Why I made the change to direct care practice

Probably the hardest part of making the change from a traditional to a direct-care practice is the effect it has on relationships.  I am only taking a maximum of 1000 patients (less at the start) and will be no longer accepting insurance.  These changes make it impossible for me to continue in a doctor-patient relationship with most of my patients.

For some, this transition will be more hassle than anything.  Some people do everything they can to avoid my office, and so are not going to be greatly affected by my absence.  They will simply choose another provider in our office and continue avoidance as always.  There are others who see me as their doctor, but they haven’t built a strong bond with me (despite my charm), so the change may even be a welcome relief, or a chance to avoid initiating the change to another doctor.

But there are many people, some of which have already expressed this, for whom my departure will be traumatic.  ”Nobody else knows me or understands me like you do,” one person told me this week.  ”I’ve seen you for so many years, you just know so much more about me than any other doctor,” said another.  I’ve seen tears, have gotten hugs, and get frequent demands for a clearer explanation as to what I am doing and why.  It’s been a rough week for me, as I don’t feel I can cut off these relationships without some sort of closure.  Fore someone who sometimes goes overboard in the importance of others not being mad, it’s been hell.

In truth, the depth of the response I’ve seen underlines the main reason I am going to this new kind of practice: I care too much.  I have always run behind because I talk to people, joke with them, tickle the kids, and ask open-ended questions.  When I am running behind (I try to keep it under an hour), I don’t let that stop me from giving my full attention to the next person in the exam room.   Despite my chronic lateness, people don’t complain much.  They know that I will give them the time they need when I am in with them; I can’t cheat them of the time they need (and are paying for).

I’ve always been puzzled when people say things like, “you are the first doctor who’s really listened to me,” or “you always give me your time and attention when I come in.”  Isn’t this what being a doctor is about?  Aren’t they paying for my attention, for explanations, for listening?  Isn’t it dangerous as a doctor to not listen?  If those doctors don’t talk, what are they doing?  Singing?  Doing sign language?  Using their psychic powers to probe the patients’ minds?  Whatever the case, I see from these statements (which are frequent from new patients) that I either care more than many doctors, or I just love to talk.  The last one is definitely true, but the burn-out has occurred because of my inability to not care.

The most gratifying thing that has happened since my announcement is that patients have almost universally expressed their happiness for me in making this change.  They aren’t surprised that I burned out, and they are pretty fed up with the system, so they don’t question why that would happen.  But the genuine happiness for me as a person has really touched me.  The relationship really does go both ways.  Many of them have observed my increasing signs of burn-out over the past few years, while others have heard me voice my frustration with a system that tries to push me away from them.

For those I’ve taken care of for many years (some of them nearly 18 years), there is a bond that is hard to explain.  I’ve walked through life with them, and for many, that life has been very hard.  I’ve been through sickness, sorrow, death, pain, and despair with them, and not just as a bystander; I have taken an active role in their pain and hurt.  I knew the husband or child who died 10 years ago, and remember how crazy their parents were.  I’ve been through good things as well, and have felt joy when they came back with good news.  I recently saw a patient I hadn’t seen for 5 years who, when I last saw them, had been using drugs and getting into very bad relationships as a teenager.  I was thrilled when I saw how much they had changed, not letting bad choices ruin their life, and I told them how happy I was.

This is one of the reasons it is a huge advantage to have a primary care doctor who you trust.  When I walk into a room with one of my patients, I know more of the back-story in their life than most, if not all other people.  I remember how anxious they used to be, and see the little bit of anxiety they still have as a dramatic improvement.  Any other doctor would see it as a problem, not a victory.  I recently walked into the room of a mother with her newborn child and was struck by how much about this child’s legacy I knew.  I knew about her grandparents, who went through very difficult times and have since died.  I knew about the uncle with lung problems and the aunt with anxiety.  I took care of the mother as a child and knew some “interesting” things about her past as well.  When I was looking at this child I thought about all of the other people in that legacy and was struck by my privilege to have been witness to both the good and bad.

My decision to leave my current practice didn’t involve money.  I am paid just fine for what I do (although I wouldn’t mind a little more help on college tuition), and haven’t seen a drop in salary, despite the mess our system is in.  My decision was largely driven by relationship.  I’ve watched  as my ability to draw close to my patients has been slowly taken away.  Some (on other blogs that will remain nameless) have suggested that I have been selfish in this decision, bolting from the sinking ship instead of trying to fix it.  This, of course, is beyond crazy; I have been obsessed with fixing the system – first through use of computers to improve the process, and then through my voice on the Internet through writing.  I have done all I can to change the system from within; now it’s time to be real disruptive, and change it by stepping out.

To those patients who follow me on this “adventure:” thanks.  Thanks for trusting me enough to follow me to a different planet.  I had a patient grin at me yesterday and tell me, “this is just you.  I am not at all surprised at this because it’s just the way you do things.”  I guess I’ve always been a little subversive.  Maybe it was the sandals.  Maybe it’s the computers.

No, I just cared for them in a system erroneously labeled as “health care,” and they cared back at me because I did.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • http://www.zdoggmd.com ZDoggMD

    “Now it’s time to be real disruptive, and change it by stepping out.” WORD.

    • http://doctor-rob.org/ Dr. Rob

      Thanks dogg.

  • AMS

    Great article. I’m an MS-II right now and plan to go into primary care for the sole purpose of having a direct primary care practice. I find the idea exciting, disruptive (in a good way), and rewarding. The community I live in does not have a direct care or concierge practice so I know it will be a shock when I open the doors 5 years from now. Good luck and I wish the great success.

    • http://doctor-rob.org/ Dr. Rob

      It’s interesting that the docs I’ve talked to who are doing this model all seem to have a smirk, as if they are being subversive or revolutionary. We may be, but the key is that we are not letting others stand between us and our patients. It’s great to hear med students and residents seeing this as a real option. Hopefully by the time you get to doing it the market will have shifted significantly in that direction.

  • southerndoc1

    Congratulations, Dr. Lamberts. I know this will work out well for you and your patients. Just a little terminology quibble: why “direct care”? Isn’t “direct pay” more to the point?

  • http://www.thehappymd.com/ Dike Drummond MD

    Congratulations Rob … you put your own needs to maintain meaningful relationships with your patients on equal footing with the demands of “the system” where you used to practice. That is true work-life balance

    In my experience the business model / Culture / Context of your practice goes a long way to determining your satisfaction with being a doctor. There are two basic options
    High Volume … the system you are moving away from
    High Touch … the system you are creating in your new practice

    And you do get to choose how you practice medicine and how you live your life. Most doctors don’t realize all the ways they can change their life if they are dissatisfied … this is one of the most extreme choices available. AND it does not surprise me that you have been called selfish by those still mired in their burnout and unwilling to make a similar change for themselves.

    Please keep posting here and let us know how things go for you. This move will expose two areas where you will need to beef up your skills in my experience … leadership and marketing. And the adventure is well worth it.

    Dike Drummond MD

  • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

    Very, very happy for you and the joy of practicing you’re about to experience.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Good luck. You will be amazed at how fast your smile returns.

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