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.
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).
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).
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.
[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.
It’s been a long time since I wrote a post. My life, you see, is incredibly dull and boring. There has been so little to write about that I’ve been at a loss.
No, actually that’s a load of crap. It’s become a fantasy of mine to have such boredom. In reality, my life is as un-boring as it could be. It’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.
So how’s my new practice going? In some ways things are going about as well as they could. My patients are amazed when I answer their emails or (even more surprisingly) answer the phone. ”Hello, this is Dr. Lamberts,” I say. This usually results in a long pause, followed by a confused and timid voice saying something like, “well…uh…I was expecting to get Jamie.” Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem. It’s amazingly efficient to answer the phone.
Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly. The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine. It’s also not that I am so busy at 250 patients that growth is difficult. In truth, when we aren’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse. In that sense I’ve proved concept: that it’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.
Which brings us to the area of conflict, the crisis point of this story: the system I have in place. The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.
The Passenger Pigeon. The Dodo bird. The primary care clinic nurse. All are extinct, driven out existence by a changing habitat, competition and over-hunting. Ask the average person when they’ve last seen these species and you’re likely to get the same baffled look that your columnist’s spouse gives when she’s asked about her compliant husband who does what he’s told.
Yet, this columnist wasn’t aware of the primary care nurses’ total absence until a recent conversation with a nurse-colleague who has been helping smaller physician-owned outpatient offices develop local care management programs. “There are no ‘nurses'” she said. “They’ve all been replaced by office assistants and the docs are trying to get them to do the patient education.”
Which makes sense. While articles like this have been lauding health care “teams” made up of physicians and non-physician professionals for years, the fact is that poor reimbursement, the allure of other specialties and lifestyle has long-hollowed out these clinics, often leaving a skeleton crew of part-time medical assistants shuttling patients in and out of the patient rooms. True, some of the larger health systems with a stake in primary care have kept nurses in the mix, your columnist thinks that’s merely part of a market-preserving loss-leader strategy.
This columnist looked for medical literature on the topic. He can’t find any surveys or other descriptions on how nurses have largely disappeared from the primary care landscape. If he’s wrong, he wants to hear from his readers.
If true, what are the implications?
A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.
Now, not everyone believes that a shortfall of PCPs is a serious problem.
However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.
So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.
I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.
Walgreens, the country’s largest drugstore chain, announced on April 4th that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The Nurse Practitioners (NPs) and Physician Assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose staff help manage already-established chronic illnesses or are limited to testing for and treating minor, short-lived ailments like strep throat.
A one-stop shop for toothpaste, prescription drugs, and a diabetes diagnosis? The retail clinic phenomenon has its appeal: it allows patients convenience and better access to care through longer hours and more locations than our health care system now provides. Walgreens leaders bill their latest offering as a complementary service to traditional medical care. They envision close collaboration with physicians and even inclusion in Accountable Care Organizations, according to reporting by Forbes’ Bruce Japsen (though it’s not clear how the retailer would share the financial risk or savings in such a model).
It’s official. The road sign clearly welcomed me here. I guess all business start-ups have to go through this town (Hell).
What? No bravado? No chest pounding about how my ideas will change health care while making patients smell as springtime fresh? Nope. None of that. It’s hard to get excited about ideas when only money pays the bills.
Having now left the safe confines of my leftover earnings from my old practice, I am now supposed to be self-supporting. Two big things have caused this to not go as smoothly as I have planned:
- My construction took twice as long as I expected.
- I have yet to find a computer system that doesn’t make me want to pound on my desk and wantonly overuse the word “inconceivable.”