Boom Goes the Dynamite

Oh yeah.  Hot dang.  All right.  Groovy.  

Boom goes the dynamite.


I had a very great day yesterday. 

I saw three patients who had recent diagnoses of cancer.  Yeah, those two statements seem to contradict.  They don\’t.  Each person I saw gave me a clear view of how the practice I\’ve been building over the past 18 months is making a difference.  A big, big difference.

The first patient was a guy who is pretty far along in the treatment of his cancer.  I sent him to a specialist about a year ago and he was diagnosed with a serious, but treatable form of cancer.  While he\’s happy with the overall outcome of his disease, he has a complication called \”lymphedema\” which is making him very uncomfortable.  Lymphedema causes swelling of soft tissue that is very difficult to treat, as it cuts off the normal drainage system for the fluid that is outside of blood vessels surrounding cells.  

When he asked his specialists about this, they told him that nothing could be done.  He expressed his frustration at the fact, so I did what every red-blooded person in 2014 would do: I googled his problem.  I immediately found a number of useful websites which talked about the exact problem he was facing, one of which was written by a physician who had dealt with his form of cancer (and has written a book chronicling his experience).  While I read aloud from the website, he purchased the book from Amazon.  I discovered that the pessimism of his specialists was not exactly right.  In fact, I found out that there were important steps to take to prevent this problem from becoming permanent.

\”Why didn\’t my other doctors tell me this?\” he asked.  

I shrugged my shoulders.  \”I guess they didn\’t have the time to do it.\”  We had just spend about an hour together talking about his cancer experience and other non-medical things (computers, music).  He nodded in agreement, acknowledging the reality the big advantage he has in my office: access to me.

The second patient, coincidentally, had the same kind of cancer.  In fact, it was my experience with the first patient was just a few months before this second patient\’s presentation that allowed me to quickly diagnose and treat his problem.

He had a peaceful expression as he sat across me in my office.  \”This whole thing got me thinking differently about spiritual issues.\” he explained.  \”I just keep thinking about how many things worked out to get me diagnosed and treated.  I noticed the lump and thought to myself: \’I should make an appointment with Dr. Rob.\’ and then you saw me the next day.  Within a week I was diagnosed with cancer and things took off from there.\”

I reminded him that before he got treatment, we had a discussion using secure messaging about \”alternative\” treatments for the cancer that were suggested by a family member.  \”You remember when I told you about how Steve Jobs\’ death was probably due to the time he spent going after alternative treatments before getting standard medical care?\”

He nodded.  \”Yeah, and I\’m real glad I listened to you. Everyone has told me I\’m doing amazingly well and have a good chance to be cured.\” he told me. He looked away from me and took a deep breath. \”I just wonder what would\’ve happened if you weren\’t in this office.  I usually hate going to the doctor and put stuff off.  I just wonder if things would\’ve turned out like they did.  It makes me feel like angels were around me.\”

The third patient was a younger woman who was recently diagnosed with a very serious cancer.  I saw her and her husband for the first time since the diagnosis.  After tearful hugs and warm greetings, I asked how they were doing.

\”Once we got over the initial shock of the diagnosis,\” she explained, \”we are doing much better.\”

She had presented with symptoms not generally suggestive of cancer which persisted and grew worse.  After going after the most likely causes, I got a secure message from the husband expressing his worry and asking me to do more to diagnose and treat her.  After his message we immediately ordered the test that made the diagnosis. \”She got really mad at me for doing that,\” he said with a smile, \”but I sure am glad that I did.\”

She grudgingly agreed that he was right, and that (for once) a husband actually had an \”I told you so\” to hold over his wife.  It\’s usually the other way around.  \”I would have waited much longer before doing that test.  I\’d probably have been nearly dead before making the diagnosis.\”  She paused and wiped away a tear.  \”I\’m just so glad you are our doctor.\”

All three patients were significantly impacted by the different ways we do things in my new practice.  Two of them may owe their lives to these differences.  The main difference is the markedly better access my patients have to me.  They don\’t have a frustrating phone system to navigate, an army of office staff to convince, or a 2 hour wait to endure to get my time or attention.  They needed my help, and they had easy access me when they most needed me.

One of the worst parts of the job of being a doctor is to diagnose people with cancer.  At the same time, however, there is a sense of this being the highest honor paid to me as a person: I am the person who is there to help when the stakes are highest and the future looks darkest.  I have the opportunity to be the right person at the right place at the right time.  Bad stuff happens, and I will likely face many more sad yet meaningful days in the future where I am called on to stand beside people on the hardest days of their lives.

But yesterday made me happy.  The hardest thing I\’ve done in my life — giving up my old practice and starting something completely different — is succeeding.  No, I\’ve not yet earned enough to pay all of my bills (I am getting closer on that front).  The success is measured in other ways: I\’ve saved patients\’ time, saved them lots of money, decreased their frustration, and restored some of their trust in doctors.  This way of practicing medicine is not just different; it\’s better.

Yesterday was the day when I saw its biggest success: my new practice saves lives.

Boom.  Dynamite.  Boom.

3 thoughts on “Boom Goes the Dynamite”

  1. Jennifer Bollen, MD

    Attribution error or selectively fitting evidence to the hypothesis Dave. Lets check in with the 1500 patients you dropped from your practice and see how they are doing..

    Patients can have all of those without having to pay a surcharge for access – in fact millions at Mayo, Partners etc all have same day appts, email access, caring docs..

    You are a good guy trying to do what you can to keep your income as high as possible and still see some patients but the model is elitism not a scalable model of care. If even 10% of docs flip to panels 1/3 the size guess what will happen? Tens of Millions with NO care.. Primary care docs don’t need to make 500k a year.. Being a doctor includes an ethical obligation to carry your share. I am sorry you didn’t figure out how t be efficient without having to abandon 2/3’s of your patients but the rest of us believe First do no harm..

    1. You are entirely wrong, Jennifer:
      1. My name’s not Dave.
      2. I am earning far less than I did in my old practice (here did you get $500K/year??). I was doing quite well in the old system; I just couldn’t accept that I was unable to give good quality care for my patients (due to the increasing percentage of my time spent dealing with finding proper codes, creating bloated notes, and complying with meaningful use requirements). I’ve taken a cut in pay to do better for my patients. I hope to get my pay back to the level I used to have, but that’s far in the future.
      3. My practice panel is up to 500 and is not anywhere near full. I do believe I can build this practice to be bigger – possibly up to 1000 or more patients if I use other providers (counselor, dietician, pharmacist) to cover all of my patients’ needs. I do hope that this practice model can become more efficient and become a viable alternative to the bad practice model most PCP’s face. Wouldn’t that be a better world for both patients and doctors?
      4. About half of my patients have no insurance. My fees are between $30 and $60 per month, which is hardly elitist. People pay that much for far less. Plus, I feel that because of the care they get, I save more than that for many if not most of my patients (by taking the time to find cost savings and to practice more efficient care). Most of my patients are grateful for what I do, not elitist or entitled.

      Again, the reason I left my old practice and started this new practice in this model was because I felt I was harming people by not having time for them. It seemed worse to me to take care of a lot of people if that care is forced to be low-quality. If you don’t understand that, you probably are not a PCP.

      Some advice: don’t preach at your patients like you did to me in your comment. It’s condescending and presumptuous, and it totally undermines any point you are trying to make.

  2. Boom indeed. You’re clearing new ground, and I reallyreallyREALLY hope that your model spreads. I’d happily pay $100/month for access to a doc like you, and carry insurance [what we geezers knew back in the day as "major medical"] for any dx that required treatment beyond a prescription.

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