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
- Personal insights from a doctor's perspective
- Bob Saget
- Patient-centered care
- Body odor
- Whether it is "Health Care" or Healthcare
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.
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.
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.
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.
I gave a TED talk. Okay, it was really a TEDx talk, done right here in Augusta, GA (the garden city...which sounds good until you realize New Jersey is the garden state) on February 3. The talk was entitled "Hi, I'm Rob and I'm a Recovering Doctor," and it focused on how two basic changes in how doctors are paid can totally change the patient experience
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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.
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.
I am normal.
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 grumpy and (despite multiple cups of coffee) continue it through the day. 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.
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.
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.
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.
“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.
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.
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.
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.
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.
"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.
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