Tag: Rob Lamberts

Running Behind

Rob Lamberts

I walk into the exam room and the patient looks up at me with a surprised expression.  ”Wow!  I didn’t expect to see you so quickly!”

I smile and turn around to walk out of the door, saying: “Sorry!  I’ll leave then and come back later.”

“No, no!”  They respond, smiling.  ”I’m happy to see you so soon.  It’s just a surprise.”

I walk back into the room with a smirk.  ”I just don’t want to offend you by being on time.  I’ll try to do better next time.”

I am not sure if I should be happy or sad with such an interchange.  On one hand, it feels good to stay on time with my appointments, holding up my end of the bargain of the schedule.  On the other hand, the patient’s surprise betrays the fact that this is not the usual state of affairs.  And it isn’t.  I generally don’t run on time and don’t expect to run on time.

When I first started practice, the stated objective was to get the person out of the office within an hour of their scheduled appointment.  This seemed a blend of realism and responsibility.  At first it was easy to stay up on things.  My schedule was sparsely filled, so I could make up time.  After sixteen years of practice, however, my schedule almost never has open slots; when it does have openings, they are quickly filled.  I still try to get them out within an hour.Continue reading…

To Med Students Considering Primary Care


Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately-owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I’d give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? ”Being a doctor” covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he’s not the target of Oprah’s contempt like I am – but that’s a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors spend time with humans – normal humans. This is both good and bad, as you see all sides of people, the good, bad , crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don’t do it. The single most important thing I have with my patients that most non-pcp’s don’t have is relationship. I see people over their lifetime, and that gives me a unique perspective.

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Three Wishes

So I was walking down the hallway in my office, mildly distracted,
when I kicked something.  It was a USB “thumb drive.”  I picked it up
and inspected it, trying to figure out who had dropped it.  The side of
the drive had a picture that I couldn’t make out, as it was all smudged
with something.  I pulled out a tissue and rubbed it, thinking it may be
a clue as to whose drive it was.

There was a sudden rushing sound and a strong wind.  Out of the thumb drive emerged a large blue figure wearing a turban.

“Are you a genie?”  I asked

“No, I am David Blumenthal, the health IT ‘czar.’” he responded.

I hung my head down, “I guess this is about the fact that I write the word healthcare instead of health care. I was wondering how long it would be before the feds came down on me for that.

“No, that’s not my realm.  That would be the job of the Department of
Language Security, and they’ll be appearing in some creative way next
week to get on your case about the whole healthcare thing.  It has Matthew Holt and Maggie Mahar in a big tiff.”

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My Side

I was planning on leaving behind the seriousness of the past few posts and going back to my usual inane writing, but some of the comments have made it too hard for me to keep quiet.  The response has been largely positive, and overall it has been overwhelming.  More people have read or commented on my letter to patients with chronic disease than any in recent history.  I am grateful that it is circulating around the web for others to contemplate, perhaps understanding the intent of what I wrote and improving their relationship with their doctors in the process.

The purpose of the letter was to give some helpful insight into the emotion on the other side of the equation.  I can’t understand what it is like to have a chronic illness without having the disease, but it is still fruitful for me to try to figure this out.  In the same way, patients with chronic illnesses benefit from a better understanding of the doctors they see so frequently and depend on so greatly.  I can sympathize, but I can’t feel the pain.  Still, I do need to listen closely to patients so I can have the best relationship possible.

Some folks felt that I was saying that doctors need their egos stroked and to be treated special, but that is not what I meant to say.  Each person needs to be understood and treated as their situation dictates.  People with chronic illness want to be understood (as witnessed by the incredible response to my letter!) and treated based on that understanding.  Doctors want to be understood as well.  So let me tell you my side of the story.  What is it like to sit in my chair?  I don’t say this for sympathy or pats on the back, I say it to be understood.  If I am better understood by my patients (and readers), my relationship with them is better, which is good for both of us.  I think I represent a fair percentage of primary care docs in these ways.

1. I care about my patients – As hard as I try to “just do the job,” and not expend the emotion I do during the day, I couldn’t live with myself if I let my patients down.  They depend on me for a lot, they pay for my service, and they deserve my best.  I’ve been told I do this to a pathological degree (along with my llama obsession), but it is there.  I want to help them.  I get frustrated at my powerlessness and am genuinely happy when they do well.

2.  I am tired – Each day demands an emotional price.  Some days the demand is not so high, others suck the life out of me.  Being “needed” cuts two ways; on one side it is nice to truly help people when they need the most help, it’s satisfying to see your life making a difference.  On the other side, it is a never-ending river of need, pain, and crises to be handled.  Being patted on the back (or patting myself) is nice, but it doesn’t mean anything for the future.  Each day brings new hands to hold, needs to meet, problems to be solved.  Each day is as much a burden as it is an opportunity.  That burden won’t leave me until I take down my shingle, yet the opportunities to make a difference will make it hard to take that shingle down.

3.  I also run a business – In terms of priorities, I need to pay my staff, pay the rent, and pay my personal bills to even have the chance to take care of patients. I get frustrated when patients insinuate that I value money too much.  I get very frustrated by that, actually.  People seem more willing to pay for cable TV, cigarettes, or eating out than to pay me for what I do.  I earn less than most other medical specialists, yet some people resent my income.  The mess of a system we have works against primary care and works against complex patients.  If I spend 30 minutes with a complex patients (I do spend 30 minutes with people regularly), I am paid about 50% more than if I see a 5 minute ear infection visit.  Doing the math says that my mind is not valued and that I should see more ear infections and less chronic patients.  All of this adds to my daily stress.

4.  I am actually a person, not just a doctor – I have four children and a wife, and being a dad and a husband isn’t easy when I come from work with the emotional life sucked out of me.  I struggle with my own emotions and I get sick.  I worry a lot about money, and I feel insecure about the fact that despite being a doctor, I am not saving enough.  Hence I also struggle with working too much.  Life’s not easy for anyone, and despite my title I am not exempt.

5. I hate bad doctors – Many of the comments to the letter I wrote were lamentations about doctors who suck.  Unfortunately, doctors who take bad care of their patients make my life miserable too.  I have to clean up their messes, I have to re-teach their patients on what medicine should look like.  I have to wean their patients off of addictive drugs that they didn’t have the guts to deny. I am personally frustrated when I send a person to a specialist and they don’t do anything or upset my patient, and I hate the fact that they almost never communicate with me.  It makes my already hard job even harder.

6. My blog is a refuge and a tool – I am thankful that I have this blog as a means to vent, to use another part of my brain (some may argue that point on some of my posts), and to make a difference.  I actually have a voice in the whole healthcare reform debate.  I actually can reach a large number of people and make their medical experience better (which was the most gratifying thing to hear in the comments to my letter).  I’ve made practically no money doing this, but I’ve gotten a whole lot out of it.

That’s my story.  Like it or not, it is what it is.  I am just a guy who happens to be a doctor – the same as the rest of the doctors out there.  There will always be angry people and idiots on both sides of the doctor/patient relationship, but no matter what, the doctor-patient encounter is a human thing.  Love is human, war is human, murder is human, and so is childbirth.  You can’t put humanity into a bottle, you can’t throw a single label on it.  The highest calling is to enter into another’s life, to see things from their perspective, and to add good to it.

That goes for all of us, regardless of letters behind our names.

Thanks for listening.
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.


Rob Lamberts

I went to a patient’s funeral this past weekend. I generally don’t do that for people whose relationship I’ve built in the exam room. It’s a complex set of emotions, but invariably some family member will start telling others what a nice doctor I am and how much the person had liked me as a doctor. It’s awkward getting a eulogy (literally: good words) spoken about me at someone else’s funeral. This patient I had known prior to them becoming my patient, and his wife had been very nice to us when we first moved here from up north.

But that’s not why I am writing this. As I was sitting in the service, the thought occurred to me that a patient’s funeral would be considered by many to be a failure for a doctor. Certainly there are times when that is the case – when the doctor could have intervened and didn’t, or intervened incorrectly, causing the person to die earlier than they could have. Every doctor has some moments where regrets over missed or incorrect diagnosis take their toll. We are imperfect humans, we have bad days, and we don’t always give our patients our best. We have limits.

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Care, Primarily


He came in for his regular blood pressure and cholesterol check.  On the review of systems sheet he circled “depression.”

“I see you circled depression,” I said after dealing with his routine problems.  ”What’s up?”

“I don’t think I am actually clinically depressed, but I’ve just been finding it harder to get going recently,” he responded.  ”I can force myself to do things, but I’ve never have had to force myself.”

“I noticed that you retired recently.  Do you think that has something to do with your depression?” I asked.

“I’m not really sure.  I don’t feel like it makes me depressed.  I was definitely happy to stop going to work.”

I have taken care of him for many years, and know him to be a solid guy.  “I have seen this a lot in men who retire.  They think it’s going to be good to rest, and it is for the first few months.  But after a while, the novelty wears off and they feel directionless.  They don’t want to spend the rest of their lives entertaining themselves or completing the ‘honey do’ list, but they don’t want to go back to work either.”

He looked up and me, “Yeah, I guess that sounds like me.”

“What I have seen work in people, especially men, in your situation is to get involved in something that is focused on other people.  Volunteer work at the food pantry, work for Habitat for Humanity, or anything else that lets you help other people.  I think the reason people get depressed is that they turn their focus completely on themselves, which is not what they are used to when they are working.” (I knew that this man had a job that helped disadvantaged people).

“That’s great advice, doc.” he said, with a brighter expression on his face.

“It’s from experience,” I responded.  ”I’ve seen a lot of retirees start to feel like they are on a hamster wheel, just entertaining themselves until they die.  I know I wouldn’t want to retire that way.  Knowing you, I wouldn’t imagine you would either.”

We talked for about 15 minutes about the various groups around town that would need someone of his skills.  I told him about how my parents went to Africa for a year after Dad retired.  He actually taught physics over there, but that is what they needed.  Of all the time I spent with him, over half of it was regarding his post-retirement “blues.”  He wasn’t clinically depressed, so I couldn’t charge for depression as a diagnosis.  The code I used?  99214 for Hypertension and Hyperlipidemia.

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10 Rules for Good Medicine

The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice.  What are the rules that govern my time in the office with patients?  What determines when I see people, what I order, and what I prescribe?  What constitutes “good care” in my practice?

So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient.  They are as much for my patients as they are for me, but I think thinking this out will give clarity in the process.

Rule 1:  It’s the Patient’s Visit

The visit is for the patient’s health, not the doctor’s income or ego.  This means three things:

  1. All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
  2. Patients who request things that are harmful to themselves should be denied.  People who ask for addictive drugs or unnecessary tests should not get them.  Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
  3. All tests done on the patient should be reported to them in a way that they can understand.

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Worth It

I saw the note on the patient’s chart before I opened the door: “patient is upset that he had to come in.”

I opened the door and was greeted by a gentleman with his arms crossed tightly across his chest and a stern expression.  I barely recognized him, having only seen him a handful of times over the past few years.  Scrawled on the patient history sheet  in the space for the reason for his visits were the words: “Because I was forced to come in.”

By stomach churned.  I opened his chart and looked at his problem list, which included high blood pressure and high cholesterol – both treated with medications.  He was last in my office in November…of 2008.  I blinked, looked up at his scowling face, and frowned back.  ”You haven’t been in the office for over eighteen months.  It was really time for you to come in,” I said, trying to remain calm as I spoke.

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Dear Mr. President

I am writing this as a representative of the examination room – one who sits facing patients, dealing with   our healthcare delivery “system” on a daily basis. I am writing this as one who will bear the brunt of what you accomplish or fail to accomplish in your attempts to reform our “system.” I write this as a primary care doctor who makes a living (or not) by what I earn from that “system.” I write as someone who has seen people not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.”

I talk to patients every day about what you folks are doing, and let me tell you what they are saying: nobody has any confidence in you whatsoever. Whether conservative or liberal, insured or not, black or white, elderly or young, all of my patients express frustration, disillusionment, and pessimism over your chances at getting it right. Nobody is confident, nobody is all that passionate anymore, and nobody is holding their breath.

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If there is a cPicture 35entral theme to my work, it is this:  medicine is a human thing.

On the Facebook page of my podcast, I recently asked for readers to tell me some of the “war stories” they have from the doctor’s office.  What are some of the bad things doctors do wrong?  I quickly followed this with the flip-side, asking readers to comment on the best interactions that they’ve had with their doctors.

The response was overwhelming, and equally quick to both rant and rave.  They told stories about doctors who didn’t listen, explain, or even talk with them.  They told about arrogance and disconnectedness from the people from whom they were seeking help.  They also told about doctors who took extra effort to listen and to reach out in communication.  They talked about doctors who genuinely seemed to value them as humans.Continue reading…


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