A Country Doctor Writes:

How long does it take to diagnose guttate psoriasis versus pityriasis rosea? Swimmers ear versus a ruptured eardrum? A kidney stone? A urinary tract infection? An ankle sprain?

So why is the typical “cycle time”, the time it takes for a patient to get through a clinic such as mine for these kinds of problems, close to an hour?

Answer: Mandated screening activities that could actually be done in different ways and not even necessarily in person or in real time!

Guess how many emergency room or urgent care center visits could be avoided and handled in the primary care office if we were able to provide only the services patients thought they needed? Well over 50% and probably more like 75%.

Primary Care clinics like mine are penalized if a patient with an ankle sprain comes in late in the year and has a high blood pressure because they are in pain and that becomes the final blood pressure recording for the year. (One more uncontrolled hypertensive patient.)

We also get penalized if we see an infrequent visitor only once in a given year and don’t screen and provide interventions for depression, alcohol use, smoking and a host of other conditions unrelated to what the patient came to us for.

So we can’t afford to have quick visits since anything less than comprehensive makes us look bad.

Imagine if you pull up to an ATM for $40 in cash and the machine insists on going over your annual budget with you. That’s what primary care feels like sometimes.

Of course I will look one or two steps beyond the chief complaint. If a smoker has bronchitis, I’ll talk about smoking. And if an alcoholic falls down his front steps, I will take the opportunity…

But I can’t do everything for everybody in every visit. I can be comprehensive, over time, if I am not penalized for squeezing In patients with simple problems for quick visits. I think that is more comprehensive than declining to provide rapid access and thereby forcing patients to fragment their care between multiple unrelated providers.

Here is my simple prayer:

Dear Overlords of CMS and all you other Healthcare Policymakers and Deities,

Let us judge how to best meet our patients’ needs when they come to our clinics. Admit that sometimes a sore throat is just a sore throat.

My first job after residency was in a small mill town in central Maine. I joined two fifty something family doctors, one of whom was the son of the former town doctor. I felt like I was Dr. Kiley on “Marcus Welby, MD.” I didn’t have a motorcycle, but I did have a snazzy SAAB 900.

Will was a John Deere man, wore a flannel shirt and listened to A Prairie Home Companion. He was kind and methodical. Joe didn’t seem quite as rural, moved quicker and wore more formal clothes. I never could read his handwriting.

They each had their own patients, but covered seamlessly for each other. They were like a pair of spouses in the sense that they answered to each other as much as to their patients. They had to make everything work for the benefit of their shared practice, their shared livelihood. Their mutual loyalty was essential and obvious, although allowing for their differences in temperament and personalities.

Invited to stay on and enter into a partnership, I hesitated. How did I fit in? Could I follow in their footsteps and become an equal partner, covering for them and doing things similarly enough to fit in for the long haul?

In the end I declined and became an employed physician in the clinic I have been the Medical Director of, with some side forays, for decades.

Here, we are all employees, strangers brought here by chance, held together more loosely. We are all choosing to get along, but there isn’t the marriage-like commitment that Will and Joe had. We don’t arbitrate our differences in the same way; we, as a larger group, have the option of “doing our own thing” to a greater degree.

We do feel a strong loyalty to our growing but still small organization. Incoming providers paint a picture of what it is like to work for practices owned by much larger organizations, and in those it seems less obvious that doctors feel a deep commitment to their corporate mission.

Answering to the administration as much as, or more than, our colleagues makes it possible for us not to be team players. It also sets the stage for possible professional isolation. We must consciously cultivate clinical interchange and a collegial atmosphere.

In spite of all the talk about team based care, medical providers today are terribly isolated. There is no doctors lounge anywhere anymore. We are all collaborating with other staff categories, but not so much with each other.

There are virtual options for camaraderie and professional sharing, but with long clinic days and “pajama time” work from home, do we feel we have the time and energy for that?

I think we need to find ways to interact with each other at work. I seriously believe that this would be an investment with potentially huge return. Instead of working and eating at our desks or holing up to stare at our smartphones, and instead of giving up our lunches for structured meetings, we could eat lunch together and talk about tough cases, new things we’d like to try and challenges we face as modern medical providers.

If we talk more with each other, we can also develop a more shared vision of what we want out of our jobs for ourselves and our patients.

I’m talking about bringing back the Doctors Lounge…

You’re running late and many things didn’t go right today. You knock on the door and enter the exam room with an apology. If you’re like me, you have a few papers and an iPad or a laptop in your hand. You sit down and open the patient’s chart in your device or perhaps on the big desktop, eyes not exactly locked on the patient.

Only after getting to where you need to be in the computer do you really look the patient in the eyes. Your body language has been one of hurry and distraction. Now you try to repair the damage of that, so you try to show you’re settling down now, at least for a few moments. You might sigh, move your arms in a gesture of relaxation and say something to get the history taking underway.

So far, you’re failing. I do that often, too.

Here’s what we all know we need to do, but often don’t; we should follow these ABCs:

A – Attention:

Clear your mind. It doesn’t matter what happened in the other room with the other patient, or on the phone with the insurance company or the smug specialist or ER doc who pointed out the diagnosis you missed. Open the door (I always knock first) and immediately look at the patient. Make eye contact and observe them. Pay attention to how they look, what they are signaling. The computer can wait; a few moments of focused attention will usually save you time in the end. After all, red or teary eyes, a leg cast, a big bruise or change in grooming can make the visit go in a direction you wouldn’t have expected from he listed chief complaint. How many times have we heard a patient comment about another doctor: He didn’t pay attention to me. Do we always do that ourselves if we’re rushed or preoccupied?

B – Behavior:

Behave like a doctor. I keep saying that. But the clinical encounter is like a dance, where either one of us can lead, and we lead a little too often. Behave in a way that signals respect, interest and both confidence and humility. Behave like someone who serves, guides and helps the patient heal. Behave in a way that behooves a doctor. You have paid attention to the patient. What did you see? What does he or she need, or need you to be like, in this moment?

C – Connection:

The goal of contemplating how a good clinical encounter should begin is to establish connection. Learning about someone, counseling someone, treating someone, comforting someone all require having a connection with that person. They tell you that strangers you meet like you better if you invite them to talk about themselves. Making connections with patients requires showing genuine interest, inviting disclosure and reciprocating just enough to show that you are a real person, but not so much that you seem too fallible or self absorbed. It is better to talk about your interests than about yourself. Sharing about pets, children and hobbies that don’t portray you as uppety is safest.

In the fast paced, high pressure day to day work we do, I sometimes catch myself not engaging quite enough with my patients. Even after forty years of doing this, I need to remind myself to start every patient encounter off in a way that sets the stage for making clinical and interpersonal progress. My demeanor builds relationship equity over time so that if I sometimes don’t live up to my ambition and miss one of my ABCs, my patients are a little more likely to overlook it.

We do two things when we treat young adults with opioid use disorder in our Suboxone clinic.

The obvious one is providing the chemical that attaches to certain opiate receptors and quiets cravings without feeding the reward cycle.

Because buprenorphine is also a Kappa antagonist, it has antidepressant and anxiolytics properties that traditional opioids don’t have.

By prescribing Suboxone, we help our patients’ brains return, partly or completely, to the way they functioned before they became habituated to opioids.

The other thing we try to do, although it isn’t just our job, but that of everyone who cares about a young adult in recovery, is habilitation.

Habilitation isn’t relearning what you used to know, but acquiring skills you never had in the first place.

We generally say that your emotional and character development stops when you become addicted. It can also arrest when you suffer trauma. The life lessons of cause and effect, immediate and delayed gratification, giving and taking, joy and sadness, self and community are all skipped over to some degree when you are on a chemical roller coaster or suppressed by the weight of emotional trauma.

In our group therapy, facilitators and participants challenge newcomers who feel the world owes them things they haven’t earned. We talk about sticking with a job you don’t like to build a resume for better jobs in the future. We talk about proving to the DHHS that you can be appropriate and responsible with your children. We talk about making new social contacts and friendships, developing new interests and about coping with stress, emptiness and disappointment.

We have also started a group for friends and families of people in recovery. This group, aided by veteran Suboxone patients, serves as a sounding board for our journey. Because it isn’t a paved highway – the prescription part is pretty straightforward, but the other part is different for every patient, every group and every community. It must be local, a grassroots effort.

A lot of interest and a lot of money is flowing into opiate dependence treatment right now, mostly the chemical part.

But once that happens we must face the next big challenge, which isn’t talked about much yet, of helping a large cohort of young adults catch up from a decade or two of skipping classes in the school of life.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be – Yours Truly

It cannot be said enough: Ours is a relationship based vocation. Unless you are doing autopsies for a living, you need to establish rapport with real, live human beings in need of something, with fears or suffering, with past experiences and future hopes.

As a doctor, I play some sort of role, small or big, in the life of every patient I see, for a single visit or over the course of many years.

I am only one person, but I have a vast repertoire of demeanors and vocal inflections, a rich vocabulary of medical and non-medical words and a well honed body language I can put to use in each patient encounter depending on what my patient needs in that moment.

One obvious role is to be the one who correctly diagnoses and treats each medical problem. But medicine is more complicated than that. We know that a physician’s behavior greatly influences medical outcomes, even for conditions that don’t appear to be psychosomatic.

Another role I often think, speak and write about is that of guide. In that role, we need to carefully balance our own authority with deference to our patient’s need to develop and maintain their own. Project too much confidence in your knowledge and experience and hold the patient back; project too little and be of no help at all.

When it comes to the lifestyle related epidemics of our time, we need to be the bellwether for our patients, not by preaching from a pedestal but from a position of a near equal, just one small step ahead. Never obese, I still carried more weight than I should, and I use my own fifteen pound weight loss journey as a peer-to-peer example.

When our patients face the end of life or tragedies of any kind, like it or not, we need to shoulder the priestly mantles many modern people need us to wear as they lack religious connection or foundation. In such cases, we need to seem a little bit above the trivialities of this world, which often makes no sense to those who suffer.

Oftentimes, in the maze of the healthcare bureaucracy that our patients find themselves lost within, we as doctors need to fill the role of advocates. We cannot ever give the impression, or think to ourselves, that we aren’t working for them. Without patients who believe we are on their side, where would we be? This one is probably the most important role we play in 2019.

Choosing how to behave in any given patient encounter is not “acting” in the sense of not being yourself. It is being tuned in to each patient in each instance and filling the need each one has. It is about not barging into the exam room with our own agenda all set. It is approaching each patient with an open mind, ready to listen:

“How can I help you today?”