Telling a Good Story

It\’s been a long time since I wrote a post.  My life, you see, is incredibly dull and boring.  There has been so little to write about that I\’ve been at a loss.
No, actually that\’s a load of crap.  It\’s become a fantasy of mine to have such boredom.  In reality, my life is as un-boring as it could be.  It\’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.

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So how\’s my new practice going?  In some ways things are going about as well as they could.  My patients are amazed when I answer their emails or (even more surprisingly) answer the phone.  \”Hello, this is Dr. Lamberts,\” I say.  This usually results in a long pause, followed by a confused and timid voice saying something like, \”well…uh…I was expecting to get Jamie.\”  Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem.  It\’s amazingly efficient to answer the phone.

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Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly.  The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine.  It\’s also not that I am so busy at 250 patients that growth is difficult.  In truth, when we aren\’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse.  In that sense I\’ve proved concept: that it\’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place.  The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.  I have well documented my realization that the EMR systems I\’ve tried have not met my approval…To those who are students of writing, I just used a literary device called irony, specifically the irony of a ridiculous understatement.  I was able to use the term EMR without descriptions like \”sucks at high decibel levels\” or \”crappier than a Carnival Cruise ship.\”  Other example of this type of understatement include calling the Korean war a \”Police Action,\” and referring to congress as \”a bunch of mindless fools.\”…I\’ve tried multiple solutions to this problem, only to have found little to improve my efficiency.  Sure, I can handle the current load of patients with the (non) system I have, but what happens when I grow?  I\’m trying to build something that can grow, and something that others can emulate.  It\’s obvious that I need a better system than I\’ve found up to now.

So what do I need?  Surely the freedom from both E/M coding and the utterly ironic \”meaningful use\” criteria have made documentation of care much simpler, which they actually have.  The thing that most EMR systems devote 90% of their energy, documentation of office visits, is one of the smaller problems I face.  This has caused some readers (not on my blog, thank goodness) to conclude that I don\’t need computers at all!  I can go real \”old school\” and return to the days of paper and illegible handwriting.  These folks are morons (and they get me very irritated) because they aren\’t willing to think about what health care could look like if it weren\’t corrupted by our pitiful system.  But, I ask, would they ask their bank to stop using computers and keep their financial records on paper?  Would they go to a travel agent instead of booking their flight online?  My suggestion that they write their comments to my posts on paper and mail them to me has not been met with any understanding or aplomb.  Sad.

Perhaps the problem is that I still use the term \”medical record,\” or (worse) \”EMR\” to describe what I am looking for.  While computers have been an important part in the corruption of the system, they have not been the cause of the screwing up, they have simply made the screwing happen at a much faster rate.

So what am I looking for?  The same thing I look for in a good story.  The best stories excel in three areas:

  • Back Story – what happens before the crisis?  How did the person get to the crisis?  What are the motivations?  What are the inner conflicts?  What is at stake?
  • Narrative – How well does the story-teller communicate what\’s happening during the crisis?  How well do they describe the setting, the action, the dialog?  Do you feel what they feel?  Do you believe what they say?
  • Resolution – How does the crisis get resolved?  Does it make sense?  Does it satisfy the listener?

These are also important parts of good medical care for any given patient at any given time:

  • Back story – What has happened to the patient in the past?  Do they have diabetes?  Do they smoke?  Did their father have a heart attack at age 45?
  • Narrative – What is going on now?  What are the symptoms?
  • Resolution – What is the plan to get their problem resolved? Does it make sense?  Does it satisfy the patient?

So what system am I looking for to help this?

  • Back story – Organization of data is key here.  The information needs to be complete, but it also needs to be well-organized.  It needs to prioritize important things (like the father with a heart attack at 45), and allow me to get a quick, accurate idea of who I am dealing with. Real world examples: Evernote, Wikipedia, Google.
  • Narrative – Communication tools are key here.  While a typical EMR product stands in the way of communication, focusing instead on obfuscation by documentation, a good system would improve communication.  This has been the easiest to attain, using online communication tools and simply being free to answer the phone.  Real life examples: email, Twitter, Facebook, iPhones.
  • Resolution – This is perhaps the hardest part (as it is in story-telling), and the worst done in our current system.  I am looking for a robust task-management system that can organize what needs to be done to get to where I need to go.  Examples: Wunderlist, online calendars.

This is a simplification of what really goes on, but it gives some idea of where I am heading.  My goal is not software, it is good medical care.  I am financially motivated to keep patients well, to efficiently answer their questions, and to handle their problems early, as it means I have more time and can handle more patients. Keeping patients well and at home was bad business for me in my former life (good riddance to that), but it is what patients want.  The more efficient I can be at meeting that desire of my patient, the better off both me and my patients will be.

They still will call, though.  I think they get a kick out of me answering the phone.

10 thoughts on “Telling a Good Story”

  1. The funniest thing is not that you answer the phone sometimes but that you say “please hold for the next available agent” I have thoughts of you and Jaimie flipping a coin to see who will answer the phone or better yet a game of rock paper scissors going on to see who gets to take the call…lol. Then there is the 911 message that is worth a giggle if this is an emergency you must not be my patient because all my patients would know to go to the emergency room if it was an emergency…lol

  2. How does your lab work get done? How dependent on your local hospital is your practice? Again, thanks for sharing your adventure.

  3. Dr. Rob –

    For a number of reasons, I’ve been hooked on your blog almost since the beginning. Your gift of story telling, the way you craft the narrative, never fails to make me laugh, cry (or want to), feel joy, pain, frustration and yes, indignation.

    Have you been a natural all your life? I know you didn’t learn this stuff in medical school.

    “crappier than a Carnival Cruise ship.”? LOL!!

  4. Dr. Rob,
    I just stumbled onto your blog through Kevin Pho, Md’s aggregator. This is incredibly well written and hilarious!
    You are Lewis Thomas meets John Irving at a writer’s workshop! Can’t wait to read your other posts. I even sent this to my daughter, who is a budding journalist (NYU 2012 graduate in journalism & politics).

  5. Thanks. I never knew I was a good writer until I started blogging and folks actually started reading it. I think I just don’t BS people and am a good communicator (which helps me a lot as a PCP).

    I am pleased people enjoyed the cruise ship reference. Class clowns always like to make others laugh.

  6. I draw blood tests and send it to a reference lab (Quest) and charge folks the direct billing price (which is very cheap – $5 for CBC’s, BMP’s for example). I am not at all dependent on the hospital. I stay as independent as possible.

  7. Speaking of class clowns, that Twitter post with the Roomba Cat & friends was off the hook FUNNY! BTW, I think the duckling is actually a gosling, as in a baby goose. But I suppose if it looks like a duck, walks like a duck…..;p

  8. Gary C. Berliner, MD

    Dr. Rob : Congratulations. I’ve been doing a no-private-insurance, cash-pay, solo-practice, model for 11 years. Hard work, but fewer headaches, and very rewarding. Good to see other entrepreneurs moving out of the insurance-driven, managed-care mainstream.

  9. I’m a fourth year medical student excited to go into primary care. As I have rotated through different clinics, I have been coming to the conclusion that the cash-based “Concierge Medicine” model seems to be the most viable for primary care docs in the future. I have been mulling this about in my head recently – trying to run the numbers and figure out a way for it to be financially reliable for me, cost effective for patients, and to be able to ensure excellent care. And then I stumbled on this post. I’m so excited to read more of your blog and for you to keep the world updated on your progress. Thanks for sharing!

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