Thank you, my patients for all you have done for me. Thank you for the encouragement and support. Thank you for believing in me enough to join me in this crazy new way to do health care. Thank you for giving me the honor of being the one you call “my doctor.”
Your trust motivates me to work harder to justify that faith in me – a faith I often don’t have and, one I certainly wouldn’t have without you. I hope and pray this holiday season is a blessing to you. May you find peace in this time of year so often without peace.
May you also have a happy and healthy new year. May you stay out of the ER, away from the hospital and, yes, away from doctors. May you have no need for lab tests, procedures, x-rays and medications (and if you must have medications may they be very cheap.)
If, however, you do get sick, remember that I am here to help you get well, feel better or avoid getting any worse. And if I cannot do any of these, I will still be there to stand by your side through the hard times, and to offer whatever comfort I can give. Doing these things is what it means to me when you call me “my doctor.” It is why that is such an honor.
Again, thank you for all you do for me. God bless you.
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 an earlier version of this post first appeared.
My older brother is also a doctor, but not a PCP like me. He’s a specialist: a limnologist. If you have problems with blue-green algae in your lake, he’s the man to see. Limnology is the study of lakes, and fittingly, Bill works in the “Land of a Thousand Lakes” as a professor in fresh-water ecology.
I’m not sure he’s thinking of switching over to direct-care limnology. I’ve been afraid to bring it up.
We do have a lot in common in our professions, as we both see a mindless assault on the things we are trying to save (patients for me, lakes for Bill). My frustration with our health care system is matched by his anger toward those who deny global warming and the harm humans are causing on our world.
Just as he can get my blood pressure up by asking if his child will get autism from the immunizations, I simply have to suggest this week’s cold weather as proof against global warming to raise his systolic pressure.
So it was notable when I heard a rant against an unexpected target: “You know the Gaia hypothesis?” he asked. “They think the world is a ‘living organism’ that works toward a ‘balance’ to maintain life. They believe that humans act against nature, and so are responsible for everything that’s wrong with ‘mother earth.'”
“It’s total bullshit,” he went on to explain, not waiting to hear if I knew what he was talking about. “Do you know that when trees appeared on the earth, they caused a mass extinction (called the Permian Extinction)! Trees! There’s no mystical ‘balance of nature;’ it’s always in a constant state of flux, of imbalance.”
Let me make this clear: Bill is not saying that it’s OK that we are harming the earth, nor is he trying to absolve us of our responsibility for what we are doing. His beef was with the notion that there is some kind of ‘balance’ of nature, when the evidence clearly points to the contrary. The result of this belief is that that there is somehow an imputed moral goodness from this ‘balance’ (resulting in the idea of ‘mother earth’), and a subsequent implied immorality to any assault on our mother’s sacred ‘balance’.
This has come to mind as I have had significant changes to my thinking about giving good care my patients, especially as it applies to the area of “wellness”. Since leaving my old practice, which was immersed in a world of ICD (problem) codes and CPT (procedure) codes, I have shifted my thinking away from a medical world where every problem demands a solution. I have moved my thinking away from reacting to every thing that is going on at the moment, and toward the bigger picture. I am focusing less on problems and more on risk. I am focusing less on solutions, and more on responsibility.
I have felt from the start that this practice model is far better than the one I had in my former life, including:
Better experience for the doctor
Better experience for the patient
Better care quality
Savings for the patient and for the system.
The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice. This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against).
Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get. This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model). I realize that this does not constitute a proof of concept, but it is not without meaning.
PATIENT 1. MEDICARE. AGE: 90+
Pt had a head injury and came to my office wondering if they should go to the ER. I assessed the mental status did an exam, determining that this was not necessary. Set up imaging study that day (CT without contrast) which came back negative.
In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this.
Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price.
Savings: Avoided ER with head injury work-up. Cost: ? (More than $300 by far).
He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.
He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here. He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like. First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits. Then there is my guitar just behind me. He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music. Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person. He seems intrigued.
He owns a business, which is a service type business like mine. Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it. I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine.
He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report. Spin happens. But as we talk, there is much to find in common, and he warms up. His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.
My worst night as a doctor was during my residency. I was working the pediatric ICU and admitted a young teenager who had tried to kill herself. Well, she didn’t really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.
On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning. We did everything we could to keep her alive, but without a liver there is no chance of survival.
Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests. I told the ER doctor to check an acetaminophen level and, sadly, it was elevated. She too had taken a handful of acetaminophen at an earlier time. She too was lucid and scared at the start of the evening. The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant. I got the call later that next day with the bad news: she died.
The saddest thing about both of these kids is that they both thought they were safe. The handful of pills was a gesture, not meant to harm themselves. They were like most people; they didn’t know that this medication that is ubiquitous and reportedly safe can be so deadly. But when they finally learned this, it was too late. They are both dead. Suicides? Technically, but not in reality.
For these children the problem was that symptoms of toxicity may not show up until it is too late. People often get nausea and vomiting with acute overdose, but if the treatment isn’t initiated within 8-10 hours, the risk of going to liver failure is high. Once enough time passes, it is rare that the person can be cured without liver transplant.
According to a recent ProPublica investigation, acetaminophen overdose is the #1 cause of liver failure in the US. And between years of 2001 and 2010, 1567 people in the U.S. were reported to have died by accidentally overdosing.
So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually.
Here’s my answer to that question:
What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
What I need: No focus on billing codes, instead a focus on work-flow.
What medical records offer: Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information.
What I need: Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
What medical records offer: Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
What I need: Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
What medical records offer: Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I’ve been thinking. Dangerous thing to do, you know. It can lead to scary things like ideas, creativity, and change. I know, I should be satisfied with the usual mental vacuum state, but I’ve found it a very hard habit to kick. Perhaps there’s a 12-step group for folks with ideas they can’t suppress.
Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers. I’ve really strayed from the good ol’ days, haven’t I? The problem is, I’ve grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand. To combat this, I’ve decided to employ a technique I learned from my formative years: stories with pictures. My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.
So, here goes.
Adventures in Health Care: Part 1 – The Participants
This is a patient. Let’s call him “Chuck.” Chuck is not really a “patient,” he’s a person. Many doctors believe that people like Chuck don’t exist outside of their role as “patients,” but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck’s wacky adventures in health care, we will mainly think of Chuck in his role of “patient.”
Why are people like Chuck called “patients?” Some people think it’s to put them in their necessary subservient place in the system. I think it’s just to be ironic.
Chuck is a generally healthy guy, but occasionally he does get sick. He also worries about getting sick in the future, and want’s to keep himself as healthy as possible. This is when he uses the health care system, and when he is forced to be “patient.” Continue reading…
Unfortunately, like most mothers, she relishes telling funny (usually embarrassing) stories about us kids. I, unfortunately, seem to be the subject of the vast majority of those stories. But my big brother gets the leading role in one I will now tell. I guess it’s a small way to get back at him for…well, for lots of stuff. One day he came home from school all excited (unusual for my half-vulcan brother). ”Mom! Mom! I learned how to swim today!” he said. ”Oh?” my mother answered, not sure how and where he learned this new skill. Bill got a very pleased expression as he explained, “Steven V. taught me on the bus!” This is where my mother guffaws and my father chuckles and we kids look at each other with the well-worn “when will this story get old?” expression. He’s probably making that expression at his computer right now.
But the naïveté expressed by my brother at the nature of learning how to swim is similar to my confidence going into this project. Certainly it helps to know you can’t breathe underwater, and that swimming in a suit of armor is a bad idea, but this knowledge does not substitute for the first-hand experience of keeping afloat while the water seems to be trying to drown you. Similarly, I could read books, make a business plan, and impress people with my thought and insights, but that does not substitute for the first-hand experience of building a new business from scratch. It does nothing to keep me financially afloat while unseen forces try to pull me under.
Which brings me to my current situation. Would I have taken the plunge had I known what it’s taken up until now? It has been hard.
I hesitate to write about this, because:
I hate to sound whiney.
I don’t want people to worry that things are worse than they are. Especially my patients.
I don’t want to get a lot of advice from well-meaning people who don’t know the details of my situation.
But I want to give a realistic picture of what this journey is like, not just throw you the vaporware version. Besides, my world right now has significant stress and pressures that I didn’t anticipate.
The first sign of trouble came very early, in the renovation of my office. My goal was to start seeing patients in mid-December, and officially opening around the first of the year. Unfortunately, the office wasn’t ready until February 6th, and the construction cost twice what I expected. For those who can’t see the implication: I spent more money and lost a month of earning it. More money out, less money in. Maybe swimming’s a little harder than Steven said it was.
Then came the EMR debacle.
Of the areas I was most sure of, my ability to use computers to improve care was at the top. After all, I had won national awards and much acclaim for my use of electronic records to improve care. Two months and five EMR products later, I was beginning to see just how far the health IT industry had moved away from patient care. I din’t know what to do; I was at an impasse. Each system I tried either lacked some basic element of organization I required (such as management of outside documents) or was unable to generate anything but the voluminous documentation which succeeds only in two areas: getting physicians paid and hiding useful clinical information.
A patient calls or emails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best. Eventually, they need to come to the office to be seen – either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication. At the visit, I not only deal with one problem, but there are other issues needing to be addressed. Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.
So how do I document that?
In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office. The latter would be done largely with narrative of the conversation, and some direct quotes from the patient. The former, the “office visit” would include:
A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.
A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
A documentation of past problems (already in the record) to support the thought process documented later in the visit.
An overview of the physical exam, again to support the decisions made as a result of the visit.
A discussion of my thoughts on what I think is going on.
A telling of my plan on how to deal with this.
A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
A signature at the end, attesting to the validity of what is contained in the note.
But here’s the problem: it’s not real. I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me. Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet. This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care. Continue reading…
It has been nearly 6 months since I started my new practice, since I took the jump (or, more accurately, was pushed off the ledge) into a brave new world. It seems very distant, like I should get Shirley MacLaine or Gwyneth Paltrow to help me channel my old sad self. It is tempting.
I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care? This was a radical question because in my previous life I was an electronic health record aficionado. I was good at EMR, which meant that I was really good at finding work-arounds:
How can I work around the requirements for bloated documents and produce records that are actually useful? The goal of records in that previous life was to justify billing, not for patient care.
How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?
How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?
How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?
Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give. I was using them to give good care despite the real nature of the medical record: a vehicle for billing.
But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules). I no longer have to keep my office full and my patients sick enough to pay the bills. I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.
Ironically, in asking the question, what would a health record look like if my only concern was patient care, I was really asking the question: What does “meaningful use” of the record really look like?