It was a typical afternoon in the office.
I stood in the hallway, hesitated a moment, and then knocked. I entered the exam room, sat down, and said “How can I help you today?”
She was a young, healthy-looking woman. She seemed nervous. She reached inside her purse and pulled out what we dread the most in the exam room: the infamous “list.”Reluctantly, she handed it to me. I took a deep breath – and then I began to read it.
Her “list” shared that she bruised easily. Her hands and feet swelled. She could jog, But she could no longer do sit-ups, and it was a struggle to walk upstairs. She had a rash on her neck and chest, and her face had a ruddy complexion. She experienced lightheadedness and dizziness. She was sensitive to caffeine and sugar. Her muscles were sore.
She shared with me that she and her husband wanted to start a family, but they were having trouble getting pregnant.
And she had developed a hump on the back of her neck.
I asked her if she had an old driver’s license, and she did. It was clear that in recent years her face had changed from slim and normal-looking, to red and round and plump.
I listened, studied the “list”, asked some questions for clarification, and performed an examination. I told her I would get back to her with my recommendations after I had time to digest it all. Of course, I knew the minute I read her “list” that her diagnosis was obvious.
By now, you have guessed her diagnosis too. Round ruddy face. Proximal muscle weakness. Infertility. Buffalo hump. Yes, she had Cushing’s Syndrome. The physical features were somewhat subtle. But her “list” told the story.
Sure enough, after extensive testing, she was found to have a cortisol-producing adrenal tumor, which was successfully removed at surgery. And about a year later, she and her husband were able to conceive, and nine months later, she gave birth to a beautiful and healthy baby girl.
Now, I know what you are thinking. This is the beauty of DPC. Right? We have time. We take time. We listen. We not only accept “lists”, we eagerly welcome them. (Well, at least most of the time.) We do not tell the patient to circle the one or two problems they think are most important, and that we will address the others at the next appointment.
We are there. In the moment. For the patient.
Funny thing, the story I shared above actually did not occur in my DPC practice. It took place years ago, in the late 1980s.
Yes, long before I had even heard of DPC.
And the truth is, that afternoon I really did not have time for a patient with a “list.” I was an hour behind, as I usually was. I was expected to speed up, to be more efficient. My nurse was probably getting angry because she could already see that I would not finish by 5 pm, and she would get out late again. But I could not ignore that “list”, even if I wanted to. It connected with the reasons I became a physician.
The problem was, it was not DPC. It was in the midst of what might be politely termed a “healthcare cluster.”
Managed care was just hitting North Carolina, and the practice I was with had just signed a contract with several such companies, resulting in a sudden and huge influx of patients. We were paid a monthly fee to care for these thousands of patients. It was lucrative and at the time, actually exciting. We were growing. Literally overnight.
The excitement soon wore off. Patients were told they “could go to their new doctor any time they needed to and wanted to.” They brought their “lists.” This was, for so many, a healthcare buffet. All you can eat. No limits. No co-payments.
Not unexpectedly, this phase of managed care in our area failed. Maybe it worked in other parts of the country. The guaranteed monthly income, which initially seemed too-good-to-be-true, turned out to be exactly that. Over-utilization was a problem. Costs got very out of hand, particularly hospitalizations and expensive consultations by non-participating sub-specialists. My patient’s plan folded, as did others. It was ultimately a lose-lose-lose recipe for all.
But looking back, this managed care plan had some good ideas. Keep it simple. Pay the physicians a flat monthly fee. Remove fee-for-service incentives. But some critical features were missing, like email, text, video, portal, all of which were not available in the 1980s, and, of course, smaller and more manageable panels. In other words, more DPC-like.
Lessons learned!
There are many reasons I share this story. I am in the twilight of my career, and I think often of my most memorable patient experiences. (I prefer this term over memorable “cases.”) The story also reminds me of why I chose to be a Family Physician. I wanted to have genuine relationships with patients, have and take time to listen to them, and partner with them to achieve better health, and prevent illness when possible. But as I learned in my many years of traditional practice, being that Family Physician was going to be very difficult, if not impossible, for me without a better model, namely, DPC. The story was also a reminder for me, and hopefully for every physician who reads this, that patient “lists” can be so revealing. Even when not all the dots connect as they did for my patient, “lists” should be respected. After all, these “lists” are the patient speaking. It’s their story. It’s our responsibility to listen.
But, in order to truly listen, the model must be the right one. As I often like to say, DPC is “the way it should be.”
Oh, by the way, in case you are wondering. Yes, I have received the family’s permission to share this. And the last time I checked, that mother was still well and healthy. And her daughter? She is now a mother too!
Wow. Family Medicine at its best. And DPC before its time.