Musings

My blog has been a destination of the most discerning healthcare reader since 2006.  Come see my elegant assortment of topics, such as:

  • Health Care Policy
  • Llamas
  • Personal insights from a doctor's perspective
  • Bob Saget
  • Patient-centered care
  • Body odor
  • Whether it is "Health Care" or Healthcare

Come visit and see the site that Oprah doesn't dare admit she reads. 

Recent Posts

Musings
The Secret Back Door

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.

Accidental Smartness

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.

A Point on the Timeline

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.  

Listen

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.

All is Well in Robsville

But in our practice we live on this little island of sanity in a world where that is scarce.  We work in an place where "you're welcome" is said far more than "I'm sorry."  Patient wait times only go up when people have the nerve to show up early -- otherwise, we still have an average of around 30 seconds.  I still spend an hour with new patients, for them to get to know me and me to get to know them; and they still generally walk away with an amazed expression on their face, having never experienced a good experience at a doctor's office.  We still have a steady stream of new patients without doing much at all in the way of marketing.  So all's well in Robsville. 

Sample Blog Categories

Humor

Sometimes the best way to say something is to surprise people and make them laugh.  The best humor laughs more at itself than at others' expense.

Deep Thoughts

Sometimes my thoughts go deep.  Dealing with death and suffering can do that to an already introspective person.

Our Broken System

Health care is messed up.  Here I give both an insider's (before I started my new practice) and outsider's view of what's wrong.

Musings
Dr. Rob's Inbox
Musings

The drug test came back abnormal.  There was THC present.  I walked back to Mrs. Johnson and raised my eyebrows.

"What's wrong?" she asked, not used to whatever kind of look I was giving her.

"Uh, you forgot to mention to me that you smoke weed."

She blushed and then smirked.  "Well, yes, I guess I forgot to put that down on the sheet.  I don't do it real often, but sometimes it takes mind off of things.  I just get real anxious about my kids, my husband...and my heart problems. I only smoke one or two a night"

She's not your usual picture of a pot-head.  She's in her sixties, has coronary heart disease, irritable bowel, hypertension, is on Medicaid, and is the essential caricature of the the poor white folk who live in the deep south.  And she smokes weed. 

"I want to tell you my story now," a patient recently told me, a woman who suffers from many physical and emotional ailments.  She had the diagnosis of PTSD on her problem list, along with hospitalizations for "stress," but I never asked beyond that.

"OK," I answered, not knowing what to expect.  "Tell me your story."

She paused for about 30 seconds, but I knew not to interrupt the silence.  "I killed my husband," she finally said.  

OK.  Unexpected.  

Howard died on Friday.

Howard was the general surgeon I preferred sending my patients to because he took good care of them.  He listened to what they said, he joked around with them, and he took them seriously.  He also was famous for wearing tie-died scrubs.   This type of care is unfortunately difficult to find from consultants.

Yeah, I am still here.  Sorry I left you with Bob the Llamaturkey as my last post to see.  That is very thoughtless of me.

Many who have been reading my blog adventure as I build my new practice have noted a bit of a down mood in my writing.  Yes, that has been there (not Bob the Llamaturkey, other stuff).  The past two years have been quite a but more than I expected.  They have definitely been more rewarding and fulfilling than I could have hoped, but they have also been far more anxiety provoking and exhausting than my worries could have conjured.  The medical side of things has been wonderful, but the burden of starting a business from scratch is heavy.

Hence the absence of recent blog posts.  

Heroic

I think there is something in us that makes us want to make heroes.  This is part of the attraction of sport and other entertainment.  We want to see people doing things that are amazing, superhuman, and heroic.  As a child, I imagined me hitting the home run in the bottom of the 9th inning, or hitting the basket with no time left on the clock.  I imagined the adulation and praise of my skill from the adoring masses.  I dreamed of being a hero.

My Turning Point

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on "big ideas," such as:

  • What makes people choose things which cause themselves harm?
  • Are some people better people than others, or are they just more skilled at hiding their problems?
  • Is pain really a bad thing, or is our aversion to it a sign of human weakness?
  • Do dogs watch Oprah?
  • Does God ever wear a hat?
  • Why is "big ideas" in quotes?

Tough questions.  

Lately I've been contemplating the nature of human awareness:

  • Is self-awareness (the ability to think of ourselves in the first person) a uniquely human trait, and is lack of self-awareness the essence of mental illness?
  • Is empathy, or other-awareness the highest of human traits?  Is this what the biblical idea of being "made in the image of God" really means?

Yeah, that's a lot deeper than about dogs watching Oprah.

Musings
The Secret Back Door

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.

Of Drugs and Rectal Pain

Fortunately for this my patient, I was not only able to reunite him with the joys of sitting, but I was able, with a little research, to find him his proctological savior at a low cost.  Unfortunately, most patients don't have docs who are economically incentivized to save them money, and most people don't realize all of the games played by pharmaceutical companies and pharmacies to routinely perform wallet biopsies, nor do they know how to find the cheapest prices for their medications.

I don't know what can be done about this kind of thing aside from increasing awareness. I'm not real confident in any government solution.  People just need to be smarter shoppers when it comes to their care.  It's just a shame that people who are dealing with health problems (even if it is just trouble sitting) have to outsmart the gaming done by those supposedly trying to help them.

Sherpas Wanted

 People are quick to accept non-answers from specialists, to be misconstrued by ER doctors, and to spend a week in the hospital without knowing what is going on.  Other doctors are far too willing to accept fragmented care, not knowing the context of the current hospitalization or outpatient consultation. 

ICD-10 and Inflation of Codes

For those still unaware (perhaps looking through catalogs for gigantic inflatables for president's day), ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system.  This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible).  This change should be cause for great celebration, as  ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar.  Really.

Until our system can figure out a way to handle this kind of thing, we will pay a big price.  Waiting for problems to become emergencies is a terribly expensive practice.  I'm not sure I know exactly what needs to be done for this, but it's becoming an increasingly common problem.  Some say that a single-payor system will be the remedy, but they ignore the fact that a third-party payor system is what got us in this mess in the first place.  Things are far too expensive because patients don't have to pay for them.  That's why stress tests, which don't actually cost thousands of dollars to do, are so expensive.  That's why there is $100 hemorrhoid cream.  That's why medications are unreasonably expensive: someone else pays the bill.

Dear ACO General Hospital

Thanks for contacting me about my most recent blog post.  I'm sorry to scare your administration about HIPAA information, but I am equally concerned about that and will always do my best to respect the privacy of my patients.  At your request I hid even more of that information.

Best Of

"Best" is a relative term.  Perhaps it's like being a tall fetus, or like a small quasar.  "Best" of Rob's posts.  Yep.  Either an oxymoron or a low bar to get over.

The Physical Exam

One of my most popular Series, the physical exam combines real information with total nonsense with an aim to both educate and totally confuse my readers. 

My New Practice

Read what I've written about my new practice here.  Follow the story from my days of dissatisfaction in my old practice to the whole process of figuring this new thing out.

Musings
Dr. Rob's Inbox

I was excited.  Finally I could get my questions answered by America's doctor darling.  Since I know he's a busy guy, I thought I'd need to get his attention. No, I wasn't interested in the miracle antioxidant pill that detoxes my carotid arteries, reprograms my neuronal circuitry, melts away belly fat, and enhances me in the bedroom.  I know about that already.  I've seen his show.

No, my questions were far more important

Musings
Musings