What I recall with pleasure, and what I worry about…

From About Garrison Bliss, MD:

When I think back on my days as a practicing Primary Care physician, one of the things that I recall with clarity is the after-hours and late-night calls from patients who required either my help, or a trip to the ER for the patient.  Most of these calls lasted 5 minutes and ended in a simple solution, pleasing both patient and doctor.  However, sometimes I had to decide whether to see them myself or send them to a place where they would wait for hours and go home with a big bill.  They would never blame me if I shuttled them off.  My reputation was not at stake.  I might even be able to push their visit to tomorrow or to Monday, and to see them conveniently in the office.  It was about a 40-minute drive for me to get to my office and sometimes even longer to get to their home.  The ER was the convenient choice, but there was inevitably a voice in me asking: What would I want if I were this patient?

I have a stash of these events in my memory, mostly because these were the times I came to cherish, the moments when I felt like an old-time doctor.  

At about 1 am in the morning on a Saturday night, I got a call from a patient who was not sleeping well, perhaps because of depression or, more likely, too much alcohol.  She had decided to get up and move furniture around her living room.  She had lifted a heavy vase and dropped it on her big toe.  She was in serious pain and couldn’t walk without pain.   A quick history and a photo of the toe showed a subungual hematoma.  I remember thinking it would be easy to tell her to “go to the ER”, but instead, I opted to drive to her home in Bellevue.  It took 30 minutes for me to get there and about 1 minute to drill a tiny hole in her toenail and see the spurt of blood, as her taught face relaxed and her gratitude went through the roof.

Fairly early in my career, when my children were small, I called our pediatrician about a problem on a weekend evening, and he said: “Why don’t we do a house call at my house”?  I had never thought about that possibility before.  He saw my son, both of them in their pajamas, dealt with his medical issue and said “goodnight”.  I added that trick to my tool chest.  I can’t tell you how little I wanted to go to Children’s Hospital in Seattle and sit in a room filled with coughing children and grumpy parents.  After that, I kept a supply of IV fluids for rehydration, urinary catheters for acute urinary retention, sutures, steristrips and other gear at my house – just in case.  All of these came in handy eventually, and it cost me very little time or inconvenience.  Decades later, my now ex-patients still remember these encounters with fondness, as do I.

When I was at the Hint Health conference, I saw many talks that inspired and delighted me.   I also saw a few talks that concerned me, about designing practices that were a “good fit” for the DPC doctors.  This included designing practices that advertised to the “right” patients to make the doctor’s experience easier, less stressful and more fulfilling.  The terms “guard rails” and “boundaries” were frequently mentioned.  I not only understand, but also agree that each of us must have a life outside of healthcare that is the foundation of our world – family, sanity, faith, quiet time, etc.  None-the-less, I cannot get comfortable with the idea that certain patients are “more appropriate” for certain doctors.  Excluding the needy, the different or the most demanding patients are all potential hazards, for the rejected patients and the picky doctors.  I am not talking about abusive patients – that is something none of us should tolerate.  I am talking about anxious, culturally different, and complex patients.  There is another uncomfortable group of people who question our medical opinions and bring articles or ads that challenge medical dogma.  These people may make us squirm, but they also provide information that we would never otherwise encounter in our medical silo.  Over the years, I have taken care of a lot of people from these categories, in part because our medical system rejects them, and they migrate to DPC.  It was a big challenge, but also an opportunity to learn how to respect and care for them.  This required considerable work up front, hours of listening, researching outside of textbooks, and reassurance.  They would eventually either fire me or become fiercely loyal and grateful that there was a doctor who would take them seriously.  I also learned a lot about the holes in medical care and the patient-discovered patches that allowed these people to find solutions that worked for them, and are unaddressed in Up-To-Date.  In the days when doctors were telling their patients to avoid animal fat to lose weight, and to avoid eggs to lower cholesterol, I began to suspect that there was more dogma than data driving these recommendations.  The patients were frustrated because the advice was flat wrong, not because they didn’t follow it.  It has taken decades to upend these recommendations.  My patients with contrarian articles and views often showed me perspectives that I eventually adopted.

At the Hint Health conference, there were other talks that suggested letting patients know that their DPC doctor would only be available on certain days and times, thus reducing access to a doctor, who wanted more time for his/her family, wellness, other passions, etc.   What I didn’t hear was a discussion about who would take care of their patients when their DPC doctor was unavailable.

Before you get too angry at me, I am not saying that you must be annealed to your practice 24/7/365.  However, once you sign up as a DPC doctor, you have a responsibility to provide a way for your patients to get urgent issues dealt with urgently, by either you or someone else who IS available, can help them, and has access to your records.  Telling patients that you only work during certain hours and that they need to call ONLY then, is not a solution for your patient.  It is a perceived benefit for you.  If you limit access, you will not only be leaving your patients to work it out on their own.  You will also be missing memorable opportunities for you and your patients, when an act of unexpected kindness would cement both your reputation and your joyful practice of medicine.

The reason I am concerned when I hear about doctors creating comfortable practices and part-time practices with “guardrails” is that I have heard the same things from fee-for-service doctors for decades and I know where this can lead.  Those working in DPC know that the needs of the doctors have eclipsed the rights of patients for a long time in this country.  Inability to reach your doctor is expected these days.  Inability to see your doctor in a timely fashion is “normal” in this country.  Doctors, clinics and hospitals shovel millions of people to ERs when they include on their answering machines: “If you have a life-threatening emergency, call 911 or go to the closest ER”.  If patients call at night or on weekends, they get to talk to a doctor or nurse who is covering for 15 other doctors, sleep-deprived and overwhelmed.  These same doctors are far more likely to send you to an ER to cover themselves against lawsuits and get you off the phone.  They are more suspicious that patients are “working” them for drugs, and they are thus unwilling to prescribe medications over the phone.  It is very hard to be a great doctor when you are swamped in a sea of needy patients whom you do not know.

These are some of the flaws of American healthcare that DPC can and should eliminate, and that convince our patients that our monthly fee is well worth the cost.  Easy access to care is the number one reason patients engage with DPC.  It is also the source of a word-of-mouth miracle that leads to remarkable reviews, full panels of happy patients and a clean reputation for this movement.  I know all of this is a balancing act and I know that you want to be great doctors, but also great parents, great community members, healthier and less stressed.  My only request is that you make sure that when you are not available, someone else you trust IS.