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.

9 thoughts on “To Know and be Known”

  1. That is one of my favorite parts of seeing my patients. I love that I can walk into the room, sit down, have a toddler crawl into my lap, and chit-chat with the mom for a few minutes before we get to the nitty-gritty of the visit. A lot of my moms have had a child every year I've been a resident and I've been able to do some prenatal stuff with them as well. To me, it's very rewarding and reminds me that I don't suck at this after all.

  2. You are so right. PCPs are important for a number of reasons, but what tops the list- is that they know you.

    When I ran into a problem with pain, my PCP could tell the specialist that I wasn't a complainer and that I needed further evaluation, and an adjustment in medication. They worked together for me – no egos. The specialist listened to him; and my PCP respected what the specialist thought they should do. If my own PCP hadn't known me for years, the specialist wouldn't have had that knowledge of me either.

    It's important to know your patient as a person. You can't possibly know them in a 10 to 15 minute time slot, but over many years, you can get to know them. A PCP is invaluable in my opinion. I keep trying to get some of my friends to understand this. You don't want to wait, and then try to find one in a crisis situation. You'll need someone you trust, should you ever become ill. And we all become ill at some point in our lives. Coordination of care and follow up is necessary in my book.

  3. Okay, I'm beginning to feel like Horshack because it's hard not to comment frequently, but you're that good and I think what you said today is at the heart of everything. My husband and I have been seeing our family doctor for more than 15 years and it's not overstating it to say we trust him with our lives. He saved my husband from what could have been a permanent mobility issue (he had a tendon cut in his foot and all the ER doctor did was stitch the skin up–our doctor got him into surgery with days to spare before it was too late) and he guided me through breast cancer and all its attendant emotional ups and downs. He told me during one visit he was going to help me get through this, and he did. He's a colonel in the Army Reserve and when they sent him to Iraq two years ago, we sent cookies and spiked fruitcake and I brought prayer cards for him to take along as protection on my last patient visit. My biggest fear with healthcare reform is that it will marginalize these relationships. Dr. Rob, you must be both a great doctor and man for your patients to care for you so much. I know my doctor is. And if anyone reading this is the praying type, please say a prayer because they're sending him back to Afghanistan in November. I'm already praying for his safe return.

    Thank you–again–for an awesome post.

  4. One wonders if your patients have more successful recoveries. A doctor who cares on a personal level would seem to be something that comes naturally, but what you have shared is really more the exception rather than rule (and, I tend to think, it's a way some doctors need to deal with patients, because caring too deeply can mean emotional turmoil for the doctor?). I read on one site it apparently breaks some professional code of ethics to get to close to a patient……..yet, the patient doesn't want to be a faceless entity. They have a longing to be an individual………..and they don't want the doctor to be just another lab coat. Sometimes I find this a juxtaposition I can't completely reconcile myself to.

  5. Didn't like the dig about mid-level practitioners. I am an NP and value the relationships with my patients EXACTLY like you do. Not all mid-levels work at Walgreen's!!!

    Primary care is primary care no matter who provides it. It is the relationship that makes primary care what it is, not the level of the practitioner who provides it.

  6. Actually the dig was on the Walgreens clinics. We use midlevels and I very much think they are part of the solution. I don't like it when people say they ARE the solution, but at this point it is “all hands on deck.” I really don't mean to make it sound as if midlevels are not of high value.

  7. Thanks for pointing out another great reason for primary care of patients and the overall benefits to the system. We forget that by building relationships with our patients, even taking a few minutes to chat with a new patient, we cut costs in needless testing, malpractice insurance rates, and even wardrobe 🙂

    Great post! Keep them coming!

  8. Dr Rob, We do consider you a great friend as well as a wonderful doctor, you see to all our needs, and we are so very thankful that you are our family doctor.

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