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Tag: Rob Lamberts

The Good Doctor Learns to Fly

• 37

By Rob Lamberts, MD

This is my new office. I signed the lease for this property yesterday – another big step in the process of getting my new practice off the ground.  I should feel good about this, shouldn’t I?  I’ve had people comment that I’ve gotten a whole lot accomplished in the 4 weeks since I’ve been off, but the whole thing is still quite daunting.  Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.

I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don’t know what I want done, and nobody can tell me what I should do.  Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don’t really know which of my ideas about the practice will work, I don’t know what my needs will truly be.  How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse?  I want a space for group education, but how many resources should I put toward that?  I also want a place to record patient education videos, but some of my “good ideas” just end up being wasted time, and I don’t know if this is one of them.

I come across the same problem when I am trying to choose computer systems.  I know that I want to do that differently: I want the central record to be the patient record, not what I record in the EMR.  I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their PHR.  So do I build a “lite” EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product?  Do I use an EMR company’s “patient portal” product, or do I have a stand-alone PHR which is fed by the EMR?  I have lots of thoughts and ideas on this, but I don’t really know what will work until I start using it.

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The Organic Medical Home

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By Rob Lamberts, MD

What comes to mind when you hear the term “medical home?”  Perhaps you favor the definition put forth by our government (AHRQ):

The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

1. Comprehensive care
2. Patient-centered
3. Coordinated care
4. Accessible services
5. Quality and Safety.

The presence of these five attributes to care should then constitute a medical home, right?  It depends on who you get your definition from.

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The Day After

• 6

By Rob Lamberts, MD

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!

• 31

By Rob Lamberts, MD

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

• 2

By Rob Lamberts, MD

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

• 8

By Rob Lamberts, MD

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.

• 28

By Rob Lamberts, MD

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

• 47

By Rob Lamberts, MD

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

• 5

By ROB LAMBERTS, MD

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

• 27

By Rob Lamberts, MD

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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