Relationship

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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.

In truth, the depth of the response I\’ve seen underlines the main reason I am going to this new kind of practice: I care too much.  I have always run behind because I talk to people, joke with them, tickle the kids, and ask open-ended questions.  When I am running behind (I try to keep it under an hour), I don\’t let that stop me from giving my full attention to the next person in the exam room.   Despite my chronic lateness, people don\’t complain much.  They know that I will give them the time they need when I am in with them; I can\’t cheat them of the time they need (and are paying for).

I\’ve always been puzzled when people say things like, \”you are the first doctor who\’s really listened to me,\” or \”you always give me your time and attention when I come in.\”  Isn\’t this what being a doctor is about?  Aren\’t they paying for my attention, for explanations, for listening?  Isn\’t it dangerous as a doctor to not listen?  If those doctors don\’t talk, what are they doing?  Singing?  Doing sign language?  Using their psychic powers to probe the patients\’ minds?  Whatever the case, I see from these statements (which are frequent from new patients) that I either care more than many doctors, or I just love to talk.  The last one is definitely true, but the burn-out has occurred because of my inability to not care.

The most gratifying thing that has happened since my announcement is that patients have almost universally expressed their happiness for me in making this change.  They aren\’t surprised that I burned out, and they are pretty fed up with the system, so they don\’t question why that would happen.  But the genuine happiness for me as a person has really touched me.  The relationship really does go both ways.  Many of them have observed my increasing signs of burn-out over the past few years, while others have heard me voice my frustration with a system that tries to push me away from them.

For those I\’ve taken care of for many years (some of them nearly 18 years), there is a bond that is hard to explain.  I\’ve walked through life with them, and for many, that life has been very hard.  I\’ve been through sickness, sorrow, death, pain, and despair with them, and not just as a bystander; I have taken an active role in their pain and hurt.  I knew the husband or child who died 10 years ago, and remember how crazy their parents were.  I\’ve been through good things as well, and have felt joy when they came back with good news.  I recently saw a patient I hadn\’t seen for 5 years who, when I last saw them, had been using drugs and getting into very bad relationships as a teenager.  I was thrilled when I saw how much they had changed, not letting bad choices ruin their life, and I told them how happy I was.

This is one of the reasons it is a huge advantage to have a primary care doctor who you trust.  When I walk into a room with one of my patients, I know more of the back-story in their life than most, if not all other people.  I remember how anxious they used to be, and see the little bit of anxiety they still have as a dramatic improvement.  Any other doctor would see it as a problem, not a victory.  I recently walked into the room of a mother with her newborn child and was struck by how much about this child\’s legacy I knew.  I knew about her grandparents, who went through very difficult times and have since died.  I knew about the uncle with lung problems and the aunt with anxiety.  I took care of the mother as a child and knew some \”interesting\” things about her past as well.  When I was looking at this child I thought about all of the other people in that legacy and was struck by my privilege to have been witness to both the good and bad.

My decision to leave my current practice didn\’t involve money.  I am paid just fine for what I do (although I wouldn\’t mind a little more help on college tuition), and haven\’t seen a drop in salary, despite the mess our system is in.  My decision was largely driven by relationship.  I\’ve watched  as my ability to draw close to my patients has been slowly taken away.  Some (on other blogs that will remain nameless) have suggested that I have been selfish in this decision, bolting from the sinking ship instead of trying to fix it.  This, of course, is beyond crazy; I have been obsessed with fixing the system – first through use of computers to improve the process, and then through my voice on the Internet through writing.  I have done all I can to change the system from within; now it\’s time to be real disruptive, and change it by stepping out.

To those patients who follow me on this \”adventure:\” thanks.  Thanks for trusting me enough to follow me to a different planet.  I had a patient grin at me yesterday and tell me, \”this is just you.  I am not at all surprised at this because it\’s just the way you do things.\”  I guess I\’ve always been a little subversive.  Maybe it was the sandals.  Maybe it\’s the computers.

No, I just cared for them in a system erroneously labeled as \”health care,\” and they cared back at me because I did.

13 thoughts on “Relationship”

  1. But Dr. Rob you are changing the system. All it takes is one … then another … then another …

  2. JenniferDavisEwing

    Wow. Seriously? You’re patting yourself on the back because you *are* jumping off the sinking ship, and refusing to take insurance? No wonder your maximum new patient load will be 1000 pts. They’ll be the wealthier patients, too, since they’re the only ones who will be able to afford to see you without insurance, and with a “monthly subscription fee”. Yet you reassure yourself that you “care too much”, and that’s why you had to leave your old practice. Congratulations, Dr. Rob. Way to “fix the system”.

  3. Fair enough. I guess I will have to prove you wrong through my actions. It is certainly no small thing to leave the economic security of a healthy practice (which ours was) and do something completely different. There is an extent to which my decision is a selfish choice – in that I saw myself being crashed on the rocks and torn up by the system as it is. I don’t see how that would do good to me, to my patients, or to change the system. Being a sacrificial lamb in the for the sake of a system that favors big over small, intervention over prevention, prescription over education, and companies over individuals is not how I want to spend the rest of my career. It’s my right to make that choice.

    I guess I can ask you to read what I’ve written throughout my writing “career,” listen to the podcast I did with Mike Sevila this week, and (if you have a chance) talk to my patients to judge my sincerity. My job will be to continue doing what I think is right, and I think this is the right thing to do. I plan on doing it in front of as big an audience possible – not so I can get more pats on the back, but so others can see there are other alternatives. I would rather be accused of selfishness while doing the right thing than avoid accusations while being chewed up and spit out by the machine.

  4. Dr. Rob,I think you said it best here – “I’ve always been puzzled when people say things like, “you are the first
    doctor who’s really listened to me,” or “you always give me your time
    and attention when I come in.” Isn’t this what being a doctor is about?” You are one of a minority of doctors that cares.

    Taking myself as an example, I get treated as a 70 year old (actual age) when I ask questions about dementia or Alzheimer’s with answers like “you worry too much” and “its just part of the aging process.” In the past I did lay things off to “its just a senior moment”. but with type 2 diabetes, I know my risks for Alzheimer’s have increased. but instead of attempting to establish any baseline data, when I get put me off with the above answers, I seriously need to wonder if the doctor (a neurologist) really cares, or if his medical degree was a prize in a cereal box contest. If you think this is harsh, a close friend, a year older than I am, seeing the same doctor, was taken to another doctor by his son because he knew something was not right and after a brief interview by the second doctor, a series of evaluations was preformed and a diagnosis of mid-level Alzheimer’s was the result. The second doctor referred him to the Mayo Clinic in Rochester where it was determined that he would receive little benefit from most medications and is now confined to an Alzheimer’s facility. I clearly lay this at the feet of the healthcare system and the hospital employing the first doctor and the greed of the hospital. They clearly do not allow the doctor time to do his work and as a result the doctor is now just another cog in the profit machine.

    Do not let people discourage you from being the caring doctor you are. It is not just retiring doctors (that can afford to retire) that are leaving the current healthcare fiasco.

  5. It isn’t selfish to take care of yourself and your family. There comes a breaking point if a necessary change does not occur. You won’t be the only provider to finally do this. (Many are watching and thinking, can they do it?) Don’t blame the doctors, blame the insurance companies. They are constantly getting in between the doctor/patient relationship. Constantly making it difficult for the physician to treat. They’ve made it so it is dangerous. It isn’t selfish to take care of yourself. Your patients will receive a much better quality of patient care.

  6. I think the trouble is, for MDs who care and choose to move out of traditional practice, that only the more wealthy patients will be seen. This cohort is more healthy (statistically), more demanding, and tend to treat providers in the “cash-only” business as their employees. In the end, it’s not a question of right or wrong. It will simply be a new life-work style and if it pays the bills, then so be it. We all need to pay the bills and stay sane. The system is massively dysfunctional. Moving out won’t change that. Neither does staying in … it’s merely a personal decision. In the largest context, we will start to see even our best hospitals decline in all measures of quality, and even hygiene. So the end-game will involve the investor owned private hospital where only the wealthy will be treated. This leads to a significant skew in the status of health and public-health in the USA. I guess this is ultimately what we will see. Unfortunately, it’s like saying “hello” to the 19th century.

  7. What confuses me here is that I am giving the price range of $50 per month, which is not something that is out of the range of most people. I am not sure how this is something for only “rich people,” which is why I avoided this model until I saw it at a more reasonable price point. I do want to use this for management of complex and time-intensive patients as well as those who are healthy, and am not sure who will be more likely to follow me: those who are healthier, or those for whom I’ve helped them manage their complex diseases. The latter are certainly more likely to see the value quicker.

    I am working on a post to talk about how this type of thing could actually have an impact on the system in a bigger sense. Let me just say that if health care was made better for doctors, patients, and it saved money, reduced hospital visits, and reduced overall spending on health care, wouldn’t others be interested in it? Wouldn’t other people, insurance companies and CMS administrators, consider a cheap and effective way to improve outcomes while making care more personal and saving money? I think there is no external demand for this sort of thing because people don’t know it’s even possible.

  8. I’ve looked at this model, and similar, in the past for personal reasons. The flaw I ran into was that the Primary MD piece is smallish in today’s healthcare world. One must still have the funds to pay for Rx’s, medical equipment/supplies (via Rx or out of pocket), and then there are the bills for diagnostic tests, not to mention hospital stays if they are needed. I have not found any individual MD to be able to orchestrate (alone) all the care which may be required in complex cases. The Primary becomes a stop along the way, and so the savings and the relationships are quite bounded by the rest of the medical system reality one must face. The moment one needs to see a specialist, they are out of the nest, so to speak.

  9. I am glad for you to be able to make this type of leap and pray it works as well for you as it seems it should. I will miss being able to discuss the issues we’ve had over the last 18 years…..I do not yet find that I’m able to make the leap out of traditional healthcare, just yet…. but hope to see updates still to know you’re thriving! If it was just me, maybe, I’d pay the fee monthly, but with the family, i feel I have to remain in the tradition system for now. Good luck and you will be missed!

  10. I’m willing to accept your reasons for your decision. The system in inarguably broken. Among other places, I’ve found in “Overhauling America’s Healthcare Machine: Stop the Bleeding and Save Trillions” by Douglas A. Perednia a compelling analysis of some of the causes, although I find his solutions somewhat less compelling.
    Under your model my immediate out-of-pocket expenses would rise for primary care – more so when you consider I wind up paying the insurance company for covered services I’d never use. But the increase is probably well within manageable for my budget. My insurance provider, however, is unlikely to be a willing participant in this experiment. I can foresee an increase in aggravation and perhaps expense as the insurance company notes that it wasn’t billed for primary care services. While you would think they would find that great news, they provide automatic incentives (based on billing) for getting preventive care, and I fully anticipate that things like pre-authorization for medication, procedures, and specialists would be more difficult as they decide (because they haven’t been billed) that I didn’t appropriately and/or recently enough consult a primary care physician. Those may not be insurmountable hurdles, but they are hurdles.

    In a perfect world the choice of paying by subscription rather than encounter would be mine. In a perfect world healthcare would be about patients and providers and not insurance and government. But until the system changes, in reality you are shifting some of the pain and cost of dealing with insurance from you to your patients – and I don’t blame you. While this isn’t an issue for the uninsured, they have even more to worry about in the existing system, and I have no desire to be part of their ranks. While in a perfect world I would chose the doctor I trust and respect for my care, in the current system my insurance and FSA providers exert significant influence. I’m not sure I’m willing to fight this battle with you, but I wish you success.

  11. I can’t disagree with any of that, and some of it I hadn’t considered. Insurers do measure utilization with billing codes (notoriously inaccurate, but used to be the only option), so there may be problems created by this. There are some potential options on how to manage this, but these are the devilish details that will be cropping up as I put this into action. My hope is that any increased inconvenience created will be greatly offset by me being available, online, and willing to give patients their records. I’ve been on the cutting edge in the past, and just because it makes great sense to me doesn’t mean that others (insurance companies, in this case) will be able to understand it.

  12. @JenniferDavisEwingI have debated whether or not to commet about your commet to Dr. Rob I have decided to because someone needs to speak up. I know from what you wrote that you don’t personally know Dr. Rob. I on the other hand I know him as my Doctor of seventeen years. I saw in other post were you suffer from FM I feel your pain I say this with empathy because no two people’s pain can be compared. I suffer in moderate to severe pain 24/7/365 . My pain is not related to FM but through severe back issues I bring up the pain because I feel you can relate when I tell you about this wonderful man and Doctor who sits across from me in his office as I tell him about my problems I am having this time, I can see the pain in his eyes knowing as my doctor there is nothing else he can do to fix my problem he can only help me deal with the pain. This man cares more then I have ever seen a doctor care. I have had many health issues with myself and my family over the years so I have seen alot of doctors and none has impressed me like Dr. Rob. I am one of those who after seventeen years can’t follow him to his new practice because I can’t afford it. It’s not his services I can’t afford it’s the prescriptions That my so called “insurance ” company won’t cover if written by a out of network pcp. This is not his fault it is our system. I system he has been out spoken about for years and this very well may be the why to fix the system if the insurance companies would get on board. I am one of those who will be negatively effected by his decision and never once did I question his motives or how much he cares for me and my family. Even though I can no longer call him my doctor, I hope I will always be able to call him my friend.

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