A Country Doctor Writes:

A few years ago primary care was all about being Patient Centered. But that turned into a bureaucratic set of superficialities that didn’t do half as much for patients’ experiences, let alone outcomes, as many of its proponents had envisioned.

Now, other forces are making us reexamine not only how we do things, but even what we are doing.

Our clinic’s Federal grant for next year will be smaller. A provider is leaving. Medicare is starting to shift from paying us a per visit fee to paying us for reaching randomly chosen quality targets. The mandates of what to fit into each visit are growing continually – very specific alcohol habits, physical activity level, sexual orientation, and on and on.

We only have so many providers, so many nurses and medical assistants and so many exam rooms. Practices around us are losing providers faster than we are, and more and more patients want to enroll with us.

The Patient Centered Medical Home recognition we achieved promised to give us some modest bonus payments, but it also cost us money in its nit-picking implementation, and now we are facing financial issues that overshadow such symbolic bonuses as PCMH incentives. It is simply time to roll up our sleeves and redefine the basics of what we do while trying to figure out how to meet the increasing demands from the community we serve.

We have previously paid lip service to the idea of having staff members work to the top of their license, because we have been stuck in the notion that only providers can enter orders and sign off reports in the electronic medical record, for example. We hold our providers to productivity targets that could easily be much higher with more support staff and more effective work flows, not only in terms of units of service but also “covered lives”.

The time has come for all of us to sit down, management with providers, nurses, medical assistants and clerical staff to look at our unique situation, our resources, our patients and start from scratch:

What can we do, here and now, and what do we envision in our own future, to better serve our patients?

If we don’t have enough providers and don’t expect to get many more – increase support staff and liberate us from unnecessary clerical tasks.

If we don’t have enough exam rooms, create check-in stations between the reception and the clinic area. Use technology to let patients check in via tablets or their own smartphones in the waiting room or even from home before they show up.

If we don’t have enough people to answer the phone to triage and make same-day appointments, open blocks of time for walk-in care, and divide providers’ time between protected time for time-consuming patients and intense stints doing urgent care.

Invest in building better EMR templates for faster documentation.

If we can’t afford or don’t want scribes to follow each provider into each visit, allow use of a paper visit form and hire one data entry person to input a stack of such forms at the end of every day if that might increase provider productivity.

In other words: Imagine local solutions for local needs.

The other day I read these encouraging words in the Harvard Business Review:

“The lesson for leadership is clear: Design your practice to maximize physician capability. Productivity, cost effectiveness, and satisfaction will follow.”

PCMH wasn’t the solution, because its recognition criteria were too rigid. Maybe the latest crises we are facing will turn into opportunities to bring some real life and passion into the next round of changes we must make in how we serve our patients and our community.

As a doctor, I solve problems all day long. As a Medical Director, I welcome the opportunity to bring my experience to the table where all of us can brainstorm in order to redefine, redesign and reengineer what is still a pretty inefficient system.

The tall, youthful seventy year old woman wore her strikingly white hair in a tight bun. She was dressed like a Donald Fagen song – in jeans and pearls (”Maxine”, 1982).

She had an intense burning, itching sensation on the left side of her neck and occiput. Looking closely at her neck and hairline, I saw a couple of small, red papules. A few of them looked like early blisters.

I suspected herpes zoster and offered her a generic antiviral. The earlier you start it, the better your chances of avoiding long lasting pain afterward, I explained.

A week later, there were some red blotches and several scratch marks. Her burning and itching were worse.

I prescribed gabapentin and told her how to titrate herself up from 100 mg at bedtime to 300 mg three times a day.

The following week she still had red blotches and scratch marks and felt no better. I frowned.

She said “My granddaughters have head lice, so I asked my daughter to check me, but she couldn’t find any. Would you check me, just to make sure?”

I leaned close and removed my -11 diopter glasses. My focal point is about one finger length from my corneas.

It took me a while, but I found half a dozen nits, enough to be sure she had the real thing.

Didn’t I feel a little sheepish. Seventy year old woman with burning and itching scalp? Must be zoster, right? Head lice is more of a pediatric problem, right?

Wrong. I narrowed my differential diagnosis too quickly.

And, I didn’t take my glasses off the first time.

A couple of years ago I saw a young man with pain in his lower right abdomen. I sent him for an urgent CT scan with a “wet read” to check for appendicitis.

It was afternoon and things were crazy at the office. I forgot all about the pending CT report. I have learned this about myself: I am efficient because I have the ability to hyperfocus, but that has made me dependent on my support staff to see the big picture of my schedule or pending, unfinished tasks.

The next morning there was a fax from Cityside with a lengthy explanation saying he had an epiploic appendagitis, and it went on to explain that this is a harmless and self limited condition.

I did some reading. These appendages are little fat bumps that run along the outside of the colon. They can undergo torsion, or twisting, and become acutely inflamed. This condition is found in up to 7% of patients suspected of having appendicitis and 1% of patients with suspected diverticulitis.

I had never heard of appendagitis, and I wondered how certain the distinction was between this harmless and the other potentially lethal -itis was.

Checking with the patient, he was in more pain and more nauseous than the day before.

I suggested going to the ER just to make sure. I just didn’t feel comfortable trusting a CT and a diagnosis I had never heard of. I imagine this is a result of training before CT scans were in use and then not rubbing elbows enough with major surgery to be aware of the finer distinctions of the differential diagnosis in acute abdomens already too sick for the primary care office.

The ER report from Cityside was gracious in its description of why my young patient was there. He got an anti inflammatory medication and some pain pills and went home reassured. He was still uncomfortable when we called him a day later, but feeling better.

The other day I saw a young woman who had been to Mountainview Hospital for left lower quadrant abdominal pain.

She had a history of diverticulosis, and at her young age had already had a CT proven episode of acute diverticulitis a few years earlier. This time, the CT showed a sigmoid epiploic appendagitis with no evidence of diverticulitis. The ER doctor prescribed antibiotics that would have been appropriate if she had diverticulitis.

I saw her two days after the emergency room visit. She was feeling a bit better. Her exam was benign and I explained to her that she didn’t really need the antibiotic. But I also told her it was a rare condition that I had not heard of in my first 35 years of practice. I told her the Mountainview ER doc probably hadn’t seen a case before either, or didn’t trust the CT.

My patient was happy to stop her antibiotics and happy that her diverticular disease was not the cause of her symptoms.

You’re never too old to learn.

I guess I’m American enough, after spending ten more years here than in Sweden, to start to get a little philosophical at Thanksgiving. I spent my first Thanksgiving in this country not far from where the Pilgrims landed at Plymouth Rock, as an exchange student with a Jewish family, three houses down from an African American family in an otherwise white Anglo Saxon distant suburb of Boston.

I, too, was a pilgrim of sorts when I decided to move here. I was smitten by the sense of freedom and optimism in this country, and by the belief that hard work almost always paid off.

Because many of the specialists I started referring to when I first came to this area have now retired, I can vaguely picture the end of my own tenure, but I hope to have twenty more years in the profession that was my dream since age four.

I am thankful for the schooling I received and for the mentors that guided my progress through my early years of practice. I am thankful for the opportunity to knock on an exam room door twenty times a day and say “how can I help you today” to twenty fellow human beings. I am thankful that most of the time my advice is well received and I am humbled that so many patients have remained loyal to me for so many years.

I am thankful that I have been able to stay focused on the essence of doctoring and have had so few feelings of burnout after 38 years of being a physician.

I am thankful that I have always landed on my feet when life has seemed to trip me up. And I am thankful that I have so far been blessed with good health.

As I reflect on my own fortune, I can’t help but grieve over how many people I meet that don’t have the optimism, faith and enthusiasm I first encountered when I came to this country. My adopted homeland is a very different place from when I started my Senior year in 1971 and my Family Practice residency in 1981.

I don’t think it’s just because I’m older that I have to do a lot more life counseling with people who are losing their faith in their own future. And at the same time the health care system is squeezing the agenda of my patient visits with more and more demands that challenge my ability to really connect with my patients and help them carry on with their lives.

So, for the next twenty years or however long I have left, may I never lose my own faith in the power of the doctor-patient relationship or my gratitude for the opportunity I have been given to cure sometimes, treat often and comfort always.

The woman’s legs were so swollen that the indentation from my thumb squeeze was as deep as half my thumb. Her belly looked pregnant at sixty plus years but a recent ultrasound had shown no fluid and no change in size or texture of her already enlarged liver.

“There may be something else going on, I said. “Have you had any chest pain lately?”

“Well, yes, three weeks ago I had a pain here”, she said, pointing to her left upper chest. “It lasted three days, and I kept waking up and going back to sleep, hoping it would go away.”

“Has your breathing been worse since then?”

“Yes, but I thought it was because my belly got bigger.”

Her EKG showed q-waves in leads III and aVF, new since last winter, a sign of a possible old inferior myocardial infarction.

“It never occurred to me that it could have been a heart attack“, she said. “I should have known better.”

I have found that few people volunteer that they have had serious chest pain, so I ask at every visit with anybody who is at risk. Why is there so much denial about this?

“I didn’t want it to be my heart.” Her classic comment summarized my recurring observation.

I thought of a post I wrote four years ago, called Twenty Questions:

Adrian Bell didn’t look dehydrated, but his diarrhea had come and gone for a week and a half when I saw him a few weeks ago.