365.

That’s how many days I’ve been away from our health care system.  A year ago was my last day in my old practice.  Here’s what I wrote in my journal:

This is it. This is the last day of work at Evans Medical Group. It’s more weird than anything. I am sad to leave the comfort of my old job, but happy to be able to spread my wings and be myself. I am sad to be leaving many of my patients, but happy to be dreaming again. It’s frightening to be stepping out into the unknown as I am, but comforting to know I’ve got time to work things out. I am afraid, but I am confident. This is my new reality, a reality which changed with amazing speed.

Yesterday was a tough day in that my patients weren’t nearly as open to my ideas as they had been. It seemed I had to do a lot more explaining of things that other people understood without saying. I did well to not get angry or frustrated by things yesterday, but despite the nice going away party they held in my honor, I essentially slogged through the day. Today is that surreal last day, the day that is the period at the end of my 18 year sentence. I dreamed of today, but never dreamed of it.

Please note that the phrase “18 year sentence” was a metaphor, referring to a sentence of words, not a prison sentence.

That evening I got my favorite beer, “Three Philosophers” made by Ommegang Brewery.  It’s a beer you sip, not “throw back,” worthy of the occasion.

The next day was my first day of my new life.  I gave a talk for my patients, explaining my vision for my new practice.  Here’s what I wrote in my journal on that day:

Saturday morning, my first day off as an ex-employee of Evans Medical Group. Yesterday was kind of surreal. I didn’t do anything special (aside from buying some really good beer to celebrate). I saw my patients and tried to act as normal as possible. The morning went quite smoothly, and there were a couple of no-shows, even, which made the time go smoother. The afternoon wasn’t quite so smooth, slowing down later in the day with people who just didn’t get what I was doing and didn’t get the fact that this was my last day. It was a little frustrating, but not so much that I got angry about things. I just tired to do my job to the best of my abilities and then move on. I tried not to think about things too much.

The thought of what I am doing now still is pretty scary. I’ve got my talk for my patients today (wish I had given myself a little more time for that, but it is what it is). Then I’ve got a ton of planning to do and decisions to make. What computer system will I use? Can the system I am considering do what I need it to do, and if not, are they willing to change to become what I need? If not, then what other systems are there out there that give me what I need. What if there isn’t any system to do that? Where do I put my office? Who do I hire? How do I get the whole thing started? How many people will follow me? What will I do if more come than I can handle? What will I do about Medicare? These are the questions that are off the top of my head, and there are quite a few more my mind is not coming up with. It’s scary to step out with so many questions unanswered. It’s really scary.

So, if I had known then what it would really be like, would I have done it?

• 365 days ago, I thought I’d start seeing patients some time in December, then open up in full at the start of the year.  I ended up waiting until February 5th and spent twice what I expected to get my office done.
• 365 days ago, the one area I expected no problem was the computer system.  I had worked with EMR products for 16 years, getting a national reputation for physicians using EMR successfully.  EMR, it turns out, is so closely tied to the payment system I left that I gave up after trying multiple systems, eventually choosing to build my own system.
• 365 days ago, I expected my 18 years in practice, and my patient-centered style would overcome my patients’ caution at embracing a different system of care. Their fear of change, it turns out, is quite strong; while the majority of my patients have come from my old practice, the number who have followed is much less than expected.
• 365 days ago, I expected to remain on good terms with my old practice.  I am still surprised and disappointed about that one.

The biggest difficulty came when I realized I couldn’t use an EMR and had to build my own system.  I realized that going with a standard EMR would have two huge negative consequences: I would not be able to give the quality of care I wanted to give, and I would always feel the same “out of control” feeling that plagued me at my old practice.

But building my own system (if it was even possible) would have an immediate consequence: I would need to devote enormous time and effort to build it, limiting the growth of the practice and resultant financial stability.  The choice to do the harder thing, building for the long-term, has meant my personal income has dropped far more than expected.  There’s no danger of the business itself going under, but paying bills at home has been quite an adventure in faith.

This is no surprise to anyone who has started a business, I’ve since learned.  It’s a rite of passage, a hazing, a gauntlet to be run.  This is like basic training in the military, a time of pain and sacrifice that separates the pretenders from the truly dedicated.  It’s not fun.  365 days later I can echo my own words: It’s really scary.

But I don’t regret this path at all.

On a personal side, I have learned huge lessons of faith and perseverance.  Good ideas alone don’t make for success; there is a price in blood, sweat, and tears that forge the metal, turn the rock into a gem, turn the canvas and paint into art.  I’ve learned to disregard extremes of emotion, knowing that bad days are followed by good, and good days don’t prevent future bad ones.  The key is to not over-react to situations that push you to panic or celebration.  Panic leads to bad decisions, while excessive celebration leads to disappointment.  The best place to live is in the middle.  Satisfaction is better than celebration, and panic can be extinguished by determination.

On the medical front, I’ve learned what people want most: to communicate.  Far more than promises of fancy websites and care plans, people are thrilled at the simple fact that I answer the phone.  They need to be heard.  For the previous 6,570 days (18 years) I focused on the paying customer: the person in the office, so the phone was a burden, an enemy.  Over the past 365, this burden and enemy has become my greatest asset.  I listen.  I talk.  I connect.  This is the care that people are missing, and the thing they value the most.

My goal for the next 365?  I’ve got lots of ideas.  I want to improve communication, put better tools in the hands of my patients, become better organized (having someone besides me running the business would be nice), focus on education and outreach, and put medical records more and more in the hands of the people to whom they really belong: my patients.  But my real goal is simple: survive, improve, grow (in that order).

Thanks to everyone who helped me over the past 365.  When things get good enough I might just buy you an Ommegang.

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