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Tag: Rob Lamberts

The Day After

There is nothing exciting or glamorous about doing what I am doing: building a new practice from scratch.  It’s a slow and often mundane process that takes far longer than it looks like it should.  There are a thousand questions I need to answer: Where will my office be?  What will my logo look like?  Does it matter what my logo looks like?  Can I get the video of my presentation done?  Why is it taking so long?  Which EMR system will I use?  Will I use and EMR at all, or will a PHR product suffice?  Who will I hire?  What will I pay them?  When will I start?  How many patients will I accept at the start?  What will I do about my website?  Who should design it?  Can I do that myself?  Who should run it?  What about a phone system?  Each day uncovers a new set of questions that need answering, and each day passes with most of them left unanswered.

There are two things I’ve been doing which have kept me from becoming discouraged or overwhelmed by this process.  The first thing is something called Centering Prayer, which is well-described in the book Into the Silent Land by Martin Laird.  Whether from the tradition of the middle ages or from eastern religious practice, meditation is upheld by many in science as a sound life-practice.  What makes centering prayer, a form of meditation out of the Christian Tradition, different from other forms is the way one deals with distractions or worries.  I’m not an expert on eastern meditation, but my understanding is that the goal is to clear the mind from any thoughts and worries, coming to a place of peace and rest in the mind.  Centering prayer, however, does not push away worries or distraction, it changes the perspective on it.

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Instadoc!

I grew up in Rochester, NY. Statistically, this means that I probably had a family member who worked at Eastman Kodak, as the company employed over 62,000 people in Rochester at it’s peak. I did, in fact, have two: my father and my brother-in-law. My brother and I both worked there during two fun and profitable summers of our college years in the delightful “roll coating” division. It actually paid quite well, but was miserable work.

Kodak was, at one point, the consummate American success story, dominating its market like few others. In 1976, it had a 90% market share of film, as well as 80% of cameras sold in the US. Kodak Park, the property at the center of manufacturing once employed 29,000 employees, with its own fire company, rail system, water treatment plant, and continuously staffed medical facility.

Fast-forward to 2012, and the picture changes dramatically. In a single year, Kodak declared chapter 11 bankruptcy, received a warning from the New York Stock Exchange that its stock was below $1/share for long enough that it was at risk of being delisted, announced it is no longer making digital cameras so as to focus on its core business: printing, and then a few weeks ago announced it was no longer making inkjet printers. The job force in Rochester alone has gone down by nearly 90%, to an estimated 7200 employees. (All of this info came from Wikipedia, if you wondered).

Adding pain for former Kodak fans was the announcement in April of this year that Facebook was buying the photo sharing company Instagram (which employed 13 people at the time) for an estimated $1 Billion.

So how could a company so dominant be overcome by one with only 13 employees? Didn’t the resources of Kodak give them anything better to sell than this small start-up? And what spelled the doom of a well-proven system of photography that fueled one of the most successful companies of its time? Was it acts of congress? Was it passage of a photography reform bill, or Obamachrome? Was it formation of ACO’s (accountable camera organizations), the use of the photographic centered media home, or the willingness of the government to pay photographers over $40,000 if they prove they use digital cameras in a “meaningful” way?

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Destination Unknown

I cleaned out my office yesterday.  I gathered up the outdated pictures of my family, handwritten notes from my children when they were much younger, pictures of patients, notes from patients, and the knick knacks that accumulate over 18 years of being in one place.  Most of them were dusty or worn with the tarnish of time; things that sit in the office unnoticed until a moment like this.

I also went through the files of old information – information I seldom if ever used – detailing the financial struggles it took to build a successful practice.  Here’s what we collected in 1998.  Here are the notes from an office administration meeting in 2002.  Here are handwritten flow diagrams I made to figure out a way to improve workflow.  Here’s a list of patients from 2000 who were eligible flu shots with a sticky note affixed to the folder saying: “give to Angie.”  I’m not sure I ever gave it to her.

The majority of paper, however, was spent on spreadsheets.  There are spreadsheets of productivity, of income, of expenses, projected income, effects of adding new partners, of quality measures and of the ever ominous accounts receivable.  These are numbers my distractible brain always had difficulty wrapping around, yet they stand as a testament to the myriad of details that work in the background of life.  They mean even less to me now than they once did, like the dates on gravestones for people long forgotten, yet their existence reminds me that these days were not the dusty pictures sitting on the shelves of my memory; they were days of many small details and struggles.  Life looks like a movie from the outside, but its reality is found in the spreadsheets it leaves behind.

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Last Week

This is it.

Eighteen years of practice is now condensed to my final four days seeing patients in the practice I built.  While I am not bitter about what has happened (in fact, a large part of me is delighted), there is a sense of finality in this as one of my life’s major passings.  This has been the stage on which I’ve been asked to perform, standing beside the stories of people’s lives and living out my own drama as theirs unfolded.  This is where my life most intersected others, where I saw pain and joy, birth and death, suffering and triumph.  I helped these people and learned from them in the process.  I was teacher and student, helper and helped, healer and healed.

Whether I’ve profited most or gave myself dry (I’ve felt both often), it has been what I’ve done.  Now I walk off of that stage onto another one, still dimly lit with little substance.  I walk from the known to the unknown, the familiar to the hypothetical.  I have great ideas, but now those ideas must become reality, and that reality must work well enough to justify leaving what I have left.  Enthusiasm and innovation don’t pay the bills or heal the sick; it takes work.

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The Doctor-Patient Relationship. Is Over.

Probably the hardest part of making the change from a traditional to a direct-care practice is the effect it has on relationships.  I am only taking a maximum of 1000 patients (less at the start) and will be no longer accepting insurance.  These changes make it impossible for me to continue in a doctor-patient relationship with most of my patients.

For some, this transition will be more hassle than anything.  Some people do everything they can to avoid my office, and so are not going to be greatly affected by my absence.  They will simply choose another provider in our office and continue avoidance as always.  There are others who see me as their doctor, but they haven’t built a strong bond with me (despite my charm), so the change may even be a welcome relief, or a chance to avoid initiating the change to another doctor.

But there are many people, some of which have already expressed this, for whom my departure will be traumatic.  ”Nobody else knows me or understands me like you do,” one person told me this week.  ”I’ve seen you for so many years, you just know so much more about me than any other doctor,” said another.  I’ve seen tears, have gotten hugs, and get frequent demands for a clearer explanation as to what I am doing and why.  It’s been a rough week for me, as I don’t feel I can cut off these relationships without some sort of closure.  Fore someone who sometimes goes overboard in the importance of others not being mad, it’s been hell.

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The Great Cheesecake Robbery

In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.

The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.

I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

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Burnout

It happened again.  I was talking to a particularly sick patient recently who related another bad experience with a specialist.

“He came in and started spouting that he was busy saving someone’s life in the ER, and then he didn’t listen to what I had to say,” she told me.  ”I know that he’s a good doctor and all, but he was a real jerk!”

This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.

“I think he holds himself in pretty high esteem, if you ask me,” she replied, still angry.

“Yes,” I agreed, “he probably does.  It’s kind of hard to find a doctor who doesn’t.”

She laughed and we went on to figure out her plan.

This encounter made me wonder: was this behavior typical of this physician (something I’ve never heard about from him), or was there something else going on?  I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.

Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).

This is consistent with other data I’ve seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public.  On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to “do good” for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done.  Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.

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10 Ways to Make the EMR Meaningful and Useful

I am an EMR geek who isn’t so thrilled with the direction of EMR.  So what, I have been asked, would make EMR something that is really meaningful?  What would be the things that would truly help, and not just make more hoops for me to jump through?  A lot of this is not in the hands of the gods of MU, but in the realm of the demons of reimbursement, but I will give it a try anyhow. Here’s my list:

  1. Require all visits to have a simple summary.
    One of the biggest problems I have with EMR is the “data diarrhea” it creates, throwing piles of words into notes that is not useful for anything but assuring compliance with billing codes.  I waste a huge amount of time trying to figure out what specialists, colleagues, and even my own assessment and plan was for any given visit.  Each note should have an easily accessible visit summary (but not at the bottom of 5 pages of droll historical data I already know because I sent them the patient in the first place!).
  2. Allow coding gibberish to be hidden.
    Related to #1 would be the ability to hide as much “fluff” in notes as possible.  I only care about the review of systems and a repetition of past histories 1 out of 100 times.  Most of the time I am only interested in the history of the present illness, pertinent physical findings, and the plan generated from any given encounter.  The rest of the note (which is about 75% of the words used) should be hidden, accessed only if needed.  It is only input into the note for billing purposes. 

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Bad Directions

I love the GPS analogy for health care.  Patients need a GPS for their health, showing them the reality of their past, present, and future health.  The analogy has not only shown me how I want to give care for my patients, it has also given me insight into the pitfalls of automated medical care.

Way back in the days when GPS was new, the rental care company Hertz advertised “NeverLost,” a GPS on your dashboard (if you forked out the extra money for it).  I was asked to give a talk in Oregon, and decided I would try out this cool new technology (since others were picking up my bill).  While I found it overall very useful, there were a couple of times it didn’t work as advertised.

  • I needed a sweatshirt, so  I used the NeverLost for directions to a Wal-Mart.  It worked!  It gave me flawless directions to a Wal-Mart store…in Las Vegas (over 1000 miles away).  I stopped at a gas station and they told me that there was actually a Wal-Mart 1/2 mile down the road.
  • Then, when I was trying to get to Crater Lake, “Never Lost” repeatedly directed me down dirt roads, some of which had trees fallen across their path.  NeverLost was quite perturbed when I didn’t follow its direction, nagging me to make an immediate u-turn back toward the tree in the road.

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Us and Them-Ism

Us and Them
And after all we’re only ordinary men

The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face.  ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry.  ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”

My wife grabbed my arm, restraining me from throwing the nearest object at the television.  I cursed under my breath.

No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society.  I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.

It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving.  If only we could get rid of the bad people, we could make everything work.  If only those people weren’t oppressing us.  If only those people weren’t so lazy.  It’s the radical religious people who are the problem.  It’s the liberal atheists.  It’s the corporations.  It’s the government.  All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.

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