It was 6:30 AM. I heard the garbage truck pull up in front of my house. Crap. I hadn’t put the trash out the day before, but usually that wasn’t a serious problem; they usually come much later in the day. I ran, partially clothed, to the front of my house and looked out. The truck was pulling away.

Sigh. It was not a good way to start the day.

I logged in to the messaging app for my practice and saw several potentially serious situations. One was a calcium level that was high enough to merit a call from the laboratory with a “panic” value, the other was a person with a rapid heart rate and shortness of breath. I found times for both of them to come in so we could handle things, and then headed to my office.

When I got to work I got a message from my nurse. One of my patients had died in her sleep, apparently of a pulmonary embolism. Hard to know for certain, but the husband said that was the likely cause. We all signed a sympathy card and I added a personal message of what an honor it was to care for his wife. It is always an honor when someone entrusts you with their care. I’m never exaggerating when I say that to people. I thought back on the difficult situations I’d dealt with in this woman’s life, the encounters in the office and the crises I’d addressed. Now none of them mattered, but I was able to do something for a time, to make things better. In reality, that’s all any of us can ever do.

The patient with the high calcium level came in to get labs rechecked. “I’m doing better now,” they told me. Vitamin D level was very high, so I suspected it was an inadvertent overdose of D. Typical symptoms: some mental fogginess, blurred vision, fatigue, frequent urination. Hydrate, hydrate, hydrate, and (obviously) avoid vitamin D. Repeat testing tomorrow. I spent time looking up vitamin D intoxication and the proper approach to it. Generally, high calcium levels are not dangerous (although low levels are very serious), so I could take some time with this. Still, the day was taking a bad turn. The patient left the office and I went to my desk and took a deep breath.

Then I heard something I never like to hear: “Dr. Rob…can you PLEASE come to exam room 2 RIGHT AWAY!” Courtney is usually pretty calm, but there was a tone to her voice that belied panic. It was the person with the high heart rate. Courtney had been taking their blood pressure and they “zoned out” while she unsuccessfully tried to get a reasonable number. I went to the room, had the patient lie down, put my stethoscope to their chest and heard an extremely fast rate…over 200 easily. Ed, my partner had heard the panic in Courtney’s voice and came to the room as well. I handed the stethoscope to him and his eyes widened as he listened.

“Please call 911,” I told another staff member as calmly as possible. Despite my deep concern over the patient, there is no benefit to loosing your cool in front of the patient or your staff. The first thing you do at a code is to check your own pulse, I was taught during residency. So I remained calm. At least on the outside. The ambulance came and I had printed out all the information about the patient they’d need.

“Will you come with me to the hospital?” the patient, who was doing better, asked me. How sweet. No, I am a hands on doctor who spends extra time with my patients, but that generally doesn’t include rides in ambulances to the ER. I’d just get in the way of the EMT’s, the folks who really know what they are doing in this situation. I squeezed their hand as they headed out the front door and told the spouse to let me know when they knew what was going on. Then the office was quiet again.

The rest of the day was full of lesser crises: uncontrollable vomiting, headaches that were unremitting, panic attacks that “required a work excuse,” and other primary care delicacies. By the end of the day I was emotionally spent, and ready for relief. I came home and got on my Peloton to relieve some of my tension. It was either that or beer. The class was a kick-ass session that pushed me beyond normal and resulted in a personal record for 30 minutes. Exactly what I needed.

I got off the bike and checked my messages. An x-ray result came back from a patient I saw the day before. It was bad. There was a 9 cm mass in one of the lung fields (about the size of a softball). Damn…..damn, damn, damn, damn, damn. There was nothing to do about it that evening, but I’d have to call in the morning to tell the bad news and the need for an immediate CT scan. I hate those calls. Yeah, I know that, like rectal exams, they are worse to receive than give…but making those calls is one of the most dreaded things I have to do.

I reached out for help in the midst of this shitstorm of a day. I have a woman who is particularly supportive and encouraging, avoiding trite solutions to difficult problems. I have Toot, my cat who always thinks I have the best lap in the world. I’ve had days like this in the past, but not for a long time. The next couple of days wouldn’t be fun either, as I had to clean up the debris from this category 5 day that rammed into my generally pleasant life.

I posted on the Peloton Facebook page about my bad day, and how the kick-ass workout was just what I needed. I got about 5 thousand likes (and hugs, hearts, and sad faces), and a ton of supportive comments. Social media can be a trap, a time-waster and a soul-sucker, but it can also help soothe your soul. The outpouring of support for my post did just that for me. I got tears as I read the comments. Good tears.

All of this sucked for me last Wednesday. But as I thought about the day I realized that it sucked even more for each of my patients (and their family members). It wasn’t that I was wrong to feel the pain of the day. We clinicians have it tough at times. But the whole reason I go into the office is to help the folks who are having worse days than me. Self-care is essential to give me the fortitude to handle days like that. That’s why I exercise, and that’s why I value people who I can reach out to when I am having bad days. But the hand I hold, the sympathy I give, the thoughtfulness with which I deliver bad news is my gift to those I’m responsible for. The fact that I can make some of the worst days in peoples’ lives a little bit better is a comfort to me. It gives me purpose. It gives me resolve to get up the next morning and face new (hopefully less stressful) crises. How I handle each of them will impact those people as well, even for “lesser” problems.

I’ve recovered. I still feel the aftershocks of the day from hell, but things have moved on and I am focused on handling the aftermath as well as possible.

It’s all I can do.

Except maybe to remember to put out the trash next week.

In case you missed the news: there’s a new virus in town…and they named it after a cruddy beer!!

All of the hype surrounding the coronavirus has created a new and difficult situation for me, my staff, and on doctors around the world. How do we answer our patients who are terribly afraid of what they are hearing? China is quarantined, the Olympics might get cancelled, Oprah has been crowned Empress of civilization…OK, that Oprah thing is no true, but the rest is pretty scary. Is it hype that we should downplay, or is it seriously scary stuff that we should warn our patients, our friends, and our families about?

In response to this, I wrote a summary of what we know now about the COVID-19 virus and sent it out. The response has been overwhelming. People say that it is “concise,” “balanced,” and “level-headed.” My mom is proud of that last one. I’ve come a long way.

They also have commented on the lack of political agenda in what I wrote, a compliment that confuses me some. Why would I use a patient education piece to push a political agenda? I haven’t done so in my handouts on otitis media or ringworm. The goal of this was not to rail against the demagogues that interfere with public health, scream at the press that incites the public in attempt to increase revenue, or theorize about the authoritarian nation where this infection began and its government’s role in creating this virus for evil intent. I've heard each of those opinions, and whether or not they hold truth has nothing to do with care of my patients. The handout was written to give patients a mooring of truth and sanity in a world of hype and fake news.

So here is the handout in all its glory. Feel free to share it, to steal it, to republish it, to make wrapping paper out of it. I don’t care. Just start talking sensibly about this issue that may or may not be the scariest health crisis we’ve faced in our lifetime. Yes, it’s important to have good leadership in this crisis, but it’s more important for us to work together as a country, as a world, to minimize the likelihood of disaster. The biggest danger, in my opinion, is no from the virus, but from societal panic and the chaos that could create.

————

Information regarding the Coronavirus

This communication was originally written on 3/2/2020. It will be updated as time progresses.

What is a coronavirus?

Coronaviruses are a common type of virus that infects people and animals. They usually cause mild illness in people, with typical upper respiratory symptoms. As is the case with other viruses (influenza being the most important example), a virus strain that infects animals can mutate and transmit to humans, creating a more severe illness. Usually this doesn’t cause big problems, as these animal to human transmissions are not able to have person to person transmission. On rare occasions, an animal to human transmitted virus becomes contagious to other people. This is what is thought to have happened with the COVID-19 (the current coronavirus that is causing all of the problems).

There are several factors that make COVID-19 so concerning:
- It is quite contagious from person to person.
- It has a 14 day incubation period where it can be contagious before symptoms appear.
- A significant percentage of infected people have little to no symptoms, yet they can still spread the infection to others.
- For those who do get the illness, there is a much higher percentage who have serious, even fatal complications.

The virus has spread rapidly from China, despite the quarantines and other aggressive measures to control spread of the virus. Most public health officials feel that it is very likely we will face a pandemic (serious infection that affects a high percentage of the world population) in the near future. How soon? It’s too early to tell. But we do feel it is time to prepare (see below).

The COVID-19 Infection

Infection is spread through usual means for respiratory viruses: mainly through hand contact or contact with airborne droplets from an infected person. The incubation period is up to 14 days, but symptoms typically show up from 4 to 7 days after exposure.

As stated before, a significant percentage of those infected are completely asymptomatic, and a majority (over 80%) have mild illness (mild cough, fever, upper respiratory symptoms). The more serious illness is generally in the lungs: lung damage, pneumonia, shortness of breath. This is much more common in the typical ‘vulnerable’ populations: the elderly, diabetics (especially those with poor control), and people with significant lung disease. It is not expected (at the time this is being written) that there will be a significant number of healthy individuals getting the serious life-threatening disease. Of note, infants and young children have not had an increased death or disease rate in the areas of high rates of infection.

At the present time, the COVID-19 infection has a 2% death rate associated, which is more than 20 times that of influenza. There is not a rapid test to diagnose the infection at the present time, so most diagnoses will be made by sending samples to national labs or just presuming the diagnosis where and when the infection rate is high.

What is Being Done

As of now, there is no definitive treatment for the infection, other than supportive measures to help the person while their body deals with the infection. There are some medications under investigation for this, but none of the medications we typically prescribe have been found to be effective in treating the infection. Specifically, antibiotics and antiviral medications (like Tamiflu) have not been helpful in treating this. Vaccines are being developed, but even at the rapid pace these are being done, the most optimistic time frame for a vaccine is 12 to 18 months from now.

The main effort presently is focused on slowing the spread of the virus by isolating infected individuals and quarantining communities when appropriate. The hope is that this will slow the spread while treatments, public health measures, and vaccines are developed. The more time we have, the more prepared we will be to handle the problem.

How you can Prepare

The first and most important thing is to not panic. The vast majority of our patients are not at risk of getting serious infection, even in the midst of an epidemic. There is no reason to avoid school, work, or travel to places not effected by the virus (go to https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html to find specific travel restrictions/recommendations). Since we don’t know how fast this disease will spread, there is not yet cause to cancel plans for travel or other gatherings.

But we must be realistic: people will panic still, and that may itself cause significant problems. Stocking up on non-perishable food in case of a quarantine (which would last 2 weeks) is reasonable to do in the upcoming weeks/months. Furthermore, there are some practical things you should consider:
* If you have vulnerable family members, come up with a plan to care for them, and have alternate plans should the primary caretaker get sick.
* If you are a single parent, figure out ways to cope with illness to you or to one of your children.
* Workplaces should consider how to handle employee absences.

It should be noted that it is not advantageous for healthy people to wear masks, unless they are working directly with infected or high-risk individuals. Infected people may decrease the spread of respiratory droplets by wearing a mask. Overall, good hand-washing and common sense measures to decrease viral spread are always more effective than extreme measures. Is it reasonable to cut back on shaking people’s hands? Maybe, but mainly to just build good habits in case there is a local epidemic.

What our office is Planning

We have considered what measures we will take if/when the epidemic hits our area. Until that happens, nothing (aside from publishing educational material like this) will be different. If we are in a local epidemic, we will do the following:
* Cancel non-essential visits to leave room for the influx of coronavirus related care.
* Convert essential care visits to video or phone visits whenever possible.
* Be available to reach out to infected individuals as best we can.
* Continue to educate you and coordinate with other providers in our area.

This is a serious situation, but it is not the apocalypse. Most of us have not gone through a pandemic before, so this will create a lot of uncertainty and even panic in our communities. It is vital that we all think ahead, but not panic about what could happen. Reach out to your neighbors, talk to your coworkers, and make plans with your family on what you can do to prepare in a way that is thoughtful and meaningful. Avoid spreading information that is not from very reliable sources, and don’t use this crisis to point fingers or increase political divisiveness. This is a time where unity needs to be of highest priority.

The best case is that this is an over-reaction and the pandemic will fizzle out. The worst case is that we will be caught unprepared, and that lack of preparation will cause harm to those who need help.

Sigh. Welcome to prior-auth hell.

These are generic ear drops I ordered for presumed fungal infection of the external ear. The cash price for the drops is $15 for a 10 milliliter bottle (I checked before prescribing them). “No,” I responded, “it would be ICD-B36.9 for otomycosis.” (translation: ear fungus)

Jenn tried submitting this new diagnosis without success. She then noted that this medication was supposed to be authorized without need for authorization, so she called the pharmacist, who ran the 30 milliliter bottle through the computer system and the medication was authorized. That size bottle goes for $27 cash.

Rob bangs head on wall.

But Jenn didn’t yell. She didn’t say any profanity (that I could hear). Jenn’s a saint. She lost 30 minutes of her life to this nonsense, as did the pharmacist. As for me, I just got a little extra blood pressure points, a little acid corrosion of my stomach, and a stronger desire for beer when I get home this evening.

While my practice doesn’t accept money from insurance companies, we do serve our patients for the sake of their health. This means that we advocate on their behalf in a system that seems hell-bent on making care less accessible. Prior-auth hell is one example of this wall that has been built up between people and reasonable care. Electronic medical record hell, pharmacy trickery hell, specialist non-communication hell, bloated hospital gouging hell, media non-story hype hell, and opportunist alternative medicine hell are all contributors to the hell-fire heat we are all feeling.

By “we” I don’t just mean the people working in my office. I also don’t just mean primary care office workers. The pharmacist, the patient, and even the insurance company minions were drawn into the crisis over a $15 medication authorization. Would you want the job of explaining the reasoning behind denying a 10 ml bottle and accepting a 30 ml bottle? All-in-all there are countless hours sucked from people’s lives across the country each day, sucked away with the end product being: nothing. No, not nothing, the end product is worse than nothing; the end product is poorer care for people who need it and increasingly embittered healthcare workers.

Nobody benefits from this. Nobody is making more money because of this prior authorization for a 10 ml bottle of antifungal. The way the system works, it’s not that the insurance company refusing to pay increases their profits by denying cheap generics. Their benefit comes from having a “cost control” plan in place to prevent unnecessary or inappropriate medication cost. As is often the case, the inefficiency of the process and resultant increase in cost is passed through the insurance company and sent to the person writing the checks (whether individual, business, or government institution). The idea of “cost control” makes some sense (nobody wants expensive unnecessary drugs to be paid for without question), the total chaos of the system results in everyone gaming that system to pass the buck up to the person paying the bill.

So what can be done?

The biggest thing is to stop using insurance to pay for cheap things! Automobile insurance does not cover routine maintenance, or even expensive repairs. The car owner is expected to pay for these out of pocket, with no consideration if they can afford it. While this results in hardship, I’ve heard of no one clamoring for “MediCar for all” (universal auto coverage for all car service). So why are we paying insurance for primary care? As hard as some try, primary care docs will never give anyone a huge bill for their care.

Primary care, generic medications, and even simple emergency care don’t need to be expensive. They are only expensive because of insurance hiding the cost and putting a layer of administrative people between the patient and the care they are getting. If pharmacies competed for your business by publishing prices of drugs, what would happen to those prices? The same is true for simple emergency care and primary care.

I know that because I’ve lived in that kind of system for nearly 7 years. My patients know the price I charge for everything I do, and we don’t do something before getting their agreement on the price. Often, that’s not a difficult thing to get from them. “That medication is 75 cents per month,” or “The thyroid test costs $4” is not often met with anything but chagrin over the low price. My goal with these low prices is to make it so my patients can’t afford to stop paying my monthly fee. Because they are paying me directly I am aggressive at trying to keep them as my patient by cutting cost and improving service. This is good business for me.

So why not push that to the rest of the cheaper side of medicine? Insurance payment is why we have $100 hemorrhoid cream. It’s why a 100 year-old medicine for gout still costs $70 per month. It’s why generic ear drops for swimmer’s ear still cost over $100. It’s because someone is still willing to pay those ridiculous prices: the insurers.

The direct pay pricing can even extend to more expensive things. There is a surgery center in Oklahoma City that accepts only cash payment and posts the cost of procedures online. Doing this will significantly reduce the overall cost of these procedures (and patients can go back and recoup money from insurance if needed). While this doesn’t work all the time, the reality is that our healthcare crisis (and yes, folks, it is a crisis) doesn’t necessarily require more or better insurance to fix it. Perhaps we need to stop insuring things.

Maybe that’s the road out of hell.

It was about 10 years ago.

I was already running about an hour behind and the next patient on my schedule was a familiar one…but not for good reasons. This was a very complicated patient with huge emotional needs, whose visits would routinely go 30-45 minutes, well beyond the 15 minutes allotted. My heart sank. I would either have to hurry a visit with a genuinely needy person, or run even more late in my packed schedule. I chose option B, as I almost always did, but did so with an overwhelming sense of claustrophobia. I felt trapped.

An image came to my head as I entered that exam room. I pictured a line of patients snaking out of each exam room, going out into the lobby, out the building, and as far as the eye could see in all directions. It was a never-ending river of need flowing at me. If I solved one problem, another was soon to follow. If I made one person happy, the next would be frustrated. If I had a good day, a bad one would always be around the corner. It kept coming at me. Day after day, week after week, month after month, year after year.

That was the beginning of my struggle with burnout. The image of the never-ending line of need waiting on each exam room was depressing, anxiety-provoking, and ultimately the thing that pushed me away from fee-for-service medicine and into my direct care practice. I made that change nearly 7 years ago, and I believe it saved my life as a primary care doctor.

The real problem was that I cared too much. I couldn’t short-change the patient once I was with them in the exam room. I couldn’t force them to only give me one problem, make them reschedule for something I could handle that day, or refuse to check the ear of the child who happened to be in the exam room with the patient. I am a caretaker. I am a giver. Yeah, I get taken advantage of because of that, but I thrive off of taking care of people. It’s what gets me out of bed in the morning. It’s what I’m on this planet to do.

And I was being robbed of that.

Over the past 7 years since I left, things have just gotten worse. A new survey by Medical Economics Magazine (full disclosure: I write for them) involving more than 1200 physicians showed a deepening of the already bad situation of physician burnout.

• 92% of surveyed physicians reported feeling burnout during their career.

• 68% reported feeling burned out now.

• 73% said that the feelings of burnout made them want to quit medicine.

• Of those, only 13% sought professional help for dealing with their burnout.

There are many reasons for this growing despair among doctors:

• Too much paperwork and government/payer regulations.

• Poor work-life balance/work too many hours

• Electronic Health Records

• Lack of Autonomy/Career control

• Insufficient pay/declining reimbursement

• Overwhelmed by patient needs

The first five items on this list are non patient-related. These are the things distracting the doctor before they come to the exam room to see you. Patients aren’t more needy than before; they just have a smaller and smaller portion of the doctor’s time and attention. I probably spent 50% of my time on direct patient care, and saw between 20 and 30 patients per day, with the remainder spent on documentation, billing, and making sure all the appropriate boxes were checked for the government. In contrast, I now spend about 80% of my time on direct patient care and see between 8 and 12 patients per day.

But, I have to confess, I still feel some of the emotional fatigue and claustrophobia I felt in my old practice. Perhaps it’s just PTSD from my past life as an abused fee-for-service PCP But I think there’s something more than that. I was talking to a retired pastor recently, and the subject of burnout and professional fatigue came up. I mentioned the image of the never-ending line of need, and he nodded. “Yep. Pastors definitely feel that. You give your heart out to someone and then there’s another person coming in the room when they leave.” The teachers I’ve talked about this with deal with this as well.

Add to that the stresses and strains of life we all face, and things get harder. I have big financial stress caused by the lean years as I started my practice. I also have aging parents I want to see as much as possible. And I went through a divorce (which I don’t blame on my work, but it definitely played a part). My life is not harder than most, but it’s not easy either.

So I find myself having moments of struggle. Do I have it in my tank to do another week, month, year, or decade? I find myself wishing I didn’t care so much. I wish I could treat my work as a job — just a means to make an income.

I guess I could do that. But I’d have to give up my soul. I’d have to give the compassion that drove me to risk everything by starting this new practice. I’d have to see this profession as a job, not as a calling.

And I couldn’t look at myself in the mirror if I did that.

I know that doctors are not alone in these feelings, and am not implying that we are being victimized. But I am saying that the system as it stands selects against the very type of doctor most people want: a compassionate person who listens and gives time when needed. Those doctors are eaten alive by they system and forced either to conform to the fast-moving conveyor belt of modern healthcare, or they retire early, work in corporate medicine, or escape completely (like I did).

Medicine will always have some degree of burn-out. But we must find a way to reward doctors who are caring and compassionate, not chew them up and spit them out. It’s a hard job. Even the best of situations (like mine) can weigh heavily.

Especially if you care.

I’m back…again.

I think one of the reasons I have slowed down (big euphemism here) in my writing is that I feel like my posts are predominantly about how wonderful my new practice is. That does two things: it makes it seem like I’m just bragging all the time about how smart I am and how great my practice is, and it makes it seem like I’m saying the rest of medicine is lousy in comparison. This is not polite. This is not in my comfort zone.

But this is basically the truth.

OK, I guess I’m just a conceited SOB. Sorry.

I was struck by the difference between my care and that of the rest of the system as I cared for a patient recently. She was complaining of a strange pulsating noise in her ear that had started a few weeks before. We chatted for a while, as I asked about any sinus symptoms, if she’d ever had anything else going on like this, what other significant symptoms she was having (headache, other sensory changes), and just general medical questions. The diagnosis remained a mystery as I went to examine her. The exam was…not really helpful. She had no foreign bodies in her ear canal (something I was guessing I’d find), no fluid behind her eardrum, and basically a negative exam.

The diagnosis was “pulsatile tinnitus,” which is basically a description of her symptoms: a loud whooshing symptom in her ear. I’ve said in the past that one of the best tricks a doctor can do to bullshit patients is to use fancy words to describe exactly what the patient says to you. So when a person has a rash, you call it “dermatitis.” When they have a loose cough, you call it “bronchitis.” And when they hear their heartbeat as a “whooshing” in an ear, you call it “pulsatile tinnitus.” It offers absolutely no help to the patient, but it perhaps impresses them with your grasp of medical jargon and distracts them from the fact that you don’t know what is going on with them.

Not satisfied, I chatted with her some more, talking about tinnitus, something that I’ve had for the past 15+ years. It came on suddenly in my 40’s and was associated with the sudden inability to hear words in a crowded room. This is one of the few bad things I’ve inherited from my now 92-year-old dad. I talked to her about the frustration of this condition and how certain things make it worse. One of the main things is when other people mention the ringing in their ears. It makes me so aware that the volume of my tinnitus is turned up to “high” (it is very loud as I type these words). Another thing that makes tinnitus worse, I mentioned, is aspirin therapy.

She interrupted my rambling. “Wait. Aspirin makes it worse? I just started on aspirin therapy for my knee a couple of weeks ago.” And that is pretty much exactly when her pulsatile tinnitus began. This was about 20 minutes into my time in the room with her. Let me clarify: she had spent 25 minutes in my office, 20 of which was spent discussing her situation with me. She didn’t wait to see me, and I didn’t spend my time staring at a computer screen making her answer questions to satisfy data quality measures. I just talked to her, and this fact came out at minute 20 of that discussion. That’s a moment in the exam room that doesn’t happen often: after 20 minutes of discussion.

This is one of the reasons I believe this practice model is clearly superior to the “care as usual” with the assembly line/hamster wheel care that is done by most primary care doctors. I have time. I can listen. I can chat with people until important information emerges. In many, if not most, primary care practices, this patient would’ve been referred to ENT for a workup that may have possibly resulted in lab testing and likely CT scans or other testing.

Having the time to listen was superior to an ENT consult, labs, or a CT scan. Time is something, even after growing my practice to 800 patients, I have for them. I give patients 30 minutes of my time for normal visits, and 60 for complex care or new patient visits. Often the time I spend is shorter, but that time is available. This is exactly the opposite of what happens in most primary care settings. I used to have only 15 minutes set aside for people, much of which was devoted to documentation, and had to stretch that out to 30 or more minutes to get in the basics of care for complex problems.

With so much attention to physician burnout and the high cost of care, the discussion spends far too little time talking about the lack of time most primary care docs have for their patients. Before I left my old practice (nearly 7 years ago!), I was increasingly burdened by the fact that I was increasingly being robbed of the time necessary to give good care. I was spending too much time dealing with red tape from the insurance companies and from the rules from the government aimed at “improving care.” Since quitting, I’ve yet to see more than 15 patients in any given day, and am often reminded how much my patients appreciate the time I can spend with them.

It doesn’t matter to me how we accomplish it — whether by the direct care model or another — but we must fix this problem. Primary care just had its worst year in matching residents from medical school, this at a time when we need more primary care doctors and less specialists.

My decision to practice this way has saved my career, has healed my heart, has saved money for my patients, and has given me the time to listen, the time to care for them.

It seems that I have been suffering from a prolonged case of writer’s block. It’s not that I haven’t been writing (I write regularly for several publications); it’s just that I haven’t been able to write anything worthy of putting up on the blog. I guess it felt like I was just writing about my practice all the time (which has consumed much of my energy), and that gets a little dull.

So how to pull myself out of my writer’s block? Write about or rupturing healthcare system? Write about the abuse of doctors at the hands of our insurance (and government) overlords? Write about the insanity of politics and the mutilation of common sense? Write about the royals? About Cheetos? About mutant ducks?

Whoa. Mutant ducks. Hmmm. Maybe I should start writing again. I wonder if they eat Cheetos.

Before getting to the important subjects, however, I think I will reintroduce myself and give an update about the world of Rob. Maybe I can knock some of the rust off of the writing gears and get things moving again.

My Practice

My direct care practice continues to be successful. We just celebrated our 6th anniversary (traditionally known as the Taco Anniversary). Yes, despite being run by a doctor, my practice has succeeded! Amazing. We are up to 800 patients total, and continue to grow slowly. Despite being one of the larger single-provider direct care practices, I’m not close to overwhelmed with work. My days are steady, with an average of 8-10 patients per day. I still take Monday mornings off and close early on Friday (3 PM). I get home around 5:30 on most days and don’t have much work to do when I get home. My life is great.

I am as strong of a believer in the practice model as ever. My patients are happy (very few patients cancelling their monthly memberships) and the care I’m giving is far better than I ever could give in the brutal and patient-harming atmosphere of fee-for-service medicine. There really is no comparison.

Jenn and Jamie continue working faithfully for me (beloved by my patients) and bail out my sorry butt with great regularity. They are happy too, and get really angry when I talk about retirement any time before age 90. I’m lucky to have them. Very lucky.

New Addition

The big recent change is the addition of a new doctor to my office. Dr. Ed joined me and the troops this January, but not as an employee of the practice. He is simply using our office as his launch pad to start his own direct care practice. He’s paying half of my overhead, is surrounded by folks who know how to do this kind of practice, and has gotten some of the folks who don’t want to wait 2 months before getting a new patient appointment with me. He has already exceeded 100 patients, which is fabulous growth. It’s truly a win/win.

What I really like is to see how delighted he is to be working in this practice. It’s like someone telling you your kids are fabulous, your tacos are tasty, or your feet smell like chrysanthemums. Maybe not that last one…I got carried away. Regardless, he tells me how happy he is on a daily basis, being able to “practice the kind of medicine I became a doctor to be.”

My feet do smell pretty good, by the way.

Welcome

Additionally, there’s a third direct care practice in town, run by a husband and wife team of really talented physician assistants. The three practices are teaming together to form a network with which we can contract with small to medium sized businesses to offer them an affordable option for care. This is called the Welcome Health Network, and will be available to local businesses very soon.

We hope to also use this network to collaborate on other projects to give better patient-centered care, such as lab services, radiology, medication dispensing, and access to cheaper ancillary services. It’s a work in progress, so I can’t say exactly what will come of it, but I am very excited to have other hands moving things forward in my world.

Personal

What about my personal life? If you are reading this, you are probably a pathologically loyal reader, a stalker, or my mom. If the last one, this next stuff shouldn’t surprise you. Here’s a run-down of my life:

• I went through a divorce two years ago, but have maintained a decent relationship with my ex. We don’t hate each other; It just didn’t work out.

• My kids are doing well, with my youngest spending a large amount of my money in a private university close by.

• I lost nearly 50 lbs over the past 4 years, doing it the boring way: exercise and portion control. I ran a 10K a couple of weeks ago (despite my 50-something body) and might aim higher later this year.

• Did I mention that my feet have a floral odor to them?

• Overall I am happy with my life where it’s at right now. I am exceedingly blessed.

Anyway, it does feel good to pound out a blog post and I hope this gets my writing started again. There are topics to be covered, words to be spoken, secrets to be revealed, foes to be vanquished, ducks to be mutated, Cheetos to be eaten.

Aloha.

Here it is:

So, as I've been asked since this experience, what was the process of doing a TED talk like?  Here is my take on the process from start to finish.

Getting Started

Augusta holds TEDx talks every 2 years, and I actually applied to do one 2 years ago but got turned down.  The reason I was turned down was not because the idea was bad (otherwise I wouldn't have given it this year), but that I didn't know what they wanted.  Here is my take on what's most important in making the pitch for a TED talk:

1. Have a fairly narrow focus.  I was too broad with my initial presentation, just talking about how great direct primary care is and not distilling it down to basic ideas.  When I presented my topic this year (which I did in November), my focus was clear: two changes (not accepting insurance payments and charging by the month) together can radically change the doctor/patient experience for the better.  This. resonated well with the TEDx committee.
2. Understand that they want "bigger picture" ideas, not sales pitches.  It's the transformation of healthcare and the hope that innovation brings that made them excited.  It's not the success of my personal business that interested them.  The concepts I highlighted were applicable to all innovation.  Root problems within any system may only be fixable by changing the basic reward/payment structure.  It's the concept of, "your system is perfectly designed to yield the outcomes you are currently getting."  Changing outcomes requires system redesign.
3. Come from your passion.  One of the big selling points for my talk was my passion for it.  I clearly love what I do and that's not common in the healthcare space in our country.  Good ideas are fine, but good ideas backed with passion are transformative.

The Process

Once accepted, I was given a schedule to build my talk and distill my ideas to a concise talk.  There were three "coaching" meetings (in November, December, and January) set up with the leadership of our TEDx experience, with each one requiring more and more polish.  I went to the first coaching session with an outline and many questions.  By the second session I was developing my script, but still had many questions.  The final session (about 2 weeks before the big day) was supposed to be a reading of the near-final script.  I will discuss what really happened in a bit.

These sessions were very helpful, as the criticism (which there was plenty of) was aimed entirely at making my talk as successful as possible.  I not only welcomed criticism, I would've been disappointed if there wasn't any, as I knew my level of inexperience.  Between the sessions I developed my concepts, cut out the unnecessary fluff (lots of that), and rewrote my script repeatedly.  Fortunately, they realized my topic required more time and I was given a 15 minute time slot (which is the longest).  

The Home Stretch

Before the last coaching session I totally changed the structure of my talk, taking out a ton of fluff and writing what I thought was concise and clear.  When I presented it, though, I was hit with the terrifying label of "infomercial."  My talk was much too focused on my own practice and not the ideas the practice is built on.  To have such a horrible monicker attached to my talk was highly motivating, and I quickly cleaned things up and made the ideas the center of the talk, not my own practice.

After that, it just came down to repetition.  I gave my talk repeatedly to friends, to families, to employees, to my plants, to household appliances, to anything that would tolerate my chatter.  This was huge, as the feedback I got (especially from my microwave) was key in adding focus and polish to the talk.

The Big Day

The hard thing about a TED talk (for me at least) is that it is scripted.  I do well when chatting off the cuff about things I know and understand, but a TED talk requires far more clarity of ideas.  The script is very important, and the slides are much less so.  I made my slides to only be supportive of my very key ideas, with most of the ideas coming from me, not a Power Point.  

The script was in a teleprompter, which took a bit to get used to.  The day before the talk was the dress-rehearsal, where I finally got a shot with the teleprompter, and I found it very distracting.  By the end, however, I got the hang of it and that comfort helped a lot on the day of the talk.

The TEDx event itself was amazing.  Talks started at 10 AM and went until 4 PM.  My talk was right around the middle.  The organization of the talks with the breaks for snacks, lunch, and performances by poets and musicians was very well-done.  You'd expect the audience to get bored sitting for that long, but it really was engaging and enjoyable (even for this distractible brain).

Yeah, I was nervous (terrified) when I got up there, but the hours of repetition, coaching, and practice paid off and things went pretty well.  I really am glad I did the start of the talk as I did, as it got the audience engaged and made me feel connected to them.  It's much easier to give a talk to a smiling audience. 

The Bottom Line

I'm really glad I did the TEDx talk, and I'd do another without hesitation.  But I'd only do it if I had another subject I was equally passionate about.  I truly am more interested in the idea of direct primary care spreading than my fame for a talk.  That doesn't mean I don't want some fame, but the passion that has driven me over the past 5 years is what fueled the effort to do this.  

If you get a chance to attend a TED or TEDx event, do so.  It's absolutely worth the time and money.  And if you are eloquent, passionate, and have lots of time (and appliances), consider adding this to your bucket list.

That statement from a recent patient was a summary to me of what is bad in our healthcare “system.”  It’s a terrible summary of what is seen all over this country with people who must make the choice between financial solvency and health.

Here’s what happened:  It was a new patient I saw, who is a veteran who owns two businesses.  He went out on his own when he “kept getting laid off.”  He has largely been successful in what he’s doing, but as is the case with many these days, he couldn’t afford health insurance.  This was especially bad because he had a heart attack last year, which required stenting and a significant hospital stay.  He didn’t fill me in on the financial details, but there’s no doubt that this hurt him significantly.

Unfortunately, he has another problem: glaucoma.  His glaucoma is bad enough to need surgery done to avoid losing vision in one eye.  Sadly, he can’t afford that surgery.  We talked about the difficult choices he had to make with his health and his money.  “It seems to me that the eye problem is the most urgent problem you have.  You don’t want to lose your vision,” I told him.

That’s when he smiled, waved his hand over his right eye and said, “Don’t worry, doc.  It’s just one eye.  I’ve got two.”

My stomach lurched to hear this statement.  A guy who has done nothing wrong aside from choosing self-employment (and perhaps inheriting less-than-stellar genes) is left with the choice: financial devastation or blindness in one eye.  He works hard, has served the country, didn’t complain to me at all, yet here he is about to be swallowed by the ever widening maw of impossible medical expense.

How can we help people in this situation?  How can we care for those who need care without increasing already out of control spending?  There are many who give simplistic answers to that question, but most of them ignore the cause of our problems: the out-of-control cost of care.

In my practice, which is (by the way) a direct primary care practice, where I don’t accept payment from insurance companies but rather am paid by my patients in the form of a low ($35-$70) monthly payment.  Because I am paid directly by my patients I am motivated to save them money whenever possible, as it justifies paying me the monthly fee.  Also, me being much less busy (I see between 5 and 12 patients on a normal day), I can work to find ways to avoid unnecessary care.  This is especially important because many of my patients don’t have insurance, and those who do have high-deductible plans.  

This patient experienced this aspect of my care on this same visit.  He was also interested in being screened for colon cancer.  Some friends had urged him to do so.  “But when I called to find out what a colonoscopy costs, they said it would be more than $6000!  I can’t afford that!”  I sent a quick message to my nurse and she relayed that there is a gastroenterologist in town who can do a colonoscopy for $1600 (extra for biopsies, of course).  

He was impressed by this, as are many of my patients when we do lab tests for more than 80% discount, dispense medications that are more than 70% cheaper than the average discounted price from GoodRx, and when we know where to get $100 ultrasounds, $250 CT scans, and $450 MRI scans.  These prices are out there for any doctor to use, but my business model makes it to my advantage to give patients the best value possible.  So there are ways to cut the cost of care for many people.  Unfortunately, not many doctors use these resources, much less know about them.  

A deeper question in this man’s case is the fact that his heart disease was treated at a local hospital which specializes in heart disease.  While much of the public may see this as a positive thing, those who know healthcare realize that these hospitals are very quick to do procedures that are not always necessary.  In his case, he had a stent placed on a 65% lesion, which doesn’t have great evidence supporting its placement.  Much of interventional cardiology treads the ground lightly in the area of solid epidemiological evidence of benefit for some very expensive procedures.  It seems to be based largely on the visceral response all of us (me included) would have: “It could only help to stent the 65% lesion, wouldn’t it?   What will it hurt?”  It turns out that the evidence for much of this is light.

In this case, the stenting of a 65% lesion could result in blindness, as the money he would have spent on eye surgery was instead paid to the interventional cardiologist and the “heart specialty” hospital.  

Much of what I just said is controversial (and I expect significant objection from the interventional cardiologists), but the details are not as important as the overall point.  The hospitals and procedural specialists benefit hugely from a very permissive payment system that doesn’t demand great evidence of benefit for payment to occur.  

Our system is based on sickness, not health, so expensive procedures are favored over preventing those procedures from happening in the first place.  Until we address the elephant in the room, the “what will it hurt” mentality that justifies costly procedures for dubious benefit, we can’t expect to make any progress in fixing our system regardless of who pays for that care.

OK, aside from that llama thing.

I have good days and bad.  Some days I am content, connected, focused, and motivated.  On those days I enjoy my job, I enjoy the people I’m with, I am willing to be inconvenienced by interruptions.

On other days…not so much.  I wake up as grumpy Rob and (despite multiple cups of coffee) the old codger doesn't leave me alone.  I keep score of all the ways in which life has conspired to make the day difficult.  Too many red lights.  Too windy.  Clearly terrible things going on.  I am not patient with people, and am distracted by little things.

Like I said: I am normal.  I do my best to not let these things stand in the way of the care I give, and I try to hide my emotions from my patients.  It’s a necessary part of the job.  But there are still days I’m better at it than others.

Yesterday a patient came to the office to pick up prescriptions.  He spotted me in my office and asked if he could have a few minutes of my time.  Yesterday was a grumpy day, so I immediately felt a little miffed at this interruption of…whatever I was doing, but I quickly stuffed that down and told him to come on in.

“Are you OK, doc?” He asked as he sat on the couch.

“Yeah I’m fine,” I replied, obviously not hiding grumpy Rob as well as I thought.  “I’m just tired.”

He proceeded to ask me several questions: one about guitars (we both play) and one about medications related to a certain problem.  I banished grumpy Rob and did my best to answer his questions.

He stood up to leave and then grew serious.  “I really appreciate you and your office.”

“Thanks,” I said.  We get that a lot since I switched to direct care.  People appreciate the personal attention we can give.

He grew more intense.  “I’m serious, doc.  I don’t know what I’d do without you.  You saved my life twice, you know.”

“Twice?” I asked.  “I remember when you were on death’s door with diverticulitis and didn’t want to go to the hospital.”  He came very close to developing peritonitis, so it wasn’t an exaggeration that I saved that time.  “What was the other time?”

He made a gun with his fingers and pointed into his mouth.

“Back when things were so bad, a few years ago, I was ready to end it all.  I even bought a rope.  It was you who saved me.  Things you said gave me hope.”  He teared up as he spoke.

I remembered.  His life was falling apart: his wife abandoned him, he lost his job, he didn’t have a place to live, and he had a very painful orthopedic condition.  I recall getting him on medication, helping him find a place to live, pointed him toward agencies that could help him, and just gave him moral support.  I also remember that we didn’t pay much attention to whether or not he could pay us.

“Thanks,” I said, recovering the ability to speak.  “It’s nice to hear I make a difference.  I’m just doing my job, but it means a lot to hear that.”

I walked over to him and gave him a hug.  “I really appreciate you and your staff.  You mean so much to me.  I love you, doc.”  He wiped at his eyes and nose as he walked out.

As I sat back at my desk, the weight of what he said crashed down on me.  Recognizing someone who is critically ill with diverticulitis is easy.  I take minimal pride diagnosing the obvious, even if it is life threatening.  Even if grumpy Rob is in the room.

But this...

This isn’t about diagnostic skill.  This isn’t about intelligence, problem-solving, or clinical experience.  This is about caring.  And caring can vary based on attitude.  What if I was tired and didn’t pay as much attention?  What if I said to myself, “I’ll deal with that next time?”  What if I didn’t take the time, look him in the eye, try to do the extra thing?

I don’t feel pride about this; I feel gratitude.  I am grateful I have a job in which I can make a difference.  I am grateful to have Jenn and Jamie, who are willing to go the extra distance for people.  I’m grateful to have a practice in which I can take extra time with people (and to discount the care if I want).  I am grateful grumpy Rob was on vacation when I saw this patient.

But I am also sobered by this.  It’s not just in the exam room where words make such a difference.  It could be a text from a friend or an email from family members.  It could be on a good or a bad day.  I have to be ready to help when the next opportunity arises, regardless of how I feel.  I’m fortunate to have incredible role models in my parents, who have always lived their lives with the intent to leave people in their wake who are better off than the would’ve been. I can only strive to do so as well as they have.

There’s a lot of crappy stuff in this world.  There are a lot of things pushing people down as they struggle to survive.  While I can’t fix what’s wrong in the world, I’ve always got opportunities to put good in the balance and tip the scales back up.  

Even grumpy Rob can do that.

---------

I recently went hiking in a beautiful national park outside of Columbia, SC. This park was in a swampy area and contained all sorts of wildlife (called “critters” down here) and plant life (called “trees and those other things” down here). When I was young, my dad would take us kids on hikes through the Adirondack Park in New York, and so being on hikes in nature hits my soul in a very deep spot. It’s emotional, it’s physical, it’s a treat to my senses, and it’s a spiritual experience for me.

I was pondering what it was that moved me so much while hiking. I am the sort of guy who probably overdoes the pondering bit, as I find myself doing far too much pondering about my pondering. It’s what I refer to as being “too damn introspective.” Anyway, the forrest in this park is filled with spider webs, and since it was misting rain while we were walking, the webs glistened with beads of water that sparkled in the sun. It was stunning. As I did my damn introspection bit, I saw an especially large web with a huge yellow bodied spider in the middle. One of my hiking companions told me it was a golden orb weaver spider, and this spider sat in the center of this huge web as if to claim its beauty for her own. It was as if she wanted me to know that she had made that web and that I could applaud at any time.

I stood and appreciated both the creation and the creator for a while and then moved on, passing by tens, hundreds of other amazing webs and proud creators displaying their work. But did they really care about their audience? I thought about how many more webs there were in this forrest that I would never see. I thought about how many webs there were in the world of equal or even greater beauty that no person would see. I thought about the irrelevance my life posed to these spiders (unless I chanced into their web and destroyed their work), how they would continue living, dying, building webs, having young, catching food, and building beautiful creations. I was but a lucky observer of a minuscule segment of the beauty that spiders spin each day.

And I was humbled.

This is part of what makes nature a spiritual experience for me. I realize that I am but a small part of a huge tapestry painted on this planet. And even the entirety of the beauty that is and ever will be on this earth is but a minuscule portion of the beauty in the cosmos. And that beauty is but a speck when you consider the beauty that has ever existed and will exist until time comes to a close. 

I think about this kind of thing when I fly in a plane and see all of the tiny little cars darting around doing their crucial tasks. That’s me down there, a self-assured dot of unimportance in the big picture of things. Perhaps the birds look down on us as we see the spiders in the forrest. Perhaps they have a more realistic perspective on things. Or maybe birds too are “too damn introspective” like us. 

This all makes me take a much lighter view of life. Yes, the things that are happening in this world are important. Yes, the pain that I see daily in my office, the struggles I have in my own life, and the fears I have about all of our future are real things. But they are small things in the tapestry of all space time. They are spiders in a forrest. The cosmos won’t be altered in any significant way by any decisions I make.

So does this make us not take things seriously? No, I think that this perspective gives us more reason to hold our small time and place here as being precious. Like those spiders, we need to build our webs with skill, care, and a desire to make them as beautiful as we can. Whether we are building them for our creator/God (which is what I believe), or doing it simply because that’s what we spiders do: we make beautiful webs.

So if someone cuts you off in traffic, if you are enraged by something on Facebook, if you are desperate for love, or if you are anxious about your future, just remember: we are all spiders making our webs. Be humble. Take it easy on the other spiders out there. And build the best damn web you can in the part of the forest you call home.

When it's not always raining there'll be days like this
When there's no one complaining there'll be days like this
When everything falls into place like the flick of a switch
Well my mama told me there'll be days like this

When you don't need to worry there'll be days like this
When no one's in a hurry there'll be days like this
When you don't get betrayed by that old Judas kiss
Oh my mama told me there'll be days like this

I had been listening to that song this morning and then walked into the exam room and was greeted with a big smile.  She's a widow in her early 70's who has been my patient for around 20 years.  She takes care of her grandchildren, loves kids in general, and tries to keep active, despite significant arthritis in her back. 

She is also valium for my soul. 

Our discussion had a level of familiarity and friendship, her sharing about her granddaughter's inquisitive mind and me returning stories of my son's insatiable appetite for information when he was young (as a 4-year old he peppered me with questions about "welcome centers" for about 20 minutes).  We both laughed at each other's stories and I took care of her medical problems and preventive medicine.  She complained when I scheduled her colonoscopy.  The visit ended with the inevitable hug and an "I love you" from her.

Valium.

There is something unique in the relationships I have with my long-term patients.  I've practiced now for 23 years, and many of those who followed me to this practice were with me from very early on.  There's a level of intimacy when you know about a person's health problems, live through emergencies and tragedies in their lives, and have the responsibility of medical care for a person.  It goes beyond friendship and familiarity.  It really feels like family, but without the complications family brings.

Being a doctor involves hearing a person's narrative and working to direct it in the best direction possible.  There are some people for whom I have become a significant part of their narrative, and others whose narrative I know better than anyone else.  It's a bond that doesn't happen anywhere else.

The dangerous thing is to let the familiarity get in the way of the objectivity I have to keep to do a good job with them.  But the depth of my care for these people can also serve as a motivation, as I want to keep them around as long as possible...for selfish reasons.  Doing the job for this long, I've figured out that balance, but I'm always extra aware of my lack of objectivity with these people.

The opposite kind of patient, the ones who somehow find ways to get under my skin, pose an equal threat.  I have to put aside my own emotions and give them all the best care I can give.  Something about giving care to them will often ease the negative emotion.  I guess it's hard to feel bad toward someone while doing good for them.  In truth, I don't have many patients I feel negative toward.  Compassion and judgmental attitudes aren't good bedfellows.

But I do let my emotional walls down some with certain people.  Some people just make me smile when I see their names on my schedule.  It's not that they are nicer than other patients (although that is often true); it's more that they look at me with different eyes: eyes that are grateful, relaxed, and interested in me as a person.  My blood pressure goes down after spending time with these people.  They care for me and give me emotional care I am grateful for.

It's one of the greatest privileges of my job.

When everyone is up front and they're not playing tricks
When you don't have no freeloaders out to get their kicks
When it's nobody's business the way that you want to live
I just have to remember there'll be days like this

When no one steps on my dreams there'll be days like this
When people understand what I mean there'll be days like this
When you ring out the changes of how everything is
Well my mama told me there'll be days like this

Yeah, I know I used that line once before, but it’s a special day for me today.  Humor me.  Five years ago today I earned my last money from an insurance company.  Yep, today is my five year sobriety date.  

Five years.  

That was before the affordable care act, before the Cubs won the World Series.  Before anyone knelt for the national anthem, and if they had, people would’ve probably not minded.  It was before the election of a reality TV star to our highest office, before “fake news” became a thing (there was plenty of it, but nobody called it that).  It was before half of the rock legends died, before Anthony Wiener went to jail, back when Hamilton was a guy nobody knew much about who was on the 10 dollar bill, when the world wasn’t quite this warm, when Oprah hated me.  Actually she still does.  I’m not sure why.

I left my old practice because of “irreconcilable differences” with my ex-partners.  Instead of going to the VA, joining another practice, or moving to New Zealand, I started a different kind of practice.  My Yoda, Dave Chase (who wrote a book that you MUST read) told me about “Direct Primary Care,” where doctors don’t charge a lot, but are able to see a lot of people and give good care because they are paid by their patients.  It made sense to me.  There were a few folks doing it, and I talked to a couple (I’m looking at you, Ryan) who made it sound possible.  

So I did it.  I dumped all insurance and started charging people a flat monthly fee.  People were skeptical and only my most loyal patients followed me (about 200).  It took a while, but we figured out how to make it work, and my patients figured out that this was the best experience they ever had in healthcare.  

And we grew.

I added a second nurse, went through several medical record systems (even built my own) before finding one that actually focused on patients over billing.  Had some squirrels in my attic (some of them dead), went through an ice storm, a couple of earthquakes, and a hurricane.  I also got socks with llamas on them.

And here we are.  I have over 700 patients and still have room to grow.  My busiest day was when I saw (gasp) 15 patients in the office.  I still average between 9 and 10 (although much of the care we give is done via messaging or over the phone, so that number’s a bit deceiving).  I still take Monday mornings off, still get home around 5:30 most days, and still seldom get bothered on weekends.  My life is still much better than it ever was.

And there is still room to grow.

So what of my critics?  What of the people who said I was shirking my duty to Medicare, abandoning my patients, and putting myself over what was best for others?  They are idiots.  Was it truly better when I was unable to give good care to any of my 3000 (give or take) patients, or is it better when I can give excellent care to 700?  Am I truly abandoning my duty to the system by keeping people healthy, taking people off of medications, and keeping them away from ER’s and hospitals?  Have I truly put myself above others by taking a huge cut in pay and spending my retirement money?  Yeah, that last bit is finally changing, but I’ve got 700+ people who say I made the right choice (and I am still seeing old patients who finally come back to me from my old practice).  

What about the criticism that says that this model can’t work in the big picture?  What about the argument that if all docs convert to practices like mine, they would not be able to meet the care needs in our country?  Again, I am actually giving excellent care to 700 patients.  That’s 700 more than I was giving good care to before switching, and 700 more than most doctors give.  And there is room to grow that number beyond 700 through increased system efficiency, use of midlevel providers, and improved technology enabling better care, automation, and better communication.

This model works.  It is able to give truly good care to people, decreasing their use of the system and dropping the overall cost of care.  Do I have proof of these claims?  No, but direct primary care has dramatically grown in popularity with both patients and doctors over the past 5 years, to nearly 1000 practices around the country.  Patients and doctors chose it because it’s better.  It makes sense.  I don’t have to waste people’s time, force them to wait in my office (my wait time still averages about 30 seconds), or spend most of my time staring at a computer screen.

So I will pick up my medal for 5 years’ sobriety.  There is no temptation to go back to my old life.  I hit rock bottom and have been actually enjoying the job of doctor.  My future is bright.  My income is growing.  My schedule still has plenty of room.  My patients are happy.  How many doctors can say that?

And we are growing.

And I am happy.

Nobody is happy. It is absolutely miserable.

The solution for this problem that many doctors take is to not prescribe any pain medications, leaving patients to seek out someone who will. This takes the huge headache away from that doctor, but creates significant problems to patients who have been on these medications chronically. Beyond that, it creates a culture of suspicion, as patients are often assumed to be manipulating to get more and stronger medications.

While there are certainly some who are aggressive and deceitful in their attempts to get narcotics, many others (most, in my opinion) are led down this path without their knowledge. It goes something like this:

Step 1: Patient has legitimate pain and is given a pain medication.

Step 2: Pain medication helps with pain, and has an added bonus: a euphoric effect, which the patient equates with pain relief.

Step 3: Patient develops worse chronic pain, and is put on a regular but low dose of narcotic, getting some pain relief but acquiring a desire for the euphoria (which also helps deal with life stressors, etc).

Step 4: Patient develops a tolerance to the narcotic, requiring higher dose to get same pain relief/euphoric effect.

Step 5: Eventually patient gets to a high enough dose of narcotic that they have significant withdrawal if they miss a dose or two, making the “need” for medication even stronger. This all happens while they are not getting adequate pain relief due to tolerance.

So is the patient nefarious in their actions? No. They have legitimate pain that they want treated, and are brought down a path to a place where they not only have that pain, but also have a dependency on a dangerous drug.

The doctor may have been well-meaning at the start, but becomes careless, putting “keeping the customer satisfied” as a top priority. This isn’t nefarious either, given the time it takes to educate people in this subject and the small amount of time each primary care doctor has for actual patient care. It is too difficult to do the right thing and to address the pain properly (or explain that pain should be expected and doesn’t always need treatment).

A study presented at the American Academy of Pediatrics meeting in Chicago found that many adolescents become chronic opioid users after having common surgeries. Legitimate pain (from surgery) leads kids into the slippery slope of chronic pain medication use. It certainly doesn’t seem unreasonable to give medication for postsurgical pain, yet this is a potential gateway to the dark world of dependency and addiction.

We need to change our views on the use of these medications. I was taught that a patient with acute pain was not high risk to become abusers. I was also taught that it was our duty as doctors to treat pain. Allowing a person, much less a child, to suffer in pain seems to go against compassion. But it seems that this misguided compassion is actually causing significant harm.

The view of our society also needs to change regarding pain. I regularly have people with routine problems (back injury, ankle sprain) who request opioid pain medication. But pain is simply a part of our existence, and our desire to block out all pain with medications leads to even more pain in the end.

The solution isn’t to vilify the person on narcotics or the doctor prescribing them. The solution is to realize that pain should be an expected part of life, and learning to live with it is far better than to cover it up with substances. We also need to understand that nobody is safe (as this study demonstrates).

I do think there is a place for these medications (I certainly appreciated them when I fractured my humerus), but they need to be treated as a last resort, not a routine approach to pain. They need to be reserved for severe acute pain, and should be very closely monitored and limited. This isn’t easy for those of us taught to see pain as a “vital sign,” and were taught that acute pain should be treated.

One of the questions people ask is whether or not I see patients in the hospital.  I assume they aren’t are asking about my eyesight in the inpatient clinic.  I can see quite well in the hospital, thank you.  But what people are really asking is if my care extends to the hospital, or most importantly, will I still be their doctor if they are hospitalized?  The answer is yes, but not in the way people are asking.

One of the unfortunate things about care in the US is that it is divided up. There is very little communication, and even less coordination, between doctors working in the hospital, the ER, in specialty offices, and in primary care.  Each of us does our own thing like we are the only one caring for the patient. Obviously, people don’t take on different identities when they go to different locations of care, so why should the system treat them in that way?  In an ideal world we could get the different parts to communicate well and coordinate care, but people (including doctors) are lazy and don’t want to take the time to see what care has been done elsewhere or discuss the care with the other providers.  Some would argue that I should have used the word “busy” instead of “lazy,” and that may often be the case, but I’ve made information on my care of patients easily available to other doctors in a way that would improve care quality and even possibly make things easier, but I’ve yet to see this information used.

A solution in the hospital setting would be for me to take care of my patients when they are admitted.  The problem is that inpatient adult medicine is complex, time consuming, and something I haven’t done for a number of years.  Any advantage gained by me knowing my patients would be offset by the infrequency of my care for patients in the hospital.  So what’s the solution?  Is there a way to overcome this inevitable fracturing of care?  /The key to this is to remember that I am still your doctor, even when you are under the care of other doctors!/ When you are in the hospital, the ER, or at the specialist, I am still your doctor, your advocate, and a good source of information and advice.  The biggest benefit of paying monthly is that I don’t have to worry about being paid, so I won’t withhold care outside of the office.

So what does this mean?  Here’s what my patients should do if they are getting care outside of our office:
1.  Notify our office if you are admitted to the hospital or go to the ER. - We don’t need to know immediately, but sending a message via Spruce, sending an email, or leaving a message on our phone system will let us know things are happening.
2. Don’t assume we are notified of ER visits, hospitalizations, or specialist appointments. - That happens, optimistically, about 30% of the time.  The remaining 70% we find out in retrospect (like when you come to the office and tell us you were in the hospital for 3 weeks) and have to call for records.  It’s a broken system, folks.
3.  If you are confused in your care or feel frustrated in the hospital or ER, contact us!  - I can’t guarantee you I’ll get your message if it is 2 AM, and I won’t overtly second-guess doctors giving you care, but I can help guide you to ask the right questions, say the right things, and get better care.
4. Send us a quick message after each specialty visit and recap your visit.  It’s really helpful to get your perspective on things (often better than that of the doctor), and it puts us on the look-out for notes from them.

Too few people take advantage of this, and so end up frustrated and alone.  They fail to remember that our practice is totally different.  We work for our patients, are paid by them, and absolutely want to be there to help when they need it the most.  It may not be in person, but we are always a phone call or message away.  The system may not do well at continuity of care, but open communication between us and our patients can bridge the gulfs between different aspects of care.  It's one patient, so care shouldn't be divided.

Go to a typical primary care practice (like the one I was in for 18 years) and try to find out the cost of anything and you will only get shrugs and obfuscation.  It’s not only that they don’t know what things cost, but the design of the system on which care is built goes out of its way to hide those costs.  Why?  Because it would be infuriating to people to see that their insurance pays 100% more than someone else’s plan and it would be equally mortifying to some physicians to realize just how bad their pay is compared to the docs down the hall.

Why does this happen? The answer is quite complicated, but basically there's a secret back door that many parties use to hide cost and so continue overcharging everyone.

A. Office Visits

Insurance companies make contracts with physician groups to pay a set of fees for a set of procedures (including office visits).  These lists can be quite long and vary from group to group.  Some docs are better negotiators than others and some are part of a larger consortium of docs who negotiate on behalf of the group.  These negotiated fees are specific to a policy (usually an employer), and will vary widely, even within a single insurance company.  So one patient with Blue Cross may have insurance reimburse the doctor $15 for a strep test, while others pay $2.  

Complicating matters more is the fact that doctors don’t keep track of each of these fee schedules.  The common practice is instead to bill the highest paid amount for each item ($15 for a strep test, for example), and then write off what isn’t paid (so they’d write off $13 for the insurance company that only pays $2 for the strep test). In my old practice we had hundreds of different fee schedules from different insurance plans.  This is why billing staffs are so large for most offices: keeping track of all of this is a very tough job, and making sure that doctors put in all the right codes to get maximum payment is often even harder.  

For an office visit there are often many codes.  A well-baby check, for example, would result in a specific code for a wellness visit with an extra code if the child had any illnesses (level 3 visit, usually).  Then if immunizations were given, there were three charges per vaccine: counseling (usually just giving a handout), administration fee, and the fee for the actual vaccine.  So at a 2 or 4 month visit, a visit with 5 different vaccines given, there would be 16 or 17 different codes submitted for the visit.  Each of these codes have a different dollar amount for each insurance plan.

So you see why asking the question of “how much does an office visit cost?” is a difficult one to answer.  Now, if a person is self-pay (uninsured), they are charged the full fee-schedule price for each item (which is never what insurance companies pay).  Yeah, that’s lousy.

B.  Facility Fees

If you go to a private office, be it primary care or specialist, you have to pay the charges from the doctor as described above.  If, however, you go to an institution, such as a teaching hospital, you will also have to pay a “facility fee.”  Facility fees are exactly what they sound like: fees charged for the use of the facility (which are paid for by insurance companies), and often these charges are substantial.  An office visit that is a bargain at $100 will have a $50 or $100 fee added (for example).  These fees are not charged by private offices, although there is (at least) one exception.

You may have noticed that many specialists have their own surgical suite attached to their offices.  Most of the GI doctors in our city have them, as do many of the surgical subspecialties.  This is so they can collect the facility fee that would otherwise go to the hospital or surgical center.  This is a substantial enough fee to justify the huge expense of building and maintaining a surgical suite of their own.

C.  Drug Costs

Once you’ve dealt with my profession, you get to move on to another delightful part of healthcare: pharmacies and pharmaceuticals.  These each have their own pitfalls waiting to snare the unsuspecting bank account.

I’ve actually discussed the shenanigans pharmacies enroll to get extra money.  In short, they hugely vary in what they charge cheaply and what they charge a lot for.  Go GoodRx.com and type in any drug and see the disparity of price — not only from pharmacy to pharmacy, but also the price from which GoodRxsomehow gives the discount.  Amlodipine (Norvasc), a common medication for blood pressure is free at Publix, but costs $13 at Walmart and nearly $20 at CVS.  So why not shop at Publix for all your drugs?  Lipitor, the popular cholesterol drug, is $12 at Kroger, $21 at Walmart, and nearly $70 at Publix.  Additionally, pharmacies often will charge an insured patient the copay amount for their drug…which makes sense, but what happens when the cash price is significantly less than the copay?  I think you can guess.

Blatant gouging happens in the area of generic drugs.  Once a haven from the high price of medications, generics are often nearly equal to the price of the brand drug.  One example of many is Adderall XR, the long-acting version of the attention deficit drug, which has a cash price of nearly $200, the same as the brand drug. Even the discounted GoodRx price is still more than $100 at most pharmacies.  Why?  There are a number of reasons, but one of them is the consolidation of the generic market, with many generic companies being owned by the brand pharmaceutical companies (here is a list of the top generic companies; note how many are owned by or have an intimate relationship with a big brand pharma company).

Drug Rebates are the last issue I’ll hit on (because I care about my readers and would feel terrible about any burst aneurysms).  Rebates are basically a legal form of kick-back from a pharmaceutical company to the insurance company or pharmacy benefit manager (PBM).  Obviously, it is very beneficial for a drug to be listed on the company’s formulary — and even better if that drug is exclusive.  So a drug is listed on the formulary, and instead of giving a significant discount to prices to compete for business (and reduce cost), the rebate (often around 30% of total sales) is sent back to the insurance company/PBM. 

Solutions?

So what can be done about all of this nonsense? Simple awareness is a start, as angry consumers still have some power (albeit less than in the past).  Also, passing laws that would require simplification medical billing, restricting or eliminating facility fees, and outlawing rebates would help some. Transparency in pricing may help as well — require pharmacies to make the prices of all of their drugs public, so customers could shop around.

But more than any of this, I think the fact that many companies are still able to see American healthcare as a “cash cow” is the most pernicious force that keeps costs hidden.  Drug companies, pharmacy chains, hospital systems, and insurance companies are able to still make huge profits while the system crumbles under the weight of increased cost.  There’s no competition for consumers by lowering cost because each of these parties has a secret back door to the vault that takes much less work than the usual means of making money.  

Close the back door.  It's letting the scoundrels in and letting the health of our country out.

Those who know me understand that I don't brag much.  I do my best, follow my ideas, and try to avoid being too much of a doofus.  If I come on good ideas, it's usually accidental.  I didn't start this blog thinking that I'd gain notoriety and become a target of Oprah's hatred.  Those things just happened. 

Well, I've recently stumbled on a really great way to market my practice. It was not at all planned, nor would it ever be something you'd read about in business magazines (Forbes, Popular Mechanics, or Highlights).  But it has become a "thing" in my office much like the way that llamas have become a "thing" on this blog (and also like how I like to put quotes around the word "thing").  

My secret?  Being a goofball on the phone.

One of my pet peeves is how most medical practices greet their patients when they call.  Nearly 100% of the practices I call insert the line, "if this is a medical emergency, please hang up and dial 911."  The problem with this is that the doctor's office is asking the patient to evaluate their medical condition before talking to someone who can help them evaluate their medical condition. Some people are probably calling to figure out if their problem really is a medical emergency, but are told to doctor themselves before talking to a doctor.  

Additionally, the phone systems are generally used as defensive weapons to keep patients away from doctors and nurses, instead leading them through a digital maze where they can leave a message and hope to speak to someone in the near future.  Speech on the phones is not reimbursed (usually), and so the main goal is to get the person to make an appointment, where speech is reimbursed.  This creates a very frustrating phone environment for people who have simple questions or who don't know if they really need to be seen.  

In response to this, very early in my new practice I put the following on my voice message when people call: "I'm not going to tell you to call 911 if this is an emergency because I don't think my patients are morons."  This got a lot of laughs and pats on the back from my patients.  

And that's when all hell broke loose.  I had a new canvas on which to paint my silliness, and so my phone messages became increasingly silly.  

Here are some actual examples of my phone greeting:

Hi, you’ve reached the office of Dr. Rob Lamberts.  Actually you’ve only reached our phone system.  I’m not sure where you actually are at this moment.  But don’t be scared, this is a pretty dang good phone system.

For those of you who griped about us having the Labor Day message too long, your voice was heard.  Celebrate.  No more griping.

Our office will be closed on Thanksgiving day and the day after,  So please keep your black Friday injuries to a minimum.

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Hi, this is Dr. Rob and this is my new phone message.  I know there are lots of folks who enjoy listening to these messages, and frankly it worries me about the negative psychological effects I’m having on people.  Anyway, you can celebrate this message in the usual fashion and listen to it for educational and entertainment purposes.

Our office will be closed on December 24 and 25 for Christmas.  We will also be closed on January 1 so we can all practice writing 2016 when we date things.

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Hi, this is Dr. Rob and you have either dialed correctly or you have gotten extraordinarily lucky.  This is my new, and hopefully improved, voice message.  If you are one of those who hate waiting through these long soliloquies, please memorize the options that follow and dial them immediately the next time you call and skip my nonsense.  If you like these messages, I suggest you take up another hobby, such as stamp collecting, improv theater, or levitation. 

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Hi, this is Dr. Rob Lamberts and you’ve either accidentally or deliberately reached my office.  Please listen to the message that follows because I worked hard on it and it would be a shame for you to miss it.  Our office will be closed on Monday, July 4th to celebrate the day Will Smith saved us from the Aliens. 

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This is Dr. Rob Lamberts, and you have reached my office.  Thanks for calling in these, the dog days of summer.  If you have problems with your dog, please contact your veterinarian.  If your dogs hurt, please call your podiatrist.  If your dogs are hot, get your buns over here so we can ketchup.  I’ll pause for a moment so you can recover from that one.

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(after the election...in a Trumpian kind of voice)

Greetings.  This is Dr. Rob Lamberts and you’ve reached my magnificent office, where we work to make healthcare great again.  I promise to put a huge wall around disease and suffering and get them to pay for it. It’s a reasonable plan, and I’m sure they will do that.

In the meantime, our office is open to stun and impress you on Monday through Friday from 9 to 5.  Our awesome fax number is 706-504-9322.  Our website, doctorlamberts.org,  is the greatest one ever made.  I guarantee you will be awestruck by it.

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(People started complaining about my long messages, so I did this)

You have reached Dr. Rob Lamberts’ office.  To quiet all those who are complaining my messages are too long, I’ve put all the the good stuff at the end.  Our office will be closed Friday December 23rd and Monday December 26th, as well as Monday January 2.

(Insert options here)

There, all you curmudgeons, how was that?  Short enough for you?  OK, you can hang up now.  Go ahead.

Are they gone?  Finally.  Thought we’d never get rid of them.  Some folks you just can’t make happy.  I mean, here I have these voice messages that give people HOURS of entertainment (because some last that long) and yet they just moan, moan, moan, like I’d stolen their puppy or something.  Well, I’m glad you stayed and have such a better sense of humor than those deadbeats.  

Anyway, I’ve got to go now.  I’ve got some puppies to steal.

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You have reached the office of Dr. Rob Lamberts. Our office offers primary care service without the hassles and annoyances brought on by insurance. Some of our patients feel guilty about having such hassle-free care, and so after each visit they call Comcast customer service or go to the motor vehicle office. I understand.  It is hard to overcome the shock of having a pleasant experience at your doctor’s office.  Still, we refuse to hassle people just to help them deal with their withdrawal symptoms.  I promise, they only last for a short time.

There are more, but I think you get the picture.  

So how did my patients respond to this?  They absolutely love it, and play it for their friends.  I had one person tell me that when she feels depressed, she just calls my office to hear the message.  I've also had pharmacies, drug reps, and even other doctors' offices tell me that they love our messages and play them out loud for their coworkers.

Which is great marketing at a bargain basement price!  

I think this has another effect on my patients: it makes them feel like they are part of something special.  They feel like they have something to brag about, even if that thing is their doctor's silliness.  Given how disconnected people feel in our system, I think this is a very valuable thing.

Perhaps this is just an example of a broken clock being right twice a day, or the million monkeys typing Hamlet by random keyboard strokes.  Even an idiot doctor can accidentally do smart marketing.  It doesn't matter, really, as it proves to me that my goofiness can be used for good.

Perhaps this will keep Oprah off my back for a little while.

The consultant note read: 

Weight 250 lb. BMI 40.3.  Patient is morbidly obese.  Counselled on the dangers of excess weight.  Counselled to increase exercise and decrease calories.

I walked into her room.  She smiled at me as I walked in, a lovely smile that reached her eyes.  I scanned her record.  She was in my office for an ankle injury.  Blood pressure normal.  Weight 248 lbs, BMI 40.  

When I looked back at her, she was still smiling.  "I lost another ten pounds," she said proudly.  

I looked back in her records, noting a steady weight loss over the past two years.  She started at... "Goodness.  You have lost over 100 pounds!  Amazing!"  Her grin persisted as we started talking about her ankle injury.

Numbers.  We obsess on the numbers.  Is BMI over 30?  Obesity.  Is it over 40?  Morbid obesity.  No doubt these numbers are important, but in reality they are just points on the timeline.  People come for care with an entire lifetime of narrative in tow.  Yet most of the care that is given is ignorant, sometimes intentional and sometimes not, to the whole story of what is going on.  My patient went to the specialist and was labelled as being "morbidly obese," and given counseling on the obvious (although I suspect the specialist just checked the box to avoid censure...and financial penalty).  Yet this woman knew far more than anyone who could have counselled her.  She had lost a quarter of her body mass and was continuing to lose.  She was a hero, yet to anyone who didn't look back on her timeline, she was simply another data point proving the failures of our society.

The irony is that the way that she accomplished her weight loss was to focus on each day separately, ignoring her past history and trying to have a small victory each day.  I've often used the analogy of a baseball player who does what he should do: gets a hit.  But if that player gets hits in every game for a week, for a month, his season (and that of his team) can be significantly altered.  But each game, each at bat, is a single data point where he's only asked to do something unspectacular. But do something unspectacular for enough days, you have something transformative.  

We live in a world where patience is a diminishing commodity.  We want each day to wrap up neatly like an episode of a TV show.  We want to end all arguments by having the perfectly worded Facebook post.  We want to figure out the solution to our problems, meet our soul-mate, elect the perfect candidate, and live the rest of our lives happy and contented.  But every story has many pages, every timeline has many data points, and every life is made up of many days, many decisions.  

As a human, I do best when I understand that I live in a timeline and that my solutions take a series of decisions, not just one.  Yet I also do best when I try to win only the day's battle, not the whole war. Today matters only as a piece of something much bigger, yet today is the place where my pen is writing, and where the story is created.

As a doctor, I also do best to consider both things.  We want to criticize people for where they are without considering where they've been.  I am constantly frustrated by ER and Hospitalist providers who ignore the care I've been giving for years (and sometimes decades), viewing only what is now in front of them.  Our job is to recognize that every one comes to us with a narrative, to enter that narrative, and to direct it in the best way possible.  It's not our narrative, it's theirs. But we can have a huge impact on people if we listen, understand who it is we are seeing, and help them write today's narrative in a better way.

I know this sounds a little ethereal, or overly philosophical.  But this woman will get discouraged if nobody sees where she's been and what she's accomplished, only to criticize today's number.  Her exhilaration at my recognition of her incredible accomplishment will likely give her much more motivation and help than if I had lectured her on "eating less" and "getting more exercise."  We do our best work when we appreciate the fact that we are simply a point in the timeline. 

"Two weeks ago."

"And when did you say you started having those symptoms?"

"Uh...about...uh...let me think...it was...two weeks ago."

This kind of circumstance is my holy grail.  It is my ultimate moment where I connect the dots.  It has happened several times recently where patients have had chronic symptoms and have related to me that they have been taking medications started by other physicians within the time frame of those symptoms.  One of my rules of thumb (I don't know how the thumb always gets involved) is, when in doubt, blame the medication.  And, yes, stopping the medication in these circumstances fixed the problems the patient was having.  It doesn't always work that way, but it often does when you listen enough.

I recently had a diabetic patient come to me embarrassed with his poor control.  

"Why have you been having such a hard time lately controlling your diabetes?" I asked.

"Well," he said, looking down at his hands as he spoke, "I just haven't been taking my medications over the past month. It's hard for me to take them."

"And why is it hard for you to take them?" I pressed.

He shuffled in his chair.  Looked up at me, and then said, "I can't swallow pills.  The metformin.  They are so big.  I just have a hard time getting them down.  So I just gave up taking my pills."

I looked at him and smiled.  "You do realize that you can cut those pills into halves and quarters?"

He looked down.  Obviously not.

"Okay," I said, "let's come up with a plan that doesn't require you to swallow big pills all the time.  I know that it's not easy when you have a strong gag reflex and you have to take big pills.  Let's find something that works well for you."

He smiled broadly and seemed to relax.  I actually listened to him.  I took the time to find out why he wasn't taking his medication instead of judging his suboptimal diabetic control like he expected me to do.

That's what people want.  They want to be listened to so that they are understood.  It's not just being heard that is important; it is being heard and appreciated that is the key.  Everyone has a story to tell, and everyone has a reason to be in the place they are in at the moment they interact with you.  It's your job as a clinician to figure out what got them there and what exactly they are looking to accomplish at this moment.  My patient really did want to control his diabetes, but was very much prevented from doing so by his inability to swallow large pills.  He believed (falsely)  that this was a complete roadblock to good diabetic control and had given himself up to amputations, dialysis, and other inevitable complications of poor diabetic control.  All I needed to do was to listen a little and his myth was dispelled.  

One of the big unfortunate things about the medical system is that it turns listening into a rarity.  "You are the only doctor who has ever listened to me," I often get told.  Really?  That's like being told that I am the only chef who has ever cooked food for someone.  Isn't listening the essence of care?  How could so many people go through our system feeling like they never get listened to?  Yet they do.  It is incredibly sad.  It causes a huge amount of pain.  It probably kills a fair number of people.  

But if we are rewarding doctors for spending less time with people, what do we expect?  If we are making computer time more profitable than patient time, ICD more important than bowel sounds, Medicare compliance more important than the emotional state of the person in the room with you, then it's hard to blame clinicians for ignoring patients.  They are just doing what they are told.

Our system needs to be better than that.  The reason I can spend time with people is because I don't have to worry about the codes I can generate from each visit.  I don't have to worry about Medicare audits, or meaningful use, or MACRA.  I just focus on the person in the room with me.  I'm lucky that way.  I'm lucky that I raised my middle finger to the system that required me to spend so much time documenting that I could no longer give care.  I'm lucky that I walked away from a system that made profits for me when my patients had pain or illness, and hurt me when they were healthy.  Yep.  I am lucky.  Pure luck.

But in any situation, even in one where profits are paramount, listening is always best.  When we listen we can understand.  When we listen we can solve.  When we listen we can make good plans of action.  Without listening we are left to become box-checkers, form-fillers, and data entry monkeys.  We don't want that, and I'm pretty sure our patients don't want that