Care, Primarily


He came in for his regular blood pressure and cholesterol check.  On the review of systems sheet he circled \”depression.\”

\”I see you circled depression,\” I said after dealing with his routine problems.  \”What\’s up?\”

\”I don\’t think I am actually clinically depressed, but I\’ve just been finding it harder to get going recently,\” he responded.  \”I can force myself to do things, but I\’ve never have had to force myself.\”

\”I noticed that you retired recently.  Do you think that has something to do with your depression?\” I asked.

\”I\’m not really sure.  I don\’t feel like it makes me depressed.  I was definitely happy to stop going to work.\”

I have taken care of him for many years, and know him to be a solid guy.  \”I have seen this a lot in men who retire.  They think it\’s going to be good to rest, and it is for the first few months.  But after a while, the novelty wears off and they feel directionless.  They don\’t want to spend the rest of their lives entertaining themselves or completing the \’honey do\’ list, but they don\’t want to go back to work either.\”

He looked up and me, \”Yeah, I guess that sounds like me.\”

\”What I have seen work in people, especially men, in your situation is to get involved in something that is focused on other people.  Volunteer work at the food pantry, work for Habitat for Humanity, or anything else that lets you help other people.  I think the reason people get depressed is that they turn their focus completely on themselves, which is not what they are used to when they are working.\” (I knew that this man had a job that helped disadvantaged people).

\”That\’s great advice, doc.\” he said, with a brighter expression on his face.

\”It\’s from experience,\” I responded.  \”I\’ve seen a lot of retirees start to feel like they are on a hamster wheel, just entertaining themselves until they die.  I know I wouldn\’t want to retire that way.  Knowing you, I wouldn\’t imagine you would either.\”

We talked for about 15 minutes about the various groups around town that would need someone of his skills.  I told him about how my parents went to Africa for a year after Dad retired.  He actually taught physics over there, but that is what they needed.  Of all the time I spent with him, over half of it was regarding his post-retirement \”blues.\”  He wasn\’t clinically depressed, so I couldn\’t charge for depression as a diagnosis.  The code I used?  99214 for Hypertension and Hyperlipidemia.


I saw her name on my schedule.  She\’s a dear woman whose husband passed away recently.  I have cared for her and her husband for many years; they would always come in together – he with his dry wit and she with her motherly hugs.  I was both happy and sad that she was coming in.

When I walked into the room she looked at me with bloodshot eyes and said, \”I am doing OK\” with a wavering voice.

I didn\’t say anything; I just went over to her and hugged her.  She hugged me tightly and neither of us said anything.  Her visit was officially listed as a recheck of her hypertension, but we spent the vast bulk of the time talking about her husband.  She laughed because her blood pressure was actually lower now than it had been before.  \”I guess I know who was causing my blood pressure to go up,\” she quipped with a hint of tears still in her eyes.

I laughed, did my documentation as we talked, and scheduled her to see me back in a month.  She didn\’t need to be rechecked in a month for a medical problem, but I knew she would want to see me soon.

I coded it as a 99214 for hypertension and grief reaction.


With the debate about our healthcare system heating up, I think we lose focus on the point of the system in the first place: care.  I knew both of these patients well, which made these special interactions possible.  I didn\’t have to do the extra stuff as a doctor, but the human side of me made it impossible not to spend the extra time.  Primary care is about relationship – about doctor knowing patient and patient knowing doctor.  It is an opportunity for people to get help and to get care.

I am not unique in my relationship with my patients; this is why most people go into primary care in the first place.  But I do think the pressure to become an E/M coding machine, for focusing on the business over the patient, is getting progressively stronger.  To the system, each of these encounters are simply codes and numbers.  But they were obviously so much more than that.  They were about the humanity, the contact, the care that is becoming a scarce commodity in our system.

Some people may not want a doctor who spends extra time with them, but most people do.  Our system is progressively snuffing this out by belittling the importance of relationship and stressing drugs and procedures.  Both of these patients are Medicare, and so the idea of my practice dropping Medicare bears their faces along with many others.  Yet I can\’t really afford to take a 21% pay cut, so we\’ll have to figure out something.

Medically, these visits were routine and uninteresting.  But those moments are the pearl at the center of any system we set up.  We need to value that pearl.  We need to encourage medical students to go into primary care, so that when I get to the age of these patients, I will have someone to care for me – to really care, not just code and document.  Right now, encouraging students into primary care is like encouraging them to stand at the muzzle of a loaded gun.  We are endangered.  These visits are what is really at stake.

Does Washington realize this?  Does Washington care?

11 thoughts on “Care, Primarily”

  1. I wonder if Congress, the President and other policy makers read real life vignettes like yours. The medical blogosphere is overflowing with such poignant stories. That real-life compassion between doctor and patient is reduced to a 4 page EMR note and a 5 digit CPT code illustrates the ridiculousness of where medical reform is going.

    In your case of obvious quality care, how would an outcomes researcher sort that out from your code. Will we get extra quality points for discussing retirement blues or giving hugs to grieving patients.

    I guess if we keep writing such stories, maybe somehow, the spinning wheel will get some traction. Maybe.

    Good stuff,


  2. Thanks. That is actually why I let my posts get republished at places like The Health Care Blog. It is really true that if we keep putting out quality stuff, people will read it – eventually maybe even people that matter.

  3. Again you managed to capture the crux of the situation eloquently…as well as perhaps giving me a springboard to work off when I get people asking me what it is that bugs me about having ended up where I did within the healthcare system. Your comment speaking to the huge difference between patient encounters as “codes and numbers” versus “care that is becoming a scarce commodity” hit it dead on. When I started on that long, complicated, and at times truly insane journey that for me was higher education, I was looking for the chance to use my somewhat wacky experiences to help the next guy or gal who walked through the door; I ended up in a situation where I feel at times like nothing but a drone for the same bureaucracy that I grew up hating with a passion.

    Now if only some of the truly important of those bureaucrats would actually pay attention to the valuable insights on this here blog (or wherever else your commentary is published)…maybe there'd be some hope for fixing that system in a meaningful and lasting way!

  4. One of the qualities I try to instill in the medical students and residents I teach is the power of shutting your mouth and listening. So much can be learned from your patients if you shut up and let them talk. There is power in the open-ended questions: “What's up?”, “How's life?”, “Is there anything else you want to talk about today?”

    I see one of my patients on a monthly basis. Sometimes she has valid stuff to go over (contraception, acne; the usual teenager stuff) but most of the time we talk about school and life and what summer camps she wants to do. This kid has had a rough life and while things have been great recently, they can turn in the blink of an eye. Even though we rarely discuss anything new at these monthly visits, I always ask when she wants to come back and she always says, “In a month.”

    If the 15 minutes a month I spend listening to her talk about the new boyfriend-that's-not-a-boyfriend or other random stuff prevents her from getting into trouble in some aspect of life, I don't care how much money I make on the encounter. The time I spend with her has no monetary value.

    I teach plenty of students that won't end up in primary care. But I do try to teach them that there is value in listening.

  5. Dr. Rob,
    This is one of your best posts yet and what gives me the stone-cold heebie-jeebies over healthcare reform. If we want it to work, we need more primary care doctors and we need to respect and value your contributions. I never could have navigated the breast cancer landscape on my own, which took me from one doctor to four (my primary care doctor, my general surgeon, plastic surgeon and oncologist.) My doctor told me during one of my many visits that he was going to help me get through this, and he did. My husband and I have been seeing him for more than 15 years and our faith in him is absolute. I dread the day when he retires. It took me a long time to find him, and I fear it will take even longer to find someone else I trust (assuming I can find anyone at all.)

    Keep shining a light on this. Thank you!

  6. Dr Rob – As I was reading this ..I was thinking “This is one of the BEST posts he's ever written.! But then I thought ..”How can I say that? he's written so many good posts.” Then ..reading Jackie's comment confirmed my initial reaction!

    I was truly moved by this post.

    Thank God you listen to your “Human side”, recognizing the pearl before you. You are one fine doctor .. a blessing and obviously being blesses/enriched by your dear patients.

    I am just sorry that physicians are increasingly feeling the pressure to decrease quality pt time in order to meet all the other demands of the job. how ironic ..considering ..the goal has always been to focus on the patient. Yet the avalanche of regulations and subsequent paperwork are draining your time. And have to take care of yourselves YOU can enjoy YOUR life.

    I'm thinking physicians have an innate skill that would enable them to join a circus … or at least get on David Letterman. JUGGLING! You all sure do know how to juggle your time. Juggling is about timing and skill. Go on Doc Rob. Go find 3 objects to juggle in the air without dropping. I bet you can do it. matter of fact ..I think you'll find it easier then juggling your professional demands. Let us know how it works out. 😉

  7. P.S. That COW pic is H-I-L-A-R-I-O-U-S! Every time I come in here I get an automatic laugh at these zany pics. Thanks! 🙂

  8. I am getting ready to start my third year of med school, and I just recently stumbled across your blog. I went into med school not knowing what I wanted to do and have fallen in love with primary care/family practice over the last two years. The way you can really get to know your patients and interact with them is what sold me, but I gotta admit I'm a little nervous to follow my dreams. It's so much easier to go into a higher paying specialty just for the financial security it would provide. I hate to think like that, but when I've finished my four years I'll be $200,000 in debt, so it's something I have to think about. I feel like my dream is slipping further away each day…will I ever be able to have my dream career and afford to pay off my loans? I don't know, but I sure hope. Thank you for these posts…if it's ever going to change, it's got to start with us!

  9. No Dr Rob-I firmly believe Washington does not give a flying flip about what you are talking about here-but I as a patient do care greatly! I thank God that I have had the opportunity to have a Dr who genuinely cares about his patients & who can gather from a visit such as you have described so much more information than the patient actually states-I'm going to say it-I thank God for you! You have been a bigger blessing than I can put into words & I pray you will continue in the doctoring business for many more years because contrary to what you say, you ARE unique in your relationship with your patients-I've had many good doctors but God has really blessed our family when He put you in our lives. Forgive me if this is over the edge in praise-I don't mean to embarass you-but this time I can't keep my mouth shut! 🙂

  10. As a newly minted doc who just stepped in front of the loaded gun, I find your blog heartening and a validation of the reasons I chose primary care. I love this post and will likely return to it over the next few years when I need a little boost. Thanks Dr. Rob!

  11. Well, you just returned the favor! I should come back and read your comment when I need a little boost while blogging. Thanks!

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