How a patient feels about the quality of care they receive depends on the quality of interactions they engage in with their doctor. There are numerous reasons as to why patients do not regularly see their doctor; it could be because they don’t feel valued, or maybe it’s just because they have forgotten to make an appointment.

Regardless, as physicians, we should be encouraging our patients to be seen regularly and that begins by building a relationship with them. One day I had a nurse call a patient of mine to inquire about scheduling her over-due mammogram. It had been two years since I last seen Mary. I knew because she was between the ages of 50-74 she needed to have a mammogram.

Mary was completely shocked when she discovered that our office was keeping up with her health records, despite her infrequent visits.  She had always trusted our medical advice, but her busy schedule and good health kept her from coming in for preventive visits.

When a relationship is already established, this sets the stage for patient engagement. Since patients know us, there is an automatic trust conveyed and they are more likely to do what we ask.

Mary expressed her sincere appreciation for the telephone call and agreed to have a mammogram scheduled as soon as possible. Unfortunately, the results came back with unpleasant news. Mary had early breast cancer.

Dr. Lawrence Rosen, one of the country’s leading integrative pediatricians, describes a patient interaction as, “a two-way engagement.” Furthermore, a relationship with patients, “requires an intention, a willingness to be present, to show up and engage with our patients in a way that is mutually respectful and says, “I am here with you and what you have to say matters as much as what I have to say.””

When Mary came into my office, after finding out the dreadful news, she shared her concerns, I offered medical advice and we mutually agreed to a plan that worked for her.

From the initial phone call, Mary knew that we were not calling her to make money; we had no financial interest in that. Our simple reminder phone call was enough evidence for Mary to continue putting her health in our hands and it ended up possibly saving her life!

I do not know for sure if Mary would have reacted the same way to the requests being made by her insurance company. What I do know is that Mary was motivated to have her mammogram because she knew her health was our main concern and she trusted our advice.

Patients are motivated to engage in their health because of relationships with their doctors. As we have already discussed is past blog posts, these relationships result in pleasure for patients and physicians, encourage patient motivation and engagement and overall they improve patient’s health outcomes.

Relationships are a source of pleasure, whose absence will make you wonder why you chose primary care. The hope of many long lasting patient relationships is what drew me, as well as most of my colleagues into primary care. Leaving my clinical practice after 28 years of being a family doctor was more difficult than I anticipated. I was surprised by the emotion that I shared with both my female and male patients.

These feelings were not a result of how broken primary care has become, rather the personal connections that had been formed with my patients. I realized that I was leaving behind the best discipline that medicine had to offer.

Relationships create pleasure

Knowing people, being involved with people, helping people, watching people grow, develop and change, over a period of time, is probably the most exciting part of life and we get to experience each of these in primary care. This is what distinguishes primary care from specialty groups.

The Commonwealth Fund recently published an article on primary care being our first line of defense in light of today’s healthcare crisis. They acknowledged that it is not just about seeing any doctor trained in primary care, but more importantly seeing “a regular doctor you can trust.”

To trust someone is to become vulnerable and dependent on another person’s intentions and motivations. It is only developed within the context of a continuous relationship.

Trust creates pleasure for patients because their doctor knows them and understands their medical needs. On the other hand, trust creates pleasure for physicians because they know that they are meeting their patient’s needs.

Relationships encourage patient engagement

One of my patients, Dan, smoked 3 packs of cigarettes a day for 30 years. From the time I first met him, I talked with him about his smoking habit. Over the course of several years, I encouraged him to quit and warned him of the damages he was causing his body.

The day I learned about Dan finally quitting smoking, was the day our office was being interviewed by a Business Week reporter. The reporter asked Dan what made him decide to quit smoking. He immediately turned to me and answered, “He did!” “He never gave up on me, he kept talking about it and I decided that he was right.”

That’s the value of relationships; you cannot change habits and behaviors only based on evidence. It is building a relationship that has value to a patient, which then translates into motivation for the patient, and motivated patients create different outcomes for themselves and their culture.

It goes without saying that America’s healthcare is in crisis, especially primary care. However, as I was saying goodbye to my patients, whom I had built deep meaningful relationships with, I realized that there is never a bad time to be a primary care physician.

According to Charles Dickens, writing in 1859 of the decade leading up to the French Revolution, “It was the best of times, it was the worst of times …” and as the novel proceeds, both extremes seem to hold true. I’m not sure I fully understood that particular paradox when I first read those words in high school, though I suspect that after thirty years as a family physician I’m better able to appreciate the more subtle and often ambiguous workings of the world. A good example is the situation in which generalists find themselves with regard to the Affordable Care Act (ACA) and the current state of primary care.

When the United States Supreme Court ruled in June of 2012 to uphold much of the federal health reform law passed in 2010 my first thought was how can this legislation, which had become somewhat of an ideological and political football, manage to make a positive difference in the lives of primary care physicians and their patients? What will it do to improve our ability to respond to the approaching tsunami of older Americans with chronic conditions, the workplace issues that threaten our efficiency and capacity, the specter of millions of newly insured individuals in the pipeline and practices characterized by not enough time for too many patients not to mention physicians with not enough time for themselves and their families?

To describe my feelings about the potential of the ACA as “skeptical” would have been an understatement. I would have been far more likely to express the belief that if Dickens were alive today and writing about healthcare, much of the existing scenario would certainly merit his “worst of times” designation.

I still have concerns that the ACA legislation as it currently stands doesn’t fully address some of the core issues around healthcare reform including areas related to reimbursement. In fact, my hope is that the legislation in place now is something that will evolve and clarify.

But right now it beats the status quo which, without serious structural changes, simply isn’t sustainable. I also believe that it opens the door on what can be an improved practice environment for primary care medicine with a legitimate claim to the “best of times” designation, and here’s why:

Increased reimbursement for Family Practitioners: One of the best ways to tell someone that what they do is respected and valued is to up the pay. And that’s what the Medicare 10 percent bonus on select primary care services does. Granted, the 2015 time limitation and other criteria related to the primary care prevention code are hardly ideal, but it is a beginning.

Shining a light on Primary Care as a career: Despite its rich legacy as the field of medicine most likely to create and maintain the special bond between physician and patient, primary care has been a bit of a black sheep on Match Day. And that has a lot of people concerned because primary care is unarguably the foundation of healthcare reform. Accordingly, there are provisions in the ACA related to bonus payments to work in underserved areas, loan forgiveness and other measures designed to encourage medical students to pursue primary care.

If we’re looking at a future of expanded coverage, and make that much-expanded coverage, we’re kidding ourselves if we think we can do it without getting more providers into the field. These changes represent something far less than a perfect world, but again, it’s a promising first step.

Support for the Medical Home: There are provisions in the ACA related to a Medical Home Pilot Program. I transformed my own practice to fit this model before it had a name and the focus on a family physician-led practice team coordinating care management is a bar that can never again be lowered. I saw it change every aspect of my own practice, from better reimbursement, elevated staff responsibilities and morale to improved patient satisfaction and outcomes and an opportunity for me to get off the hamster wheel.

Seeing this model become a mainstay of healthcare reform is, personally, very gratifying. But based on my own experience, I’ll let you in on a little secret: taking on the responsibilities of a patient-centered medical home holds the potential to sink your ship, unless you form a truly functional team.

What I hope I have been able to convey regarding the ACA, is that it’s one of those examples of not letting the perfect be the enemy of the good. The legislation is far from perfect, but it is a platform on which we can build. I for one, look forward to watching my family medicine colleagues introduce their own practice-based reforms into the global reform equation and be part of the effort to transform the worst of times into the best of times.

In future blogs we’ll talk more about why a functional medical home is a “property” you’ll want to invest in.

The Physicans Foundation conducted a survey of approximately 13,500 physicians. Its results were released on September 21, 2012. I strongly encourage you to read it for yourself here, but I’d like to highlight a few points. [i] Healthcare is currently in one of the most transformative eras in the history of modern healthcare and health reform. That being said, it is also a very challenging and uncertain time to be a doctor.

Did you know?

• 84% of physicians agree that the medical profession is in decline

• 78% of physicians are somewhat pessimistic or very pessimistic about the future of the medical profession

• 60% of physicians today would retire if they had the means

Even with this hopeless perspective that physicians hold about the future of healthcare, it’s amazing how difficult it is to get them to consider changing. Yesterday, I worked with a physician who works 80 hours every week. He, too, is experiencing difficulty in the way he practices his medicine to fix this problem. As difficult as the environment may be, we are not changing just for the sake of the patient, but also for the sake of the profession itself. Change is good for the health profession and for generations to follow.

Acknowledgements

[i] A survey of American’s physicians: Practice patterns and perspectives. The Physicians Foundation [online]. September 2012. Accessed October 17, 2012.

In one of my recent posts, I talked about the Lone Ranger doctor (see Hi-yo Silver!). One of the conclusions that I came to was that the Lone Ranger, despite his name, did not work alone. He had a team. So, let’s call the misconception that the provider is alone in all areas of his medical practice, the Pseudo-Lone Ranger mentality. In today’s post, I’d like to explore a few of the Pseudo-Lone Ranger misconceptions with you and explore how this leads to dysfunction in primary care.

I’m sure you know from experience that providers are trained from early on to be decision makers, relying on their own judgment and often by necessity making the hard choices all on their own. As providers, we know this is a reality of the job and we accept the responsibility.

The problem is that while the Pseudo-Lone Ranger style of leadership is a definite strength in some areas (i.e. in medical decision-making), it can often become a weakness in others.  No place is this more true than in the primary care office. The Pseudo-Lone Ranger mindset has overflowed into primary care.  As a result, we providers, who have been trained to the hilt in medical issues, can often find ourselves owning some very dysfunctional processes in the day-to-day operations of the primary care office.

Dysfunction #1 of the Pseudo-Lone Ranger mentality

The provider is the only one who has adequate training to be involved with the patient.

Picture this: A half dozen bandits are waiting in ambush for the Lone Ranger. Tonto has already scouted out their location, laying the ground work for the counter attack. It is now time for the Lone Ranger to spring into action. Tonto gears up, Silver is saddled and ready to go. But then the Lone Ranger says to his loyal team, “No, you stay here. I’ve got this.”

What?! Why would he do that? It makes no sense for him to go into the fight alone, when he has perfectly good teammates to help him save the day.

It seems like such a silly scenario, but don’t we make a similar decision day after day in primary care? We have been told that the provider is the only one with the adequate training to be competently involved with the patient in the exam room.  So when the provider enters, the nurse or MA leaves. Why not use your team to the best of its ability?

If this model were used in the operating rooms of America, the time for each surgery would need to be doubled. As primary care providers, we need to adjust our thinking.  As I analyzed the patient visit I found that it can be broken down into multiple portions, some of which can be handled very competently by other members of the clinical team.

Dysfunction #2 of the Pseudo-Lone Ranger mentality

Very little investment in training others or building a team.

Picture this: Once again, bandits are waiting in ambush. Our three heroes once again prepare to counter attack. The Lone Ranger whistles and…nothing happens. The Lone Ranger looks at Silver expectantly, Silver looks back at him in confusion. What the Lone Ranger has failed to grasp is that Silver, while fully capable of responding to the whistle, has never been trained to do so. In disgust, the Lone Ranger walks to Silver and mounts. Tonto, already on his horse, Scout, waits for the signal. The Lone Ranger raises his hand and the team springs into action. The only problem is that the Lone Ranger heads due west and Tonto goes in the opposite direction. The Lone Ranger glances back in frustration, while Tonto looks back with surprise. “Kemosabe, the bandits are to the east.” The Lone Ranger replies. “Oh, didn’t I tell you? While you were making coffee, I looked through my binoculars and watched the bandits move their location. They are now to the west.”

Imagine Tonto’s and Silver’s frustration. To be held to expectations without training and communication is not only disheartening, it’s a game changer. I’m guessing that by the time our heroes got their act together, the bandits had them captured and hogtied.

While we easily see the foolishness of the Lone Rangers actions, we need to see just as clearly that as Lone Ranger providers, we do the same thing in our practices.

Typically, in most primary care offices, minimal time is set aside for discussion, evaluation, and adjustment with staff. Communication with staff is always last resort.  We need to understand that our staff, our team, needs our time and attention. When the team is more prepared and informed, the end result will be infinitely more successful.  This type of facilitative leadership necessitates time and communication to build skills and team dynamics. You may not think you can afford the time to invest in your staff, but, really, can you afford not to?

If primary care is going to change, it is going to have to be the result of providers changing from the Pseudo-Lone Ranger mentality to the true Lone Ranger mentality.

“…It is important for professional organizations …to understand…they should embrace with equal enthusiasm and dedication the need to promote new approaches to doctoring and…to help physicians transform within themselves and in their relationships with their practice partners, patients, health care systems, and communities.” [i]

Up until now everything else changes around the provider, but not the provider. The staff may change; the patients die or leave, new medical treatments appear, but don’t ask the provider to change. Who would ever think of such a ridiculous idea? Its okay for PCP’s to ask of themselves to work 10-14 hours a day, become a ghost to their family, or hate their job, but don’t ask them to change the way they practice medicine.

And I’m not just pointing the finger. I was there, stuck in that same rut. I needed to change, but of all the forces that impact medicine, my biggest hurdle was myself.  I needed to come to grips with my Pseudo-Lone Ranger mentality and change the way I viewed my staff and myself. I needed to learn how to be a true Lone Ranger provider, by valuing my team and giving them the time and attention they needed.

So, I challenge you to be a true Lone Ranger provider.  I truly believe that if we can become effective team-leading providers, we will not only improve our own practices, but revolutionize primary care medicine.

Acknowledgements

[i] Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home Ann Fam Med 2009;7:254-260. DOI: 10.1370/afm.1002.

A recently posted article in the New England Journal of Medicine quoted a doctor who said that most residency training is “training to be the Lone Ranger, where one person goes in and is supposed to be all things to all people.” [i] This so-called Lone Ranger mentality begins in residency and continues throughout our careers as physicians.  Let’s face it, as doctors the buck stops with us. We are on our own.  We get into medical school by ourselves, go through training by ourselves, make life-impacting decisions by ourselves and practice all day long by ourselves.  As an example, I manned the ER by myself at 1:00am as a first year intern.  Our training, our instincts and of course, expectations dictate that we are the one in charge at all times.

It all comes down to the fact that you, the doctor, are the one with the necessary training to make the final decision.  And if you are making these decisions, you have to be resolute. If you waver, you undermine everyone involved and that leads to chaos. Leadership creates stability and possibly a life saved.

But today, the medical needs of our society for increased capacity and availability cannot be met by a lone practitioner. So Kemosabe, how does this Lone Ranger mentality translate to the everyday practice of primary care medicine? Well, without trying to beat poor Silver to death, let’s take a closer look at the Lone Ranger.

The popular radio show first aired in 1933 and was a success but something was missing. After 11 episodes the writers realized that the Lone Ranger could not prevail all on his own and so Tonto was born. In 1949, the Lone Ranger moved to the small screen and was a hit television series for eight seasons. Silver, the Lone Ranger’s trusty horse took on a new life in the televised version and became as much a member of the team as Tonto. It is clear that Tonto and Silver were not just trusty side kicks. The three were a team. I bet the Lone Ranger would have been the first to tell you that without Tonto and Silver, he would have quickly become the Dead Ranger.

Okay, so what does this mean for us as primary care physicians in today’s demanding environment? While admitting that we may be Lone Rangers, we need to fully understand just who the Lone Ranger is. This complete shift in thinking requires that the Lone Ranger doctor realize his or her full potential. The doctor must become an effective team leader, respecting, valuing and communicating with his staff, preparing them to face the daily challenges of a primary care office. We doctors have to remember that even the Lone Ranger had Tonto and Silver. He wasn’t expected to save the day all on his own. And we Lone Ranger doctors need to put faith in our loyal team well. Our nurses and medical assistants are capable of so much more and we will do our best work when we work as a team.

This idea of teamwork has received a lot of lip service, but can be very difficult to put into practice. However, I firmly believe that if primary care is going to change for the better in order to meet the growing medical needs of our country, we need to step outside of our cultural box, embrace the value of teamwork and become leaders of effective teams. We need to realize our full potential as Lone Ranger doctors, that is, doctors that understand that they face all the challenges standing side by side with their loyal team members.  Not only will this approach help transform primary care medicine, but it will also mean a better quality of life for the Lone Ranger.

I’ll post some more on this in my next entry.

So, let’s go save the day. Hi-yo, Silver! Away!

Acknowledgements

[i] The Evolving Primary Care Physician Susan Okie NE ENGL JOURN MED 366;20 May 17, 2012

Isn’t our professional life pretty miserable?

The nation’s system of primary care is horribly broken…primary care is maddeningly stuck in a bygone era. [i]

…primary care medicine is such a soul-wrenching, demeaning endeavor [ii]

…there is another major crisis: the continued deterioration of primary care that threatens to break up the very foundation of U.S. health care…less than one in five U.S. medical graduates are now entering a primary care specialty[iii]

It certainly is easy to find alarming statements about primary care across the media. That is neither new nor surprising.  The fact that medical students have been walking away from primary care has been known for the past 10 years.

What has astounded me in the past year is how resistant many primary care physicians are to change. If primary care physicians were happy with their professional life, had enough family time, or got paid at the top levels, then maybe “no change” would make sense. But the exact opposite of all the above is true.

The frustration over the present working situation is seen in the entire country – I have personally met three PCP’s who were suicidal due to work issues and needed professional help because of this reality. I spoke at a  AAFP national meeting and all the 150 physicians in attendance rated the presentation very high, but zero were willing to try the change.

No question that the practice of primary care is miserable, but what makes change so difficult? Some possible reasons:

• No credible change to try

• Don’t have time or energy to investigate a new idea

• Changes for the staff would overwhelm them – their job is frustrating enough as it is

• Don’t have the finances to consider any changes

• Administration will not allow us to make any changes

• The government and payers have too many controls in place to allow any changes

• It will make me too vulnerable – at least I am familiar with this present situation

Change is always a risk: sometimes right, sometimes wrong, but always a risk. The familiar seems safe, even though it may be outdated or destructive. We all hesitate to change. Even the best can get it wrong.

“This ‘telephone’ has too many shortcomings to be seriously considered as a means of communication. This device is inherently of no value to us.”

– Western Union memo, 1876

Who knew communications in 1876 better than Western Union? Was their refusal to change because the phone was a bad idea or was it just an internal resistance to change? They got it wrong, and left the door open for ATT .

“But what…is it good for?”

– Engineer at the Advanced Computing Systems Division of IBM, commenting on the microchip, 1968

Who was better at computing systems than IBM in 1968? What has changed our lives more than the chip in the last 30 years?

This internal resistance to change is in all of us, but this resistance can be very harmful. The status quo seems like “home” because we are familiar with it. Because we all love being “home”, we are very vulnerable to missing good changes. If the home is in the path of a coming interstate, one better accept change.

With the advent of modern medicine in the 1920’s, the delivery of health care had to change. The house call had been the standard of health care delivery for 200 – 300 years. But now with the development of new treatments ( insulin, penicillin ), the discovery of new technology ( the x ray and blood work), and our growing population, the tried and true house call was too inefficient and cumbersome. The traditional office became the standard.

Has managed care, our aging population, and significant pharmaceutical advances now made the tried and true traditional visit of primary care inefficient and cumbersome? To be wrong on this could have devastating consequences.

Acknowledgements

[i] Reinventing Primary Care: A Task That Is Far ‘Too Important To Fail’, Susan Dentzer, Health Affairs May 2010 29:757;

[ii] The Top 10 Most Overblown Health Stories of the Past Decade By Richard N. Fogoros, M.D., About.com Guide Updated December 23, 2009

[iii] The Decline Of Primary Care: The Silent Crisis Undermining U.S. HealthCare Posted: 08/11/11 11:16 AM ET Huffington Post.