To Know and Be Known

I was happy when I looked at today’s schedule.

Two husband and wife pairs were on my schedule, both of whom have been seeing me for over ten years.  Their visits are comfortable for me; we talk about life and they are genuinely interested in how my family is doing.  They remember that I have a son in college and want to know how my blog and podcast are doing.  I can tell that they not only like me as a doctor; they see me, to some degree, as a friend.

Another patient on the schedule is a woman from South America.  She has also been seeing me for over ten years.  I helped her through her husband’s sudden death in an accident.  She brings me gifts whenever she goes on her trips, and also brings very tasteful gifts for my wife.  Today she brought me a Panama hat.

I know these people well.  I know about their past illnesses and those of their children.  I know about their grandchildren, having hospitalized one of them over the past year for an infection.  I know about the trauma in their lives as well as what they take joy in.  They tell me about their trips and tell me their opinions about the health care reform bill.

I spend a large part of their visits being social.  I can do this because I know their medical situation so well. I am their doctor and have an immediate grasp of the context of any new problems in a way that nobody else can.  This is not just in the context of their own medical ecosystem, it is in the larger family context.  This means that I know how to read between the lines when they say something – knowing what I can ignore and what subtle things are out of character.  This also means that I don’t have to practice defensive medicine – as I not only have a low risk of lawsuit, I also can rely on my intimate knowledge of them to keep excessive ordering of tests and referrals to a minimum.

That is the joy of primary care that doesn’t get talked about as often as it should: I have a genuine personal investment in my long-term patients.  I know them and am known by them.  It is also a much more efficient way to practice medicine.  I don’t have to order tests to get information when my personal information is so great.

A 21% cut in Medicare may have put an end to it.  When we were staring down the barrel of losing that much revenue, we seriously talked about our threshold for dropping Medicare.  The political game of chicken was not only played at the expense of physicians, it put great fear into many of my long-term patients that they would lose me as their doctor.  Yes, many of them would probably ante up and pay cash to maintain that relationship, but a new negative dynamic would definitely be thrown into the mix.  Some just couldn’t afford to pay me out of pocket (even with a discount).

We need a system that encourages relational medicine rather than discouraging it as our system does now.  Getting a bunch of mid-level providers in Walgreens is not the same as having an adequate primary care workforce.  I cherish my relationships with these people and they are, to a very large extent, the reason why I haven’t seriously contemplated dropping Medicare until recently.  I am a very important part of their lives – a stabilizing force that helps them deal with the difficulties of getting older and getting sick.  But they are an important part of my life as well.  I have a personal stake in their health because they bring me joy and connection.

After the visit, I gave the woman a big hug.  I was wearing my Panama hat.

My nurse says it would look good with my Jimmy Buffett shirt.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

7 replies »

  1. A side note here is that I am an early adopter of EMR and do not see it at all standing between myself and my patients. Yes, doctors can hide behind anything if they want, but I firmly believe that it is the doctor, not the technology that makes the relationship. I use the technology so I can spend less time with the part of the care I don’t like (keeping records) and more time with the part I do (interacting with the patient).

  2. The forging and maintaining of these relationships can save lives. When I was 23 years old I went to see my family doctor (my medical record showed my first appointment with him was the day before my 1st birthday) with a set of vague symptoms. I remember thinking these vague symptoms were a “good excuse” to see him. Turns out that the vague symptoms were Stage III lymphoma. I can tell you, for certain, that without that relationship I would not have gone to see any doctor – perhaps until it was too late for successful treatment.
    The relationships you forge with your patients now have consequences far into the future. That’s a big responsibility. I am grateful for those of you who recognize it and take up that burden. There aren’t many left.

  3. Excellent post. It makes me think of the great relationship with my doc over the years. We really need to figure out a way to put a value on the patient provider relationship. I suspect it matters more than we know in terms of overall health of the system and the patient.

  4. This is why EMR’s and PCMH is so valuable. I understand the difficulties in getting the different groups (payor, specialists, hospitals, primary care) to communicate. But the value of the EMR & PCMH is that if one of your patients is hospitalized you can know right away to schedule a follow up visit 72 hours after discharge or if specialist puts a patient on a new medication, you can compare that to the existing medications they are on.
    The point that seems to always be lost in the EMR discussion is not if it needs to be implemented, but how it needs to be implemented. EMR, Internet, Spreadsheets, Powerpoints essentially all do the same thing – communicate information from one party to another party. It is not the information that is communicated, it is what is done with the information that is key.

  5. Gaining efficiencies in a system is not always about implementing a new process or re-egineering. From my experience, efficient systems are created when there is mutual respect, collaboration, and shared interests and goals.
    As you point out, relationships in healthcare create dynamic exchanges of information not one-off episodes which defines so much of our healthcare. With so much at stake, you have to ask if the new central policies soon to be unleashed promote that environment.
    Thank you for sharing your view from the real world and giving us a vivid picture of what does work.

  6. Excellent post, and so true. The really sad thing is that, because what you describe can’t be measured, digitalized, and entered into a national data base, it is considered to be of no value in the PCMH model that is being shoved down our throats.

  7. Relationships, stories, and time to listen. These are the three key elements in successful and joyful primary care.
    So important, so under valued, and so threatened.