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I’ve been a primary-care doctor at Massachusetts General Hospital and Harvard Medical School for 12 years. I always thought that I was great at what I did. Then I had an accident. In becoming a patient, I became a better physician — but I also faced the uncomfortable truth that our health-care system isn’t set up to support being a good primary-care doctor.
In July 2018, I was on a late-afternoon, 30-mile Sunday bike ride to Dover, Mass. By the time I made my way back home, it was dusk. About two miles from my house, at the bottom of a steep downhill section, a construction crew had left a pile of sand in the middle of the road. I hit the sand straight on. My back tire fishtailed, and I found myself heading straight into a pond. I decided to jump off the bike. As I landed, I smashed my forehead into the road and cracked my helmet in half. I didn’t lose consciousness. I foolishly got up and biked home, took a shower, drank some wine, and went to bed.
The next morning when I started seeing patients, I found that their words were passing directly through me. The room began spinning and I couldn’t think. I was certain I was about to die in my own exam room. I called for help and was rushed down to the ER. Fortunately, a scan showed that my brain looked normal. I had a concussion and was told that I needed to take it easy for 10 days.
Ten days turned into nearly 100. I could not read, use screens or spend time with my amazing, but amazingly loud, children. I could not bend down to put clothes into the laundry without vertigo. I talked to a lot of doctor friends who told me that this was just how concussions were and that I’d improve soon. But I didn’t.
A month in, I sent a panicked message to my primary-care physician, who connected me directly to the concussion guy at my hospital. He was an internationally renowned expert and also a great caregiver, two things that don’t necessarily go hand in hand. We immediately began having frequent, long appointments with lots of phone calls in between.
I didn’t need medication, but I did need a doctor who had the patience and time to determine what would serve me best. My doctor performed a thorough physical exam and found that my vertigo could be reversed with special maneuvers, and he connected me to a physical therapist with the expertise I needed. My doctor determined that my brain injury had caused a vision issue that made it difficult to focus on things close by, such as books or a computer screen. I was given eye exercises and special glasses, which, over time, allowed me to begin reading again. He referred me to a psychologist who helped me work through the intense anxiety that is common after a traumatic brain injury. Through it all, my concussion doctor was the shepherd, ready to guide me though every step. It really mattered: My recovery was an agonizing two years long, and the real medical magic was in talking, listening, access and advocacy.
The experience ultimately transformed my own medical practice. Early in my career, I was concerned with fixing the problems that plague primary care: extraordinarily high rates of burnout, a sense that we are governed by the electronic health record and unreasonable expectations about the number of patients we could see in a day. I did things like establishing team-based protocols so that my patients would be better cared for by the phenomenal nurses and medical assistants on our team. I implemented a medical scribe program, providing assistants who could transcribe physicians’ notes into the electronic health record. I was able to meet all the targets for quality, volume and revenue set by my institution. I quickly became a leader within my organization. I was a happy, fulfilled primary-care doctor.
At the same time, my passion for fixing problems had translated to an excessive focus on boundary setting, delegation of important tasks and clock management. There were layers of staff between me and my patients, even when things were going really wrong. I never went out of my way to connect my patients with specific specialists because I relied on our referral management system to do its job. I scorned my colleagues who always made sure to see their own patients who were admitted to the hospital — what dinosaurs!
My accident taught me that most of the work I was doing isn’t what really matters to patients. Now, I listen to my patients more attentively, talking through their concerns and their goals. I make sure they know how to reach me if something is going wrong. I call them and their family members to discuss important issues. I offer hugs and high-fives. I routinely write personal notes to the specialists I am sending my patients to, framing the clinical scenario for them. I even started serving as the doctor of record when my patients are in the hospital. The magic is in the talking, listening, access and advocacy.
In doing all of that, however, I’m practicing medicine in a manner that is unsustainable for the average doctor. A typical primary-care doctor cares for an active patient load of more than 2,300 patients. That allows barely enough time to see each patient once per year, and many need to be seen far more frequently than that. The overwhelming volume of patients, coupled with a payment model that pays less for primary-care visits than for minor specialty procedures, forces primary-care physicians to see patients every 15 to 20 minutes. In a recent national survey, 25 percent of primary-care physicians indicated that they expected to leave clinical practice in the next three years. That’s why I focused on boundary setting, delegation and clock management early in my career: I wanted to survive in primary care for the long term.
How do I manage to do things differently now? Simple: I see patients part-time. I care for elderly patients with highly complex medical conditions, and I can serve them the way I want to only if I care for no more than 500 at a time. That is equivalent to about 25 percent of a full-time clinical effort. But let’s be clear: If I didn’t have an academic job that supports the rest of my salary, I would make only around $65,000 per year for that 25 percent effort. That salary wouldn’t allow a typical doctor to pay down their average medical student debt of $241,600 while living in an expensive metropolitan area.
Things are changing. Many innovators are building primary-care delivery models that pay doctors full-time salaries to provide high-touch care to a total of around 500 elderly patients with multiple health issues. A concept called direct primary care is also steadily growing. In this model, employers or patients pay a monthly membership fee that averages between $20 and $85 per person. In exchange, their care teams provide them ready access and attention, either in person or virtually, when they need it. They can do so because the average load for a full-time direct primary-care doctor ranges from 400 to 600 patients. (Amazon has plans to purchase One Medical, a direct primary-care company. Amazon founder Jeff Bezos owns The Washington Post.)
The problem is that as these models grow and offer a more appealing way to practice medicine, they will rapidly suck up the available primary-care clinicians, exacerbating a severe workforce shortage. In many parts of the country it is already impossible to find a primary-care doctor accepting new patients, and as physicians see fewer patients in these new models of care, things will only get worse. We will need to increase the number of medical students, nurse practitioners and physician assistants going into primary care dramatically. Most important, these private-sector models risk neglecting our most vulnerable communities.
So how do I reconcile my experiences since my accident — as a patient and as a doctor — with the fact that there are so many problems still to solve in primary care? I have learned that physicians need to be empowered to care for their patients with the dedication and compassion they envisioned when they first went to medical school. More important, the medical system must find a way to appropriately value that dedication and compassion, talking and listening. In doing so, we can restore love to the practice of medicine — and we may save primary care.
Paying doctors to listen to their patients would improve primary care – The Washington Post
