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Dropping Out

• 111

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.Continue reading…

Patient Rights

• 5

By Rob Lamberts

I was talking to a patient a few days ago who was raving about a local grocery store.

”They get it,” she said. ”They understand how to take care of their customers.”

It made me think about how far medicine has drifted away from the same idea. Ironically, despite the fact that our “customers” (people who pay us for our services) are seeking us so we can “take care of” them, we do a lousy job of taking care of our customers. It has been an obsession of mine since I started practice, but it has been something that has been increasingly difficult to accomplish. I now have to fight against the need to meet “meaningful use” criteria so that I can have time to make the record meaningful and useful to my patients. I have to fight against the need to conform to “medical home,” criteria so that I can make my practice the place my patients see as their ultimate medical haven.

The more the government and insurance industries push me toward focusing on my patients, the less time I have for my patients because of the need to meet criteria proving that I am caring for my patients. It’s a mess.

So I went back to my roots. What do I really think should be the rights of my patients? Here is a list that I made:

Patients have the following rights:

The right to have access to care when it’s needed
This does not mean the care is done in the office either. It can be done over the phone or via computer.
The schedule of the office should accommodate the patients’ needs as much as is reasonable to expect.
The right to have care that is convenient
They should not have to wait to be seen or wait on the phone to be heard

Continue reading…

Buckle Up

• 6

By ROB LAMBERTS, MD

Rob Lamberts, MDLipitor can destroy your liver.

Back surgery can leave you paralyzed.

People who take Chantix might kill themselves.

You may never wake up from a simple surgery.

These statements are all true.  They also are very confusing to many of my patients when I am prescribing drugs or recommending surgery.  What should they do when they hear such bad things about drugs, surgeries, or procedures?  How much do they risk when they follow my advice?

It’s a hard world out there, with the attorneys advertising on TV about drugs my patients have taken, with the websites devoted to the harms brought on by a drug or an immunization, with Dr. Oz and other seemingly smart people telling them things that are contrary to my advice, and with friends and neighbors who give dire warnings about the dangers of following my advice.

There are so many voices out there competing with mine, that I sometimes spend more time reassuring than I do anything else.  A doctor in our practice believes that Dr. Oz ought to issue a statement to doctors whenever he voices another controversial opinion as gospel fact so that we can be ready with our counter-arguments.

What can doctors do?  We can’t quiet the other voices that speak against us.  In truth, those voices have an important role in preventing us from becoming comfortable and dogmatic in our beliefs.  So how do I combat such a heavy current against our advice?

By talking about seat belts.

Seat belts can kill you, you know.  You can be trapped inside your car by your seat belt and not be able to get out before your car explodes.  It’s not a fable; it can really happen.

You may be sealing your fate to die terribly every time you buckle your seat belt.

Continue reading…

The Awkward World of Private Insurance in the UK

• 10

By Bob Wachter, MD

I remember reading an article that observed that systems of universal insurance – which need to put their energy into providing a “decent minimum” for the masses – must also offer a “safety valve for the wealthy disaffected.” Canada bans private insurance for basic hospital and medical care services. So, when affluent Canadians want “the best,” some of them pop across the border to Cleveland or Ann Arbor.

But from the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. Here’s how it works:

The insurance part isn’t too difficult to understand. People living in Britain can obtain private insurance, and about 10 percent of them do. About one-third of people with private insurance purchase it with their own money, while the rest receive it as a benefit of employment. Many of the big multinationals provide such insurance, either to all their employees or to senior executives. It’s considered a plum perk for everyone, and most expats coming to work in the UK consider it an essential benefit.

Continue reading…

Errors of Omission

• 17

By ANONYMOUS MD

I am a rural Family Physician who has been in solo practice for more than 22 years.  I am neither a technophobe nor an information technology Luddite.  I have been using electronic prescribing for over 6 years and am in the market for an EHR that is net-based, scalable, interoperable and linked to a nationwide patient database.

While I wait, over the years I am seeing more and more patient care that is less co-ordinated and even thwarted by the very health information technology (HIT) that is supposed to increase efficiency. In my opinion, this is leading to decreased information transfer that is wasting precious time and putting patients at risk with errors of omission.

I will give anecdotal and real examples of HIT run amok that I suspect are more common than generally appreciated.  Alarmed by the lack of awareness of the potential frequency of these errors, I am writing this hoping that the blogosphere can somehow counter the momentum of an all-powerful HIT cerebrosphere.

1.     e-Prescribing (ERX): While mandated alerts about potential drug interactions in this software is often life-saving, it can also be life impairing.  There are two reasons for this:  1) at point of care, the warnings are just too darn sensitive and I’m being conditioned to ignore 90 percent of them.  I am afraid that this will cause me to click the “ignore” pop-up at the wrong time.  For instance, doxycycline and Dilantin have an interaction and a prescription of one in the presence in the other always prompts a warning.  When I researched this, I found the plasma concentration of doxycycline is decreased by a clinically negligible amount.   2) at the pharmacy window, the warnings can override physician judgment. A colleague of mine described to me how he prescribed a fluoroquinolone antibiotic to a patient on Coumadin and, aware that there was an interaction,  ordered the appropriate follow up testing and dosage modifications.  The pharmacist not only refused to fill the prescription,  they also did not notify him.  Instead, he asked the patient to call the doctor.  Two days later the patient was admitted to an ICU with life-threatening sepsis.  In both cases, needed prescriptions were omitted.

Continue reading…

The Last Best Hope

• 3

By MARGALIT GUR-ARIE

According to the recently published CMS Accountable Care Organization (ACO) rules, an ACO needs to care for at least 5000 Medicare beneficiaries. Theoretically, two primary care physicians and a nurse, practicing in a garage, or cottage, in Boonville Missouri (yes, there is such a place), seeing nothing but Medicare folks, could become an ACO. Of course, they would have to set up a business entity with a board of directors, hire a couple of lawyers, several accountants and contract with a hospital or two and a score of specialists, and be ready to accept financial risk for their patients in a couple of years; all this on top of seeing twenty to thirty elderly and complex patients every single day. Nope. Not going to happen.

ACOs are for the big boys, hospitals and/or extra-large multi-specialty groups, to set up, manage and perhaps eventually benefit from. Big systems, as we all know, enjoy economies of scale, are better able to manage and coordinate care, and are therefore uniquely equipped to solve our health care crisis by providing better care at lower costs, and ACOs are just the vehicle by which these systems will be rewarded for all that good work. If you care for people in a small primary care practice, you could bite the bullet and sell out to a large system, or you could retire if you are one of those last standing dinosaurs, or you could become a concierge practice, or you could sit still and watch your practice dwindle and die, or you could buy an EHR, which is the last best hope to keep primary care independent.

Science, the type of science that employs mathematical hypotheses, theorems, proofs and equations, is timidly asserting that the emperor is in need of some serious clothing. A 2009 paper published in a non-medical, non-health care venue, “examines the staffing, division of labor, and resulting profitability of primary care physician practices”. The authors who are researchers from the University of Rochester and Vanderbilt University conclude that “many physicians are gaining little financial benefit from delegating work to support staff. This suggests that small practices with few staff may be viable alternatives to traditional practice designs.” Although I did not check the math, which is extensive, I would have expected that such controversial conclusion would make headline news in health care policy forums for at least two or three days. It did not.Continue reading…

My EMR Reality

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By ROB LAMBERTS

OK, I am an EMR fan-boy, I will admit it.  I seem real “rah rah” in my approach to computers in the exam room, and to many I seem to have my head in the clouds; I seem to be out of touch with reality.  In response to posts I have written on the subject, comments have been thus:

“I couldn’t see as many patients if I had an EMR.  It would slow me down too much.”

“Using an EMR makes doctors ignore their patients and focus too much on the computer screen.”

“EMR is too expensive for the small practice or primary-care physician.  It will reduce their income in a time when it’s hard enough to function as a PCP.”

Yeah, yeah, yeah.  This is very familiar to me.  It’s also wrong.

True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away.  True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.  True, EMR start-up expense is high enough to make doctors, especially PCP’s, wonder if they can afford the cost in this time of austerity.

I understand these things better than most people give me credit for, because I have lived through each of these troublesome sides of EMR personally.  Here is my EMR story:

I started thinking about using an EMR in 1995, when I saw how difficult it was for me to keep track of information in the record.  This came to a head in 1996 when the result of a test was missed, causing harm to a patient.  The problem wasn’t in the thought-process or in the intelligence of the doctor; the problem was from flaws inherent in a paper medical record.

I was practicing with another PCP at that time.  We were employed by a hospital, but were growing increasingly frustrated with their lack of interest in running our practice efficiently.  So we left them in 1996, bucking the trend at that time of hospital ownership of practices for the sake of personal control.  It put us under far more financial pressure, but the control made it worthwhile for both of us.

Feeling the sting of the missed test result, and feeling the empowerment that self-employment brought, my partner and I set about to look at EMR products.  My brother-in-law worked in a nearby practice that had already been on EMR for a few years and was functioning far more efficiently than we could ever hope with our paper record.  We both visited his practice and saw just how much we could gain from a computerized record.  Once we saw this, the question was not whether we were going up on an EMR, it was which EMR product we’d choose.

We narrowed our choice down to two products: one that was well-known and well respected, but more expensive; and one that was cheap, slick, but had a very small user-base.  We were sorely tempted by the slick sales presentation, but listened to our better judgement and went with the more established product.  After buying the product, the cost would end up being $1000 extra per month per physician (given the terms of the loan we could secure for an $80,000 installation).  We both winced at this, given our short time of independence, but then my partner boiled it down very simply:

  • How much do we earn on average per patient visit? We shot low, and said $50 per visit.
  • How many days do we work each month? Both of us worked 20 days per month at that time.
  • How many extra patients would we each have to see to pay the $1000 monthly loan payment? One extra patient per day would easily cover our expense.

One patient per day?  That’s all??  It made the decision quite easy, and it made the ROI quite easy to grasp.  Our goal was to use the EMR in such a way that it would improve efficiency (something we had seen in my brother-in-law’s practice) and focus on other benefits of EMR once we had it paying for itself.  We reached that goal easily within the first 6 months of using our EMR, and exceeded it soon thereafter. Neither of us saw ourselves as slaves to the EMR, we saw the EMR as a tool.  Consequently, we found our own means of accomplishing our goals, using the EMR in ways that other users hadn’t considered.

  • We didn’t care about being paperless, the goal was efficiency and quality of care, not saving trees.
  • We didn’t like the standard templates supplied by the EMR vendor, so we made our own.
  • Whenever I became frustrated with a process, I talked to my partner and then changed the template to fix the process.  I soon became an expert at template development, gaining prominence among users of our product.
  • When the process inefficiency was not template-driven, such as the use of nurses, the process of answering phone calls, or other common situations encountered in our office, we talked with our office manager and staff and came up with a solution.  Our EMR gave us a bunch of options for solutions we would have not had without computers.
  • We quickly realized that fixing too many things at once created trouble.  I adopted the philosophy: “a good idea at the wrong time is a bad idea.”  So we worked to prioritize problems in terms of their seriousness and how easy the solution was.
  • Once we had an efficient workflow, we realized there were incredible gains to be had from a care-quality standpoint.  We were not paid more for good quality, but our efficient workflow afforded us the opportunity to focus on it nonetheless.  That may seem backwards for non-clinicians, but it is the reality of private practice.  In truth, our quality had already gotten significantly better simply from the improved organization of our records and instant accessibility anywhere, any time.

Forward to 2010, and here is where we stand:

  • I see on average 25 patients per day, working 4 days per week.
  • We have 5 Physicians and 2 PA’s.  The efficiency of our office has increased with each additional provider, as we haven’t had to increase overhead much at all with each addition.
  • We no longer see patients in the hospital (except pediatrics, which is a small number), and we don’t do many in-office labs or other procedures.
  • Despite this, our income has been very good – well above the national average for PCP’s.
  • On quality measures, our practice has excelled every time we’ve been measured.  We easily qualified for NCQA diabetes certification, and our measures for prevention are impressive – with colon cancer screening, childhood immunizations, adult immunizations, and cholesterol screening far above national averages.
  • Most importantly, I give my patients the time they need.  I make a point to not rush my visits.  Each visit is given 15 minutes, no matter of the type, but visits that require 30 minutes are given that time (which is usually offset by the 5 minute sinus or ear infection visit).

That is why the arguments against EMR ring hollow to me.  I see it like the arguments people give against exercise:

“I don’t have enough time to devote to exercise.”

“I hurt after I exercise, and basically feel lousy.  I can’t afford to feel that bad.”

“I need my sleep in the mornings and am too tired at night to exercise.  I’m doing OK without it for now.”

Yes, I sympathize with these arguments.  I have made them all myself, and still struggle to exercise regularly.  But anyone who says people are better off not exercising are just plain wrong.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, 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.