To say that Dr. Rob Lamberts is enthusiastic about providing quality care to his patients would be an understatement. Before I sat down to interview with the Augusta, Georgia based primary care doc, I scrolled through his blog and stumbled across this gem: “Yay for boredom! Yay for healthy patients! Yay for a job that doesn’t encourage me to have sick patients!” with which he concluded a brief yet deeply compelling piece on why having an empty office isn’t always a bad thing.
Listening to his experiences as a Direct Primary Care provider only confirmed my initial impressions from his website: Rob Lamberts is easy-going, creative, thoughtful, and thoroughly committed to his patients’ well-being--even when that means interfering less. “I focus on what my patients need,” he says. “I focus on reducing their costs. I focus on keeping their medications to a minimum. I focus on not giving them unnecessary care.”
Sometimes what we don’t see tells us more than what we do.
Switching to the Direct Primary Care model has completely transformed the way Dr. Lamberts measures the success of his practice. “Most of the care I gave at the old practice was limited to office visits. We would answer some questions over the phone, but we would eventually force patients to come in to be seen because we would have to see them in order to get paid. That’s why a full office was important. Now, an empty office is my goal.”
It may seem counterintuitive to assess the health of a business based on the absence of customers; after all, most brick-and-mortar businesses--restaurants, hair salons, and even fee-for-services medical practices--rely on a steady stream of paying customers to stay afloat. For them, no visitors means no revenue. For them, families with good cooks, good hair, and good health is a nightmare.
For Dr. Lamberts’ practice, the opposite is true. Happy, healthy customers means a healthy practice--and a happy physician. “Here, it just clogs up the office to be taking care of problems that don’t require a visit.” In a recent blog post entitled, “The Joy of Boredom”, Dr. Lamberts explains the hidden beauty in a slow week. “[Few appointments] would be a problem in most offices, as revenue depends on people having problems...In practices like mine, however, this is what we want; after all, I am paid just as much for an empty office as a full one.”
That’s not the only change that has resulted in Dr. Lamberts’ switch to a membership-based model. On his practice’s homepage, he states: “My office is different.” In our interview, he tells us why.
Traditional to Transformational Care
Dr. Lamberts had been working as a physician at a traditional medical practice for eighteen years when he realized that he was on the road to burnout. “I was quite successful, but I was beginning to get more and more tired. I wanted to change things, to alter our practice in a way that would still allow us to spend extra time with patients. Honestly, it was getting on the nerves of my business partners.” When he left the practice, he had no idea what his next move would be, but after speaking with several doctors who had made a similar transition, he decided to give the Direct Primary Care model a chance. “I thought I knew what it would be like, but I really didn’t have any idea what a typical day would be like in the office, how many patients would come in, or how many patients I would need to have to be at full capacity. On top of that, I wasn’t sure how I would do documentation, charting, or how I would bill. I was basically starting completely from scratch. I ended up asking bunch of people for advice, but I essentially made it up as I went along.”
Evidently, this strategy worked just fine for Dr. Lamberts’ and his team. “I had a huge amount of patients who were fairly loyal to me--around three hundred patients followed me to the new practice.” Two and half years later, Dr. Lamberts’ practice serves over six-hundred patients. When asked how his Direct Primary Care practice compares to the fee-for-service model, he says, “It’s really so different. It’s hard to fathom going back to the old practice.”
Then: During a typical day at the old practice, Dr. Lamberts saw as many as thirty patients a day, significantly curtailing meaningful patient-doctor interaction. “I was constantly putting stuff into charts, filling out forms, and answering questions the nurses were asked by patients. There was not a whole lot of direct interaction with patients.” Because the success of his old practice depended entirely on insurance billing, patients who didn’t necessarily need to be seen in the office were brought in anyways, causing long waits for patients who developed an illness unexpectedly.
“Let’s say somebody had just a simple upper respiratory tract infection. They feel like they might have a sinus infection, but they’re not quite sure about it. At the old practice, they would have to decide whether or not they were sick enough for it to be worth it to come in. They could call the office, but invariably the office folks would tell them they had to come in. When they did, they would have to wait around for at least an hour to be seen, and then I would have to rush through the appointment because we were always behind schedule.” On top of that, Dr. Lamberts’ inability to give the level of care he thought patients deserved compelled him to prescribe medication when it wasn’t always necessary. “If patients came in with these type of problems early on, I would think, ‘Oh gosh, if I could give them a medication, maybe they will feel like they’re getting something treated.’ It also meant that they were not going to call back, and they wouldn’t later be told they need to come back in for another office visit. Patients were oftentimes begging to get a prescription because they didn’t want to have to wait a second time to get seen.”
Now: A busy day at Dr. Lamberts’ Direct Primary Care practice consists of eleven patient visits--at most. The elimination of the need to bring in patients for the sake of billing has completely transformed the process of treating common problems. “Usually the patient will send a message via our messaging application, Twistle. I would say about seventy-five percent of patients use it to describe their symptoms. We give advice and we give recommendations, talking back and forth with the person about their problem. For example, if somebody has a condition that appears to be swimmer’s ear, I’ll just ask, ‘Does it hurt when you wiggle the ear?’ That’s all you have to ask. If it hurts when you wiggle the outside of the ear, and it’s June or July when people are swimming a lot, then it’s definitely swimmer’s ear. If they come in, all you’re going to do is wiggle their ear and ask if it hurts. That’s a waste of everyone’s time. We can just call in ear drops for that type of problem--they don’t even have to come in.”
When patients do end up needing to come into Dr. Lamberts’ office, their experience is radically different. “They get put in a room the minute they come in, and I am able to see them right away.” And because patients have had the chance to explain their symptoms over chat, Dr. Lamberts already knows the relevant questions to ask in person. “I’m usually just looking for one thing. I don’t have to hear the story because I’ve already been interacting with them. If I find something, I treat it, but if I don’t find anything, my patients are far more happy with me deciding we should wait it out. They’re no longer afraid that they won’t be able to get me later. It’s not a hassle--they have access to me anytime.”
Then: Dr. Lamberts emphasizes how drained he felt when he left work everyday at the old practice. “I remember at the end of each day feeling like I wasn’t giving good care. Despite my efforts and the extra hours I put it, I just wasn’t getting people what they really needed.” Frustration with the structure of the old practice made work unfulfilling, especially as providing quality care became less and less attainable under the financial and time constraints of the traditional model.
Now: Under the Direct Primary Care model, work and play coexist in ways they couldn’t in the high stress, incredibly rigid work environment of the traditional care model. “At the end of the day, I feel a lot more energetic. To be clear, I don’t have anybody covering my patient population when I’m not in the office, so I am on-call 24/7, but the reality is, on any given evening, I get one or two secure messages from patients asking me questions. They all take me a few minutes to answer and then they’re done. I’ve decided that the sacrifice of always having to be near my cell phone is totally worth it. The total amount of time over an evening that I spend dealing with patients is ten to fifteen minutes at most; over a weekend, I probably spend thirty to forty minutes. Sure, sometimes I will complain when I get a few too many people texting me, but then I ask myself, ‘Do you really want to go back to the old way of doing things?’” Dr. Lamberts’ answer is always the same: “Hell no.”
Then: At his previous practice, nurses were responsible for making sure that any one patient didn’t take up too much of the doctors’ time. “At the old practice, there was this mentality that the nursing staff needed to protect the doctor from the patients. That’s the truth--it’s not an exaggeration. Patients wanted to get the doctor on the phone and get as much care out of them as possible without having to come in and pay for treatment. The nurses would do everything to make sure the doctor didn’t have to call the patient back. If we did, the nurses were very apologetic about the fact that we actually had to speak with the patient.”
Now: Dr. Lamberts finds himself with enough availability to share some of the office responsibilities with the nurses--something that would have been unfathomable at his previous practice. “I’ll answer the phone sometimes when patients or pharmacies call. It’s so funny, they just get so confused. But the reality is, speaking directly to patient is often the fastest way to solve the problem.” Redistributing conventional office duties has allowed Dr. Lamberts and his nurses work together to provide the best care possible “We’re just totally different in how we interact with each other. We’re part of a team. We spend our days advocating for our patients and answering questions. All of us are totally dedicated to this idea of making this business model work, because if it doesn’t, then we all have to go back to the old model--the model we hated.”
Then: Dr. Lamberts estimates that he used to spend upwards of sixty percent of his time in the office on documentation. “The majority of my time was spent documenting and interacting with computers rather than patients.” All patient visits were required to have a corresponding computerized record of the interaction which had to include the chief complaint, all the symptoms they have as well as the ones they don’t have, their past history, their social history, and the results of the physical exam. The advent of the meaningful use criteria further increased the amount of time that Dr. Lamberts spent on the computer. “We had requirements to prove that we were using the records in a meaningful way,” he explains. “You had to include information about every recommendation you gave the patients like: ‘I advised the patient to stop smoking’ or ‘Here are all the preventative care guidelines I presented on this visit.’ It just added a whole bunch of gibberish that had nothing to do with the office visit for the day. If you really looked at what percentage of the notations were relevant to patient care, it was very small.”
Now: Dr. Lamberts spends ten percent of his day documenting patient interaction and ninety percent of his day actually having it. “Here, I’m pretty much done with documentation by the time I leave the room.” After years of recording useless information about brief, fragmented office visits, Dr. Lamberts is committed to figuring out a way to document care that lasts for the long haul. “It doesn’t matter what procedures I do or what illness a patient has during any given appointment because I am treating them over a continuum. I’m following their illness on a weekly or daily basis sometimes. And it’s not just centered around one form of communication or a single office visit. A patient and I can go from emailing about a given problem to texting to a secure message to a phone call to an office visit. How do you document something that isn’t just a single interaction? How do you tell that narrative?” In the long-term, Dr. Lamberts imagines a documentation solution that captures patient health in a more personal way. “I love the idea of a collaborative medical record, giving patients more access to their charts.” In the short-term, he’s just sure of one thing: “It’s not about code submission anymore--it’s about storytelling.”
Towards the end of our interview, I asked Dr. Lamberts what types of problems his patients typically came into the office for, and if those problems varied from his patients at the old practice. His response moved me, and expanded my own understanding of patient care in the process. I think it will do the same for you:
“When I was working at my old practice, I did a mental inventory of the days I worked over the last six months and tried to figure out what percentage of patients who came into the office actually needed to be physically present for their care. The number I came up with was twenty-five percent. Even of those necessary visits, only a small portion actually required interaction with me. The majority of the visits just involved gathering information which we could have done from home. Patients don’t necessarily have to come in to get seen in order for us to take care of their problem.
I’ll share a little vignette from today: I had a woman who was under a ton of stress and had a lot of questions. The questions were not about her, but actually about her son who was living two hours away. I didn’t care that I wasn’t talking specifically about her. If I am answering questions for her family, it’s fine--in fact, it’s part of the care. It gives her peace of mind.
The family was waiting to find out if her son had cancer. That period between the biopsy and when they give back the results is the absolute worst. It reminded me of this sketch that a stand-up comedian--Mike Birbiglia--did about a tumor in his bladder. It is absolutely one of the funniest things I have ever heard, and the whole thing was very similar to what her son was going through, so I asked her if she wanted to listen to it. For about ten minutes, we just sat there and listened to this skit. It lifted her spirits so much for us to just laugh at this together. She needed that. I would have never done that sort of thing in the old office; they would have thought it was nuts. But it’s not--it’s human care.”