Dropping Out

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.

Here are some things that are not reasons for my big change:

  1. I am not angry with my partners.  I have been frustrated that they didn\’t see things as I did, but I realize that they are not restless for change like I am.  They do believe in me (and are doing their best to help me on this new venture), but they don\’t want to ride shotgun while I drive to a location yet undisclosed.
  2. I am not upset about the ACA (Obamacare).  In truth, the changes primary care has seen have been more positive than negative.  The ACA also favors the type of practice I am planning on building, allowing businesses to contract directly with direct care practices along with a high-deductible insurance to meet the requirement to provide insurance.  Now, if I did think the government could fix healthcare I would probably not be making the changes I am.  But it\’s the overall dysfunctional nature of Washington that quenches my hope for significant change, not the ACA.

What will my practice look like?  Here are the cornerstones on which I hope to build a new kind of practice.

  1. I want the cost to be reasonable.  Direct Care practices generally charge between $50 and $100 per patient per month for full access.  I don\’t want to limit my care to the wealthy.  I want my practice to be part of a solution that will be able to expand around the country (as it has been doing).
  2. I want to keep my patient volume manageable.  I will limit the number of patients I have (1000 being the maximum, at the present time).  I want to go home each day feeling that I\’ve done what I can to help all of my patients to be healthy.
  3. I want to keep people away from health care.  As strange as this may sound, the goal of most people is to spend less time dealing with their health, not more. I don\’t want to make people wait in my office, I don\’t want them to go to the ER when they don\’t need to.  I also don\’t want them going to specialists who don\’t know why they were sent, getting duplicate tests they don\’t need, being put on medications that don\’t help, or getting sick from illnesses they were afraid to address.  I will use phones, online forms, text messages, house calls, or whatever other means I can use to keep people as people, not health care consumers.
  4. People need access to me.  I want them to be able to call me, text me, or send an email when they have questions, not afraid that I will withhold an answer and force them to come in to see me.  If someone is thinking about going to the ER, they should be able to see what I think.  Preventing a single ER visit will save thousands of dollars, and many unnecessary tests.
  5. Patients should own their medical records.  It is ridiculous (and horrible) how we treat patient records as the property of doctors and hospitals.  It\’s like a bank saying they own your money, and will give you access to it for a fee.  I should be asking my patients for access to their records, not the reverse!  This means that patients will be maintaining these records, and I am working on a way to give incentive to do so.  Why should I always have to ask for people information to update my records, when I could just look at theirs?
  6. I want this to be a project built as a cooperative between me and my patients.  Do they have better ideas on how to do things?  They should tell me what works and what does not.  Perhaps I can meet my diabetics at a grocery store and have a dietician talk about buying food.  Perhaps I can bring a child psychologist in to talk about parenting.  I don\’t know, and I don\’t want to answer those questions until I hear from my patients.

This is the first of a whole bunch of posts on this subject.  My hope is that the dialog started by my big change (and those of other doctors) will have bigger effects on the whole health care scene.  Even if it doesn\’t, however, I plan on having a practice where I can take better care of my patients while not getting burned out in the process.

Is this scary?  Heck yeah, it\’s terrifying in many ways.  But the relief to be changing from being a nail, constantly pounded by an unreasonable system, to a hammer is enormous.

(To Be Continued – the new web site for my practice is http://doctorlamberts.org)

25 thoughts on “Dropping Out”

  1. My only problem with this is that I am not near enough for you to be my physician! : ) I’ll be following your journey every step of the way. Of course, it WILL be successful. : )

  2. Oh wow! I wish you the best of luck Dr. Rob! You got so many awesome ideas and I hope you get to develop them all and that your patients contribute to make it work as well! =D I’m looking forward to read more about your new journey. Kelnia.

  3. This sounds perfect for you and the patients who will be taking the journey with you. I commend you for your commitment to disease prevention while of course being there on the treatment end. And as a dietitian, I think your idea of having diabetics (or hypertensives, or those with high cholesterol, GERD, etc) meet with a food professional to help with treatment is the way to go.

  4. I love that you have chosen to take this step. I hope that your passion catches on to others and that this is the first step in medical revolution.

  5. Fascinating…I hope it works out for you and am looking forward to seeing how it pans out. Hopefully that desire to do things a bit differently will turn into something better than our current system, for both you and your patients.

  6. praying for you to have a miraculous transition; days of grace, serenity and patience while this all unrolls, And wishing I lived in your area so I could use your services.

  7. Good luck with your new venture!I’m curious who you see your patient population being. Adults? Children? Families?

    If it was just myself, I’d be willing to pay a $50 monthly fee for full access to my primary doctor, despite the fact that that fee is in addition to the $1700/mo I already pay for insurance. I have no idea where I’d find that $50 in my budget, but my doctor is excellent and I’d want to keep him, so I’d try to find a way to make it work – if it was just myself. The problem, though, is that I can’t only consider myself, but my entire family. Adding $50/mo for every member of my family to be able to keep our current physician would make our family’s monthly medical expenses over $2,000 (plus extra for tests, prescriptions, vaccines…). Not knowing your criteria for deciding who is charged $50 and who is charged $100, I’m making some guesses and thinking that those people with conditions needing extra time and thought might cost more, which might bump me and my daughter up to the top tier. Lots of places offer family discounts, but it wouldn’t seem like that would be an option with medical care, would it? Does the nature of the fee structure automatically exclude families?
    If not, and you are seeing all the members of a family, when one kid moves to college, would the family pay monthly for the absent college student, just to hold a place in the practice for when the student returns over Christmas and summer breaks? How would that work?

  8. Awesome, Dr. Rob, just awesome.As someone else on the front lines, with similar concerns about how this job should be done, I am excited for you. And I plan to follow your journey closely, if you continue to blog about the experience.
    I bet many others who want to follow in your footsteps might gather up the momentum to do so (partially because of your journey).
    now off to check out your new website…….

  9. Dr Lamberts,

    That is a brave and noble decision.

    This is not intended to sound opportunistic. In the future, when the setting up work for your new practice is less frantic, you might want review our remote queueing app. Patients can view your queue from 6 miles away and ask for a queue number from there. They wait in the comfort of their home or office until the clinic ping them with a single tap on the app. We named the service/app Qender . . . ending boring physical in person queueing, comfortable waiting instead.
    We launched this in English globally and only in iOS at this time; Android later but it will always only on smartphones, not basic phones. In Singapore where I’m based, the family doctors use an open queue system per session, and not appointments. They are now trialing the system and are happy with the simplicity. We charge US$29 per month to manage the queue. Patients use the app for free forever.

    Our next update of the app will make it work smoothly in an “Appointment Preferred, Walk-in Welcome” setting. Patients can be selectively pinged out of order.
    Save this email. At the right time, have a look at our service at http://qender.com. Or go the Apple app store and download Qender Mobile Queue.
    All the best for the new venture.
    Cheers, Tantsh@qender.com

  10. my email should read tsh at qender dot com. Definitely do not want to cause grief to anyone trying to email tantsh. Sorry

  11. Rob, I’ve been wondering just when you would make this move. Congratulations, you are about to find a wonderful quality of life ahead, not just for yourself, but for the patients that will be in your practice. I am so happy for you to embark on this. It was a long time coming.

  12. Good for you! I wish I lived in your city. (I’m wondering if you’re planning to have a health coach join you in your practice, or do all the patient education yourself?) Bravo.

  13. Congratulations on such a big step! I too was a family doc. I left medicine 15 years ago myself, for a variety of reasons, but I always had the same frustrations you have been describing (I still have nightmares in which there are too many tasks and people to see, and not enough time!). I just found a PCP for myself who is in the “Ideal Medical Practice” model, and this Direct Care Model you speak of sounds great too. It’s great to see that we are beginning to have options where we can ‘vote with our feet.’ I wish you the best in this transition and appreciate your blog. Love your new website and all it portends.

  14. I think you are doing a great thing! I wish you the best of luck. If your practice was near me then I would definitely ask that you be my doctor. Everything you said is true, from a patient perspective. Good luck, push forward, don’t give up! Change the world my friend.

  15. I agree that patient portals are a good idea, and patients should own the test results that they pay for. What they should not own, however, is the physician note. A note is a device by which a trained diagnostician recalls key facts. As a Rheumatologist my diagnosis often involves taking a history of sexual abuse, domestic abuse, or other delicate details. My interactions are not sterile discussions of USPSTF recommendations and white coat HTN treatment. Allowing open acccess to my records could lead to a battered wife. Additionally, my notes are ruminations on challinging diagnostic considerations, not ACA approved billing documents. Physician notes are NOT public property, they are my personal notes as I pursue the profession of medicine.

  16. It depends what part of the note you are talking about. The plan is of great interest to the patient, and the open notes study showed patients who were given access to their notes were more compliant and their physicians happier. “Taking a history” in my experience is to get a story from the patent. How does sharing that with them in the note do anything, since it’s information they provided in the first place? I think there is certainly parts of the note that may be better to keep from patients, but that is a very small portion of the chart. Unfortunately, we have used the need to “protect” patients from a small part of their chart to withhold most of the chart from them, causing significant harm.

  17. Could you explain more about how the ACA favors the type of practice you are doing? My first thought was that if more people had insurance, they would be less likely to pay a monthly fee out of pocket for direct care, but it seems that’s not the case from your post here. I’ve tried to be well-versed in what the ACA does, but am not an expert by any means. How does the ACA help you to interact with high-deductible health plans?

    Thanks for your great blog and work. As a healthcare statistician on a growing team, I always point our new hires who are new to healthcare to your blog to help them understand some of the issues our healthcare system faces.

  18. There is a provision in ACA to allow businesses the option to contract directly with a direct care practice along with a high-deductable plan to qualify and avoid the fines for the ACA.

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