my patients. I am convinced that my patients will get the best care if they have access to their information. But this needs to be done in a way that is both simple and secure. I want “one stop shopping” for people to communicate or look at their records.
5. Keep my books. I don’t want to go bankrupt and don’t want to go to jail for keeping disorganized books. It’s possible to get freed from the fear of Medicare audits, but not from IRS audits.
6. Organize the future. There are far too many missed opportunities for care. Integrated task-management (shared between patient and their care team) is my goal.
7. Grow with me. If I accomplish 1-6, my practice will grow. I don’t want that growth to outpace my system.

So far I’ve been focusing on 1, 2, and 5, with eyes on the rest. I’ve made great progress, but there’s much more needing to be done. My ultimate goal of this is to build working prototypes of both this practice model and the software that will enable it to be more than just a side-show, an alternative for doctors who want to escape. I believe that this is truly better care. It is focused on what the patient wants: to be healthy and to spend as little time thinking about their health care as possible. It’s working so far, but it can be much more than it is now.

What the EMR Saw

Jul 3, 2013• 2

By Country Doctor

Lately, my virtual inbox in our electronic medical record has seen a surge in requests for prescriptions for the vaccine against Herpes Zoster, shingles. This has made me think a lot about our responsibility as physicians to inform patients about the evidence behind our recommendations – but who informs the patients when doctors are kept out of the loop or put under pressure to prescribe without seeing the patient?

What has happened is that our local Rite-Aid Pharmacy started to give these shots, covered by many insurers, but still requiring a doctor’s prescription.

I cannot give the shots in my clinic, because as a Federally Qualified Health Center, we are reimbursed at a fixed rate. The shingles vaccine costs more for us to buy than we charge for an entire office visit. I used to have the discussion about the shot, and would give patients a prescription to take to the pharmacy if they wanted it.

The pharmacy can give the shot at a profit, because it is considered a medication, just like a bottle of Lipitor.

The new system creates a bit of a dilemma for me. I get a message through the pharmacy that the patient wants the shot, and I don’t have the opportunity to sit down and review the effectiveness, side effects and long-term efficacy according to the available evidence with the patient.

For example, the shingles vaccine only cuts the risk of getting shingles in half. This is about the same effectiveness as the flu vaccine, but far less than, say, the vaccine against smallpox, which has now been eradicated.

Most patients are very surprised to hear about the 50% efficacy when I catch up with them at some later date; so many health care interventions are portrayed as both completely effective and absolutely necessary.

I see my role as a primary care physician as a guide and resource for patients, who are bombarded with overly optimistic claims and recommendations by mass media, drug companies and retailers.

How Patients Can Assess the Quality of Their Outpatient Care

Jun 27, 2013• 6

By Leslie Kernisan, MD

Even before I launched my geriatric consultation practice, I found myself often pouring over another doctor’s outpatient notes, trying to explain to a patient what the other doctor was doing.

Sometimes these other doctors were specialists to whom I’d referred the patient. But often they were simply clinicians – either previous PCPs or currently involved specialists — whose involvement with the patient predated my own.

Not every patient had questions and concerns about what their other healthcare providers were saying, and doing, but a fair number of them did. And family caregivers, in particular, were often concerned that perhaps their older loved one hadn’t been getting the “right” medical care.

These are, in truth, legitimate concerns patients have. In a busy outpatient setting, doctors often don’t have the time to explain the assessment and plan to a patient and family. And in many cases, the care that clinicians provide may not correspond to best practice guidelines – if applicable to the situation – or to the patient’s preferences and values.

So if you are a concerned patient or family member, and you’re not entirely sure about the medical care you’re getting, what to do?

Should you:

Look up the provider’s quality ratings online, through a government, non-profit, or other website?
Figure that the ACO or payer is on top of it, now that we are moving to pay-for-quality and fee-for-value?
See what other patients have said about the provider’s care?
See how many doctors are referring to the provider in question, and assume that if many doctors refer to this clinician, the clinician must be good?
Look up your medical problems online, and try to determine for yourself whether you’d been getting the right medical care?
Get a second opinion from another doctor?

My guess is that most patients and families end up trying one – or both – of the last options. In this post, I’ll explain why I’ve come to believe that facilitating second opinions is integral to empowering patients, and to improving the quality of outpatient care.

Why seek a second opinion

I don’t know about you, but when I’ve found myself trying to solve a problem in which I lacked adequate expertise, I’ve turned to a professional for help. (I haven’t had to do this for medical reasons in the past decade, but have done it for issues such as home renovation and website design.)

And in many cases, after meeting with an expert for a while, I’ve then turned to yet another expert to get an additional perspective on the issue at hand.

The Art of Measuring Blood Pressure

Jun 24, 2013• 9

By Country Doctor

Edna Lavoie has had horrendous blood pressure readings for several decades, but she has never had a stroke or heart attack. Her eye doctor swears her retinae are healthy. Whenever she takes a pill that even begins to normalize her blood pressure, she complains of severe dizziness.

Dwayne Lieber’s home blood pressure cuff never reads anywhere close to our manual office sphygmomanometers, even though it is a good brand that usually seems quite accurate for our other patients who own the same model.

Donald Dickinson and Jane Green seem to be a pair of Jekyll and Hyde characters as far as their blood pressures are concerned; every other visit they seem to have a normal blood pressure in the 125/80 range and the rest of the time their systolic pressures are between 180 and 200.

Blood pressure measurements are routinely done every time a patient visits the doctor and hypertension is one of the most common diagnoses in primary care. A patient’s blood pressure is sometimes done with an automatic cuff, sometimes by the nurse or medical assistant and sometimes by the doctor. It is actually a complicated matter, fraught with problems and potential pitfalls.

My Name is Rob. And I’m a Recovering Doctor.

Jun 22, 2013• 13

By Rob Lamberts, MD

Yeah, I am recovering…doing a lot better, actually. Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies. I’ve had to learn how to manage my own money (now that I can’t count on them to bail me out any more), but things are looking a lot better. I am beginning to see how much better it will be to be on my own.

The key was when I realized that the system wasn’t going to change no matter how much I accommodated its unreasonable requests. I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients. But I’ve come to see that all the promises to take care of me and my patients were written in sand, and that it couldn’t resist the temptation to cheat on me. I tried to do what it asked of me, but as time went by I couldn’t take how dirty it made me feel.

I want to believe it was sincere when it told me it wanted to change. I think at its core, it wants to help patients and doesn’t want to go on those spending binges. But no matter how sincere the promises sounded, I was always left alone as it threw its money at every sexy treatment, procedure, or drug that walked by. Then it would go off on tirades about how much I spent and that I didn’t do enough to keep to our budget. It was always my fault. I think it’s just easier to pass blame on others than it is to do the hard things necessary to really change. To be honest, I think it was terrified at how much real change would hurt.

But I can’t sit around and wait for the system to change any more. My patients were getting less and less of my time, and I was getting to the breaking point. I know there are a lot of other doctors who are willing to do whatever the system asks, but I can’t sit around and watch it self-destruct. It’s not what’s best for the system, for us doctors, and for our patients. Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons. I just hope that happens soon.

The Doctor is Viral

Jun 4, 2013• 5

By Rob Lamberts, MD

A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments. It’s a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don’t get better. There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them. If you haven’t done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.

Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger? The corollary to this question is perhaps more important: what can be done to heal this broken relationship? A reader of my last post (about viewing patients from a different perspective) asked me point blank: ”Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?”

I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt. Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit. No, I’m also not putting myself down out of false-modesty; I’ve made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags. Of course, as my best friend (and best man) used to remind me: “remember, I am doctor scum bag to you.”

Now, I don’t lay the whole problem at the feet of the fallen nature of mankind. I believe that our system of “health care” doesn’t just fail to counter the flaws of our nature, it actively promotes bad relationships. It does this by:

Reducing patients to “problems.” The payment system requires we use “problem codes” to classify patients and justify visits. The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education. Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure. Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love “interesting cases.” But nobody ever wants to be an “interesting case.” Ask any of the people who commented on the blog post. Boring is better.

The Good Doctor’s Mind Map

May 30, 2013• 14

By Rob Lamberts, MD

This, apparently, is a map of my mind. It’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable. Actually, “Rob’s mind” and “vegetable” are often used in the same sentence.

Someone suggested to me that I may benefit from mind mapping. I don’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things. I write that way, I solve problems that way, I even play music that way. Maybe it’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction. Like I said: it’s hard to describe.

Anyhow, I was thinking about task-management with my patients, wondering what’s the best way to think about it and what is the best design for a system helping with this. Task management is perhaps the most important thing in health care that’s never talked about. Maybe that’s because it makes doctors feel less special, reducing our “magical” knowledge and “miracle” cures to algorithms and checklists. Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).

The Doctor Is Happy

May 23, 2013• 17

By Rob Lamberts, MD

It feels dangerous to write this, but…my practice seems to be working.

I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning. I don’t know why I wrote that.

But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.

The past few weeks have been totally consumed by my need to have an underlying system of organization. After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision. Despite being totally obsessed with how data tables connect and whether I’ve left a parenthesis off of a script I’ve written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor. I’ve also found some strong local tech talent who gets what I am doing and yet doesn’t simply see the market potential for my software.

The reality is, my whole focus is on the practice model, and that model seems to work. As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem. We continue to get several new patients signing up every day, and now the reluctant spouses of establish patients are joining (which is a very good sign – for both my practice and for their marriages).

Let me appease the gods and state clearly that this is by no means a sure thing. There are many, many things that could go wrong. A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck). I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas. We all know the llama apocalypse is happening; it’s just a question of when, not if. So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).

The DIY Electronic Medical Record

May 13, 2013• 17

By Rob Lamberts, MD

There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber. Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father. Why not hire someone to come fix it? I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet. So this hole was giving me shame in surround-sound.

I attempted to fix it the hole last year, even going to the degree of asking for a router table for my birthday. Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly. Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.

I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!

This home project is actually a late comer to the DIY party I’ve been holding for the past few months.

Don’t like your practice? Build your own from scratch!
Don’t like the health care system, build a new one!

My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.

The Problem-Oriented Medical Record

May 10, 2013• 10

By Leslie Kernisan, MD

[This post is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.

The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.

Specifically, the Weeds make the following points:

Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.

Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.

For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.

Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”

Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.

In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.