Thursday, July 18, 2013
I'm Rob and I am a recovering doctor. Yeah, I am recovering ... doing a lot better, actually. Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies. I've had to learn how to manage my own money (now that I can't count on them to bail me out any more), but things are looking a lot better. I am beginning to see how much better it will be to be on my own.
The key was when I realized that the system wasn't going to change no matter how much I accommodated its unreasonable requests. I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients. But I've come to see that all the promises to take care of me and my patients were written in sand, and that it couldn't resist the temptation to cheat on me. I tried to do what it asked of me, but as time went by I couldn't take how dirty it made me feel.
I want to believe it was sincere when it told me it wanted to change. I think at its core, it wants to help patients and doesn't want to go on those spending binges. But no matter how sincere the promises sounded, I was always left alone as it threw its money at every sexy treatment, procedure, or drug that walked by. Then it would go off on tirades about how much I spent and that I didn't do enough to keep to our budget. It was always my fault. I think it's just easier to pass blame on others than it is to do the hard things necessary to really change. To be honest, I think it was terrified at how much real change would hurt.
But I can't sit around and wait for the system to change any more. My patients were getting less and less of my time, and I was getting to the breaking point. I know there are a lot of other doctors who are willing to do whatever the system asks, but I can't sit around and watch it self-destruct. It's not what's best for the system, for us doctors, and for our patients. Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons. I just hope that happens soon.
So what of my life? Rebuilding everything from scratch has taken all of my energy, but I have much more of that energy when I know it will do good. I can spend more time with my patients, answer their questions, and focus on them, not the system. Even though I see how much more I could give my patients, how far their care is from where I want it to be, they are delighted with my attention and availability. They are used to doctors giving them the leftover scraps of attention, not the bulk of it. I hope they believe me when I say that my plans for them are much, much bigger than what I am giving at this time.
I've resisted the temptation to run to the arms of another for the sake of financial security. My experience with the system shows that nobody pays you without expecting more in return. Then I'd just end up compromising to keep the money flowing, and that is a kind of relationship I just got out of. Instead, I am trying to do it the right way, keeping my focus on what is important: giving my patients the best care possible. It's not been real exciting--there hasn't been much to write about, spending my creative energy on a building system that will actually improve care, not hinder it. I've also had to pay much more attention to the little details: tracking where the money comes from and where it goes. I'm not real good at that, so it's been a steep learning curve, but it's given me a sense of control I've not had for a very long time.
I can't tell you how different it is, working in a job that actually rewards me for doing the right thing. I am no longer penalized for healthy patients or an empty waiting room. I am no longer paid less to spend more time with people or to handle their problems without forcing them to come in. I don't have to live in fear of the Medicare audit. I can spend my time with my patients as they need it. I had a guy come in wanting me to help him with his struggle over a decision about his elderly father. We talked for nearly an hour, and I realized that I wasn't at all frustrated by that fact. There's no CPT or E/M code for this kind of thing, but it was what my patient needed, and it is what he pays me for. He left with a look of appreciation we doctors seldom see. It is incredibly freeing to not have to apologize for doing the right thing.
But I don't want to brag. I'm no saint, and the system I've built to this point is far from perfect. I've still not taken a paycheck, and that can't go on too much longer. Things could still go wrong. But my decision to no longer try to live in my dysfunctional and destructive relationship has been worth the pain and uncertainty. I miss the patients I had to leave behind, and I am sad to hear about the care they are getting. I hope I can build something good enough that lets me offer to them what my new patients have, something I'd given up on: hope for the future of health care.
That's all I've got for now. Thanks for listening. One day at a time.
Live and let live.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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