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Friday, November 1, 2013

365

That’s how many days I’ve been away from our health care system. A year ago yesterday was my last day in my old practice. Here’s what I wrote in my journal: “This is it; this is the last day of work at Evans Medical Group. It’s more weird than anything. I am sad to leave the comfort of my old job, but happy to be able to spread my wings and be myself. I am sad to be leaving many of my patients, but happy to be dreaming again. It’s frightening to be stepping out into the unknown as I am, but comforting to know I’ve got time to work things out. I am afraid, but I am confident. This is my new reality, a reality which changed with amazing speed.”

“Yesterday was a tough day in that my patients weren’t nearly as open to my ideas as they had been. It seemed I had to do a lot more explaining of things that other people understood without saying. I did well to not get angry or frustrated by things yesterday, but despite the nice going away party they held in my honor, I essentially slogged through the day. Today is that surreal last day, the day that is the period at the end of my 18-year sentence. I dreamed of today, but never dreamed of it.”

Please note that the phrase “18 year sentence” was a metaphor, referring to a sentence of words, not a prison sentence.

That evening I got my favorite beer, “Three Philosophers” made by Ommegang Brewery. It’s a beer you sip, not “throw back,” worthy of the occasion.

The next day, a year ago today, was my first day of my new life. I gave a talk for my patients, explaining my vision for my new practice. Here’s what I wrote in my journal on that day: “Saturday morning, my first day off as an ex-employee of Evans Medical Group. Yesterday was kind of surreal. I didn’t do anything special (aside from buying some really good beer to celebrate). I saw my patients and tried to act as normal as possible. The morning went quite smoothly, and there were a couple of no-shows, even, which made the time go smoother. The afternoon wasn’t quite so smooth, slowing down later in the day with people who just didn’t get what I was doing and didn’t get the fact that this was my last day. It was a little frustrating, but not so much that I got angry about things. I just tried to do my job to the best of my abilities and then move on. I tried not to think about things too much.”

“The thought of what I am doing now still is pretty scary. I’ve got my talk for my patients today (wish I had given myself a little more time for that, but it is what it is). Then I’ve got a ton of planning to do and decisions to make. What computer system will I use? Can the system I am considering do what I need it to do, and if not, are they willing to change to become what I need? If not, then what other systems are out there that give me what I need. What if there isn’t any system to do that? Where do I put my office? Who do I hire? How do I get the whole thing started? How many people will follow me? What will I do if more come than I can handle? What will I do about Medicare? These are the questions that are off the top of my head, and there are quite a few more my mind is not coming up with. It’s scary to step out with so many questions unanswered. It’s really scary.”

So, if I had known then what it would really be like, would I have done it?
• 365 days ago, I thought I’d start seeing patients some time in December, then open up in full at the start of the year. I ended up waiting until Feb. 5 and spent twice what I expected to get my office done.
• 365 days ago, the one area I expected no problem was the computer system. I had worked with EMR products for 16 years, getting a national reputation for physicians using EMR successfully. EMR, it turns out, is so closely tied to the payment system I left that I gave up after trying multiple systems, eventually choosing to build my own system.
• 365 days ago, I expected my 18 years in practice, and my patient-centered style would overcome my patients’ caution at embracing a different system of care. Their fear of change, it turns out, is quite strong; while the majority of my patients have come from my old practice, the number who have followed is much less than expected.
• 365 days ago, I expected to remain on good terms with my old practice. I am still surprised and disappointed about that one.

The biggest difficulty came when I realized I couldn’t use an EMR and had to build my own system. I realized that going with a standard EMR would have two huge negative consequences: I would not be able to give the quality of care I wanted to give, and I would always feel the same “out of control” feeling that plagued me at my old practice. But building my own system (if it was even possible) would have an immediate consequence: I would need to devote enormous time and effort to build it, limiting the growth of the practice and resultant financial stability. The choice to do the harder thing, building for the long-term, has meant my personal income has dropped far more than expected. There’s no danger of the business itself going under, but paying bills at home has been quite an adventure in faith.

This is no surprise to anyone who has started a business, I’ve since learned. It’s a rite of passage, a hazing, a gauntlet to be run. This is like basic training in the military, a time of pain and sacrifice that separates the pretenders from the truly dedicated. It’s not fun. 365 days later I can echo my own words: It’s really scary.

But I don’t regret this path at all.

On a personal side, I have learned huge lessons of faith and perseverance. Good ideas alone don’t make for success; there is a price in blood, sweat, and tears that forge the metal, turn the rock into a gem, turn the canvas and paint into art. I’ve learned to disregard extremes of emotion, knowing that bad days are followed by good, and good days don’t prevent future bad ones. The key is to not over-react to situations that push you to panic or celebration. Panic leads to bad decisions, while excessive celebration leads to disappointment. The best place to live is in the middle. Satisfaction is better than celebration, and panic can be extinguished by determination.

On the medical front, I’ve learned what people want most: to communicate. Far more than promises of fancy websites and care plans, people are thrilled at the simple fact that I answer the phone. They need to be heard. For the previous 6,570 days (18 years) I focused on the paying customer: the person in the office, so the phone was a burden, an enemy. Over the past 365, this burden and enemy has become my greatest asset. I listen. I talk. I connect. This is the care that people are missing, and the thing they value the most.

My goal for the next 365? I’ve got lots of ideas. I want to improve communication, put better tools in the hands of my patients, become better organized (having someone besides me running the business would be nice), focus on education and outreach, and put medical records more and more in the hands of the people to whom they really belong: my patients. But my real goal is simple: survive, improve, grow (in that order).

Thanks to everyone who helped me over the past 365. When things get good enough I might just buy you an Ommegang.

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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
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.

Auscultation
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
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.

Controversies in Hospital Infection Prevention
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).

db's Medical Rants
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.

DrDialogue
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.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
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.

Glass Hospital
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.

Gut Check
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.

I'm dok
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.

Informatics Professor
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
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
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.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
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.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
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.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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