In July 2018 I was on a late afternoon 30 mile Sunday bike ride to Dover, Mass. By the time I got home it was dark. About two miles from my house, at the bottom of a steep hill, a construction crew had left a pile of sand in the middle of the road. I hit the sand straight. My rear tire fishtailed and I landed straight in a pond. I decided to jump off the bike. Upon landing, I hit my forehead against the road and broke my helmet in half. I did not lose consciousness. I foolishly got up and rode my bike home, took a shower, drank wine and went to bed.
The next morning when I started seeing patients, I found their words flowing directly through me. The room started spinning and I couldn’t think. I was sure I was going to die in my own exam room. I called for help and was taken to the emergency room. Luckily, a CT scan showed my brain looked normal. I had a concussion and was told I needed to calm down for 10 days.
Ten days turned into nearly 100. I couldn’t read, use screens, or spend time with my amazing, but incredibly noisy kids. I couldn’t bend down to put clothes in the laundry without dizziness. I’ve talked to a lot of doctor friends who told me that’s how concussions are and that I’ll get better soon. But I did not do it.
A month later, I sent a panicked message to my GP, who put me in direct contact with the type of concussion at my hospital. He was an internationally renowned expert and also a great caregiver, two things that do not necessarily go hand in hand. We immediately started having frequent and long dates with lots of phone calls in between.
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I didn’t need medication, but I needed a doctor who had the patience and the time to figure out what would serve me best. My doctor performed a thorough physical examination and found that my dizziness could be reversed with special maneuvers, and he connected me with a physical therapist with the expertise I needed. My doctor determined that my brain injury had caused a vision problem that made it difficult to focus on nearby objects, like books or a computer screen. I was given eye exercises and special glasses, which over time allowed me to start reading again. He referred me to a psychologist who helped me overcome the intense anxiety that is common after traumatic brain injury. Through it all, my concussion doctor was the shepherd, ready to guide me every step of the way. It was really important: my recovery took two years, and the real medical magic was in talking, listening, accessing and advocating.
The experience ultimately transformed my own medical practice. Early in my career, I was preoccupied with solving the problems plaguing primary care: extraordinarily high burnout rates, a sense of being ruled by the electronic health record, and unreasonable patient that we could see in a day. I did things like establish team protocols so that my patients were best cared for by the phenomenal nurses and physician assistants on our team. I set up a medical scribe program, providing assistants who could transcribe doctors’ notes into the electronic health record. I was able to achieve all the quality, volume and turnover objectives set by my establishment. I quickly became a leader within my organization. I was a happy and fulfilled GP.
At the same time, my passion for problem solving had translated into an excessive focus on setting boundaries, delegating important tasks, and managing the clock. There were layers of staff between me and my patients, even when things were really bad. I never went out of my way to connect my patients to specific specialists, as I relied on our referral management system to do its job. I despised my colleagues who always made sure to see their own patients admitted to the hospital, what dinosaurs!
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My accident taught me that most of the work I was doing wasn’t really important to the patients. Now I listen to my patients more carefully, I talk to them about their concerns and their goals. I make sure they know how to reach me if something goes wrong. I call them and their family members to discuss important issues. I offer hugs and high-fives. I regularly write personal notes to the specialists I refer my patients to, framing the clinical scenario for them. I even started to serve as an attending physician when my patients are in the hospital. The magic lies in speaking, listening, accessing and defending.
By doing all of this, however, I am practicing medicine in a way that the average doctor cannot sustain. A typical primary care physician has an active patient load of over 2,300 patients. That barely leaves enough time to see every patient once a year, and many need to be seen much 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% of primary care physicians indicated that they expected to leave clinical practice within the next three years. That’s why I focused on setting boundaries, delegating, and managing the clock early in my career: I wanted to survive in primary care long-term.
How can I do things differently now? Simple: I see part-time patients. I care for elderly patients with very complex medical conditions and can only serve them as I wish if I don’t care for more than 500 people at a time. This equates to approximately 25% of full-time clinical effort. But let’s be clear: If I didn’t have a college job that supports the rest of my salary, I’d only be making about $65,000 a year for that 25% effort. That salary wouldn’t allow a typical doctor to pay off their average medical student debt of $241,600 while living in an expensive metropolitan area.
Things change. Many innovators are developing primary care delivery models that pay physicians full-time salaries to provide intensive care to a total of approximately 500 elderly patients with multiple health conditions. A concept called direct primary care is also growing steadily. In this model, employers or patients pay a monthly membership fee that averages between $20 and $85 per person. In return, their care teams provide them with prompt access and attention, in person or virtually, when they need it. They can do this because the average full-time direct primary care physician load ranges from 400 to 600 patients. (Amazon is currently considering buying One Medical, a direct primary care company. Amazon founder Jeff Bezos owns The Washington Post.)
The problem is that as these models expand and provide a more attractive way to practice medicine, they will quickly suck up available primary care clinicians, compounding a severe labor shortage. In many parts of the country, it’s already impossible to find a primary care physician accepting new patients, and as physicians see fewer patients in these new models of care, things will only get worse. We will need to dramatically increase the number of medical students, nurse practitioners and physician assistants entering primary care. More importantly, 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 physician – with the fact that there are still so many unresolved issues in primary care? I learned that physicians must be empowered to care for their patients with the dedication and compassion they envisioned when they went to medical school. More importantly, the medical system must find a way to appropriately value that dedication and compassion, that speaking and listening. By doing so, we can put the love back into the practice of medicine – and we can save primary care.