My new practice saves lives

Oh yeah.  Hot dang.  All right.  Groovy.

Boom goes the dynamite.

I had a very great day yesterday.

I saw three patients who had recent diagnoses of cancer.  Yeah, those two statements seem to contradict.  They don’t.  Each person I saw gave me a clear view of how the practice I’ve been building over the past 18 months is making a difference.  A big, big difference.

The first patient was a guy who is pretty far along in the treatment of his cancer.  I sent him to a specialist about a year ago and he was diagnosed with a serious, but treatable form of cancer.  While he’s happy with the overall outcome of his disease, he has a complication called lymphedema which is making him very uncomfortable.  Lymphedema causes swelling of soft tissue that is very difficult to treat, as it cuts off the normal drainage system for the fluid that is outside of blood vessels surrounding cells.

When he asked his specialists about this, they told him that nothing could be done.  He expressed his frustration at the fact, so I did what every red-blooded person in 2014 would do: I Googled his problem.  I immediately found a number of useful websites which talked about the exact problem he was facing, one of which was written by a physician who had dealt with his form of cancer (and has written a book chronicling his experience).  While I read aloud from the website, he purchased the book from Amazon.  I discovered that the pessimism of his specialists was not exactly right.  In fact, I found out that there were important steps to take to prevent this problem from becoming permanent.

“Why didn’t my other doctors tell me this?” he asked.

I shrugged my shoulders.  “I guess they didn’t have the time to do it.”  We had just spend about an hour together talking about his cancer experience and other non-medical things (computers, music).  He nodded in agreement, acknowledging the reality the big advantage he has in my office: access to me.

The second patient, coincidentally, had the same kind of cancer.  In fact, it was my experience with the first patient was just a few months before this second patient’s presentation that allowed me to quickly diagnose and treat his problem.

He had a peaceful expression as he sat across me in my office.  “This whole thing got me thinking differently about spiritual issues,” he explained.  “I just keep thinking about how many things worked out to get me diagnosed and treated.  I noticed the lump and thought to myself: ‘I should make an appointment with Dr. Rob.’ and then you saw me the next day.  Within a week I was diagnosed with cancer and things took off from there.”

I reminded him that before he got treatment, we had a discussion using secure messaging about “alternative” treatments for the cancer that were suggested by a family member.  “You remember when I told you about how Steve Jobs’ death was probably due to the time he spent going after alternative treatments before getting standard medical care?”

He nodded.  “Yeah, and I’m real glad I listened to you. Everyone has told me I’m doing amazingly well and have a good chance to be cured,” he told me. He looked away from me and took a deep breath. “I just wonder what would’ve happened if you weren’t in this office.  I usually hate going to the doctor and put stuff off.  I just wonder if things would’ve turned out like they did.  It makes me feel like angels were around me.”

The third patient was a younger woman who was recently diagnosed with a very serious cancer.  I saw her and her husband for the first time since the diagnosis.  After tearful hugs and warm greetings, I asked how they were doing.

“Once we got over the initial shock of the diagnosis,” she explained, “we are doing much better.”

She had presented with symptoms not generally suggestive of cancer which persisted and grew worse.  After going after the most likely causes, I got a secure message from the husband expressing his worry and asking me to do more to diagnose and treat her.  After his message we immediately ordered the test that made the diagnosis. “She got really mad at me for doing that,” he said with a smile, “but I sure am glad that I did.”

She grudgingly agreed that he was right, and that (for once) a husband actually had an “I told you so” to hold over his wife.  It’s usually the other way around.  “I would have waited much longer before doing that test.  I’d probably have been nearly dead before making the diagnosis.”  She paused and wiped away a tear.  “I’m just so glad you are our doctor.”

All three patients were significantly impacted by the different ways we do things in my new practice.  Two of them may owe their lives to these differences.  The main difference is the markedly better access my patients have to me.  They don’t have a frustrating phone system to navigate, an army of office staff to convince, or a 2-hour wait to endure to get my time or attention.  They needed my help, and they had easy access me when they most needed me.

One of the worst parts of the job of being a doctor is to diagnose people with cancer.  At the same time, however, there is a sense of this being the highest honor paid to me as a person: I am the person who is there to help when the stakes are highest and the future looks darkest.  I have the opportunity to be the right person at the right place at the right time.  Bad stuff happens, and I will likely face many more sad yet meaningful days in the future where I am called on to stand beside people on the hardest days of their lives.

But yesterday made me happy.  The hardest thing I’ve done in my life — giving up my old practice and starting something completely different — is succeeding.  No, I’ve not yet earned enough to pay all of my bills (I am getting closer on that front).  The success is measured in other ways: I’ve saved patients time, saved them lots of money, decreased their frustration, and restored some of their trust in doctors.  This way of practicing medicine is not just different; it’s better.

Yesterday was the day when I saw its biggest success: My new practice saves lives.

Boom.  Dynamite.  Boom.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.

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  • Suzi Q 38

    Good job, Dr. Lamberts.
    We need more doctors like you.

  • Kristy Sokoloski

    I am glad that you found a formula that works for you Dr. Rob.

  • Patient Kit

    Good to hear that you and your patients are happy with your relationships. As a cancer patient myself who is struggling to understand the DPC model, can you give us a rough idea of how much specialist treatment and procedures your three patients with cancer have needed (anything that you, as a primary care doc can’t do for a cancer patient) and what kind of insurance those patients have to cover treatment they need beyond what you can provide? Do they have comprehensive or catastrophic insurance? Has insurance covered everything they need outside of primary care?

    • http://doctor-rob.org/ Dr. Rob

      Some have insurance, some don’t. Those who have insurance will have everything (outside of my monthly fee) covered by the policy. Those with catastrophic/deductible, I am totally geared toward keeping them from spending their deductible if at all possible. I prefer people having some sort of insurance, as it makes it easier to order tests/procedures that are necessary. Overall it works pretty good, and I feel like I save money for most of my patients.

      • Patient Kit

        Thanks for responding. But I was asking specifically about the three patients you wrote about in your OP who are dealing with cancer right now. Do they have insurance that covers their regular visits with their oncologists and any treatments they have needed? I’m assuming they are all seeing an oncologist regularly and are not being treated for cancer by their primary care doc, regardless of how much they may like their primary care doc. And I’m also assuming that oncologists are expensive.

        • http://doctor-rob.org/ Dr. Rob

          2 have insurance, one doesn’t. The one who doesn’t (with the colon CA) is probably going to qualify for some sort of indigent care, as cancer is so expensive that there are a very, very small percentage of people who can afford the cost of the treatment.

          • Patient Kit

            Agreed that very, very few Americans can afford to pay for cancer treatment. That’s why, short of a single payer system that covers all of us, I think people need comprehensive insurance, not the catastrophic insurance that many DPC docs seem to be recommending. I sincerely hope all of your patients are able to get all the medical care that they need. It is far from a given that people without money and/or good insurance will get all the cancer care they need in this country. Far too many go without the care they need. For starters, it depends on where you live in the US, how much help may be available. I hope it goes without saying though that patients with cancer need oncologists. And a PCP is not an oncologist.

          • http://doctor-rob.org/ Dr. Rob

            The ideal patient to me is one with a high-deductible plan with a cash plan (HSA or Flex-spending) to cover the deductible. The problem with comprehensive insurance is that it encourages overspending by paying for most requested procedures, meds, tests, whether or not they are necessary. In the ideal circumstance I am working to be as efficient with the patient’s money as possible. This is best for the patient, it eliminates unnecessary testing, and even works better for the insurance company (as I am trying to keep people from spending their deductibles).

            The core problem in our system is not that it’s too expensive. The cost of our system is secondary to the root problem: the “reward for doing more” mode of the third-party payors which encourages excess. Health care is obscenely wasteful of money, and that waste doesn’t hurt anyone directly in the typical insurance arrangement. The system is imploding because of excesses in spending, not lack of access. Nobody is accountable for the wanton spending. With me and my patients, they know why I order every test and prescribe each medication. I am accountable because I am asking my patients to pay for the colonoscopy or specialist visits. They do need insurance to help them with this, but not to remove that accountability.

          • Patient Kit

            I guess I’m forever emotionally scarred by my experience of being diagnosed with ovarian cancer a year and a half ago while uninsured and broke (post-layoff/loss of employer-based insurance). It was a truly horrifying and daunting experience trying to navigate our healthcare system uninsured and desperately in need of expensive care ASAP.

            Things worked out well for me partly because I live in NYC, home of numerous excellent academic medical centers and teaching hospitals (where I received excellent treatment), I live in a state where single adults without dependent children can get Medicaid help and my cancer was early stage and so didn’t need extensive expensive treatment like chemo. But the surgery and 4x/yr monitoring checkups with my wonderful GYN ONC are expensive enough to require good insurance.

            I can’t stand the thought of others going through what I went through while trying to access and navigate the system. Our healthcare system should not be scarier than cancer. For this reason, I don’t think I’ll ever be comfortable with the DPC-catastrophic insurance-cash plan. It would not have worked well for me in the above-described situation, especially if there was no cash in the cash plan part of that model. That model seems like a huge gamble to me and nobody ever thinks “it” will happen to them. (“It” doesn’t have to be cancer but can be any equally bad illness or injury.)

            My awesome GYN ONC does not over-order testing, btw. He’s very cautious about CTs, for example. I can’t understand an oncologist who couldn’t or wouldn’t help your patient deal with lymphedema. An angel on my shoulder apparently put me in the hands of my oncologist.

            Finally, I disagree with you about whether medical care in our system is expensive. It is very expensive. Because healthcare in this country is, first and foremost, a profit-driven big business. And those who are making the boatloads of money have a vested interest in keeping healthcare expensive. I don’t think that will change until our system stops being, first and foremost, a profit-driven big industry. I realize that the insurance companies are a big part of that profit-driven industry. But, short of a single payer system, I think they will remain a necessary evil.

          • southerndoc1

            “the root problem: the “reward for doing more” mode of the third-party payors which encourages excess”

            Don’t you mean the “reward for doing more expensive procedures and selling more overpriced DME and charging more for inexpensive supplies?”

            I don’t think the current system encourages more office visits or more talking to the patient or more thinking about difficult cases – it would be great if we did encourage more of those.

            Nothing’s inherently wrong with a system that encourages doing more – it’s just that the one we have has been incredibly perverted by the RUC, and doesn’t encourage the right things.

          • Lisa

            I have comprehensive insurance; with no or low deductibles depending if see an in network or out of network provider. I also know why my doctors order every test; I know the reason for every prescription I am given.

            Medical care is expensive because of the profits built into the system. DPC shifts some of the profits to primary care doctors, but will not reduce overall costs to patients because of the need for comprehensive insurance. High deductible insurance combined with DPC is really a path to medical bankruptcy for many may patients. One serious illness, one major accident will be all it takes. And as Patient Kit points out, many states have not expanded medicaid. People should not have to rely on the possibility of qualifying for indigent care to medical treatment for serious illnesses.

            One more thing, I have lymphedema, secondary to breast cancer treatment. I also lucky that I have comprehensive insurance that covers the necessary treatment and durable medical equipment to treat it. The treatment of lymphedema is beyond the scope of primary care. So while it is great you could do some research for your patient, it means little unless the patient can access the care they need. That care includes counseling about prevention. I tend to think every patient who is having cancer surgery that involves lymph node removal should see lymphedema specialist (PT or OT) before surgery to learn about risk reduction.

          • Patient Kit

            Your uninsured colon cancer patient is lucky to have you in her corner. But I guarantee you that, no matter how good your last visit with her was, she is absolutely terrified right now. She needs much more than a good primary care doc right now. Since I was diagnosed with ovarian cancer a year and a half ago while uninsured, I think I know what I’m talking about there.

            Your hope that she is “probably going to qualify for some sort of indigent care” is not very comforting to me and I doubt that it’s very comforting to her. And you really don’t know whether she will get any help. Aren’t you in GA, where Medicaid did not expand with the ACA?

            My bottom line position on this is that nobody facing what your colon cancer patient is facing should have to be dealing with worrying about whether or not she will be able to get “some sort of indigent care”. That is just not good enough in this country.

            I also have to say that, while I understand that you feel happy about making a difference with your patients, the positively gleeful celebratory tone of your OP is kind of off-putting to me, given that one of the three patients you highlighted is facing such a horrible situation.

          • http://doctor-rob.org/ Dr. Rob

            I am not saying more because of patient confidentiality issues. She’s fine.

            BTW, you might not talk down to people in your comments. It doesn’t do good to make your point.

          • Patient Kit

            I’m glad to hear that your uninsured cancer patient is “fine”. I couldn’t be “sure” about that at all from your OP. I would be terrified if I was her. With good reason, I’m very interested in hearing how cancer patients fare with DPC.

            I don’t feel like I was talking down to you because I questioned your cancer patients situation. I also don’t think I was talking down to you by questioning the tone of your OP. As a cancer patient myself, days after reading your OP, I found myself still thinking about and bothered by your “Click. Boom….groovy” opening that went on to talk about three of your patients with cancer. I understand intellectually that you were happy about being able to spend time with them and help them. But emotionally, I reacted badly to your words especially since one of those patients has colon cancer and no insurance. Not groovy.

          • http://doctor-rob.org/ Dr. Rob

            You implied/presumed that I am not far more concerned about her cancer without insurance than you are. My glee was not about the cancer, but about how I saved two lives and greatly improved another. I think that’s worth a boom of dynamite. Assuming I am equally glib about the cancer shows you don’t know me at all. I am doing this practice (with significant reduction in my personal income) because I felt like I could not stomach the poor quality of care I was giving. That’s not BS. That’s true. My income was so low last year that I am currently qualified for Medicaid. I burned out from daily feeling like I couldn’t give my patients the attention and care they deserve.

            Talking down to someone often takes the form of assuming you know their position when you don’t. Assuming I am insensitive is far off base. I am willing to make great personal sacrifice to do the right thing, so it is galling to feel I am patronized by someone who assumes I am a selfish twit. This is the hardest thing I’ve done in my entire life, and so the natural reaction to see it bear great fruit is to celebrate. Many have followed my journey through this, so I continue to write about it. I do so not to toot my horn, but to give hope to other docs who think our lives have to be the miserable hamster wheel American healthcare has become.

          • Patient Kit

            You are correct that I do not know anything about your personal story and I apologize for making you feel talked down to. That was sincerely not my intent. I certainly don’t think you are gleeful about your patient having cancer. I said she is lucky to have you as her doctor and I meant that. But, no matter how good a primary care doc is, a cancer patient needs so much more. And having a similar experience (I was diagnosed with ovarian cancer a year and a half ago while uninsured after a layoff), it does concern me how she will access the care she needs in our current healthcare system. I know from hard personal experience that it is far from a given that she will get the help she needs (beyond you).

            I read your OP in the context of (a) my own recent terrifying experience as a cancer patient and (b) the many difficult discussions here at KMD about DPC, during which some doctors have said that they think the DPC model is their way, as a primary care doc, to get paid as much as specialists. A lot of the talk about DPC here is about re-directing some of the money from third parties to the docs who actually do the work.

            So, I was completely blindsided by your revelation that you currently qualify for Medicaid. I confess that it never occured to me that a practicing physician could qualify for Medicaid since I know how hard it was for me to qualify here in NYC. In GA, a state that did not expand Medicaid with the ACA and does not help any childless adults, you would have to be a working parent with a dependent child and making less than $10,000 a year. If that is your situation as a doctor, I stand both corrected and amazed. That is a stark contrast to the way other DPC docs here are describing their new financial model.

            As I said, it is far from a given that every American will be able to get the care they need in our healthcare system. I’m struggling to be able to access the follow up monitoring I need as I am back to work (freelance without insurance) and headed toward transitioning off Medicaid.

            I do tend toward asking hard questions but I wish you, your patients and your family well as you navigate our brave new world.

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