When I was a resident at the University of Virginia, my wisest mentors gave me one piece of advice that far exceeded all the scientific and statistical jargon that others expected me to swallow. Consider this: When patients walk into your room and sit down, shut up and look into their eyes. When they are done talking, have a conversation. The key word is conversation. The visit should not include a lecture or statistics that diminish the complex needs and wants of the person sitting in front of us. Primary care doctors who care for the elderly and chronically ill confront a plethora of medical problems in virtually every patient who walks through our doors. To solve them all is not possible and may not be what the patient wants. As my mentor told me, unless you address the patients’ concerns, they will hear nothing else that spews from your mouth.
Sometimes it’s difficult to allow a patient to walk out of the room without addressing her high blood pressure, need for a mammogram, decision to stop taking statins, and lack of exercise. It can be painful to watch them leave without fulfilling any of Medicare’s quality indicators, which will be sent to the Centers for Medicare & Medicaid Services (CMS) through our computers and may cause our payments to suffer. Sometimes talking about the patient’s incontinence and back pain seems insufficient in light of all of the other medical issues. But as the patient leaves the room, I tell her that during the next visit, which will be soon, we will talk about those issues. I may encourage her to look over some data in the meantime about statins and mammograms. Many patients choose not to pursue many interventions after they see real data about them. That is their choice, as long as they make it rationally. Much of what we try to “fix” in our patients can harm them as easily as it can benefit. Their choices can lead to fewer tests and drugs and improved outcomes, even though it may mean failing grades for our quality indicators or ramifications for our pocketbooks.
What value do primary care doctors offer to our health care crisis? Conversation. It is our ability to look people in the eyes, allow them to set the agenda, converse with them about medical issues and interventions using reliable data and base decisions on their interpretation of personal risks and benefits. However, when we are forced to stare at computers and enter data, when CMS and the Affordable Care Act (ACA) have set much of the agenda by compelling us to adhere to their often perverse quality indicators, when visit times continue to shrink to pay for the escalating overhead, then none of the value we offer can exist. Being a primary care doctor is one of the most satisfying professions on this planet. We come to know our patients well over many years and live through their peaks and valleys. They rely on us to help them with some of the most difficult decisions they will ever be forced to make. We do our best to keep them healthy, active and happy. I get as much value as my patients do from a conversation that works well. Our health care system gets value, too. The bond between doctor and patient, when it allows for meaningful conversation, leads to fewer tests, fewer medicines, fewer referrals, less hospitalization, lower cost and greater satisfaction.
The ACA and CMS are trying to measure value and quality in all the wrong ways. They are talking about shared savings, incentives and disincentives that rarely work and typically decrease both patient and physician satisfaction. They throw metrics at us that have no correlation with our patients’ wants and needs and only squander our time in the exam room. The value we must insist on as primary care doctors is the ability to have a conversation, which is more difficult to measure but ultimately what will work. It brings greater satisfaction to our patients and to us. And it saves the health care system money while enhancing our patients’ health and well-being. It’s what we do best.
Andy Lazris, MD is an internal medicine physician who blogs at Primary Care Progress.
