Becoming a patient helped me remember that the best doctors listen compassionately. We need to ensure that all physicians are empowered to do the same.
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.

Chronic pain is surprisingly treatable

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!

A surprising pandemic side effect: It has improved health care

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.



Daniel M. Horn is a primary care physician and director of population health and quality for the Division of General Internal Medicine at Massachusetts General Hospital and an assistant professor at Harvard Medical School. Twitter



https://www.washingtonpost.com...umatic-brain-injury/

I think I would like to have a doctor like you. Best of luck in the future.

I hope many thousands of people will be able to read what you wrote.

Having a TBI didn't make me a better doctor. In fact it kept me from going to med school. Maybe it made me a better person, I don't know.

You do sound like an awesome doc, Doc.

With pharma, insurance, and hospitalists controlling what doctors can do and how long they spend with patients, primary care isn't fixable.

I review medical records all day from various providers, large hospital chains and small clinics. A few things are clear.

Large places have resources and staff but they seem to be the most inattentive to the patient. Yes there are forms saying all the patient's concerns and questions were answered but from subsequent entries they weren't answered in a useful patient oriented way but rather in the way the process dictated.

The best bedside manner and attention comes from small medical groups. The patients feel like their concerns are being addressed and acknowledged and they are happy with their providers because the doctors and staff listen, interact and treat the patients as a human. It's kind of hard explain but after 30 years of doing this stuff it's very easy to see.

Good OP.

Empathy is more effective than sympathy.

This message has been edited. Last edited by: darthfuster,

quote:

Originally posted by maxwayne:

I think I would like to have a doctor like you. Best of luck in the future.

I hope many thousands of people will be able to read what you wrote.

This is a quoted article from the Washington Post.

Part of me believes you ... but another part of me is still hurt by the comment you made in this thread (that I tried to make disappear, but can not):

https://sigforum.com/eve/forum...960082784#6960082784

On a positive note, my daughter is scheduled for her kidney transplant in three weeks ...

One can only imagine the roller-coaster ride our family is on now.

I saw my family general practitioner Doc this morning.

He saw me for 23 minutes as we discussed multiple things. No rush to get me out the door. He answered ALL of my questions to my understanding and satisfaction. I did sit in the waiting room for about 10 minutes before being called in.

In todays age of big corporations taking over doctors practices, etc, he is a breath of fresh air. He has discussed with me his decision to stay independent. My Brothers girlfriend just retired as a big wig at a huge hospital chain in Arizona and Southern Cal, her job was to go around and tell every doctor they had a choice, either become a Hospital Employee or leave and go practice medicine somewhere else.

He owns his own building, does not answer to any hospital boards or staff, etc. He even employs his billing person. He does have 2 Nurse Practitioners with him.

He is not open on Fridays, he is open Monday thru Thursday.

Dude is wicked smart, as you'd expect. He got his Bachelors in Finance and Business at Notre Dame, got his MBA at USC, and got his MD at OU Medical in Oklahoma City. Dude knows how to run a business, and that's what a medical practice is, a business. Darn excellent Physician too.

I can usually get a same day appointment with him if I call before 10AM, otherwise it may be a next day appointment.

I didn't ramble just for ramblings sake, it's just that I agree with a system where Doctors are not rushed rushed rushed, forced to comply to corporate weinies who dictate this and that, and takes time with patients to understand, etc and thus deliver excellent care and resolution.

Practicing Medicine is not a cookie cutter cut and dried business, it is a personal relationship between Doc and Patient with both doing what they need to do for a good communication and understanding and good healthy and happy outcome.

And, to add some fuel to the fire, we need to do something about the HUGE pharmacy chains and the Pharmacy Benefit Managers who decide what we patients can get and for how much, etc, and this also includes the Insurance Companies.
.

quote:

Originally posted by V-Tail:
This is a quoted article from the Washington Post.

Yep. ZSMichael is not the author (and is therefore not a Harvard doctor with a brain injury). He's just copying and pasting an article that he came across.

But this is not the first time that various members who skim one of his copy-paste threads like this end up assuming that he actually composed the text in the OP.

quote:

Originally posted by RogueJSK:

quote:

Originally posted by V-Tail:
This is a quoted article from the Washington Post.

Yep. ZSMichael is not the author (and is therefore not a Harvard doctor with a brain injury). He's just copying and pasting an article that he came across.

But this is not the first time that various members who skim one of his copy-paste threads like this end up assuming that he actually composed the text in the OP.

But the thread title and how it starts gives you that impression (it did for me as well). Articles posted like that should have something at the top like "Article from XYZ source:"

This is why I always post links to articles right on top of the post.

I agree, this post was deceiving.....at least it was to me.

Perspective
Will change you

quote:

Originally posted by RogueJSK:

quote:

Originally posted by V-Tail:
This is a quoted article from the Washington Post.

Yep. ZSMichael is not the author (and is therefore not a Harvard doctor with a brain injury). He's just copying and pasting an article that he came across.

But this is not the first time that various members who skim one of his copy-paste threads like this end up assuming that he actually composed the text in the OP.

Does not matter whether someone has skimmed this article or not ... ZSMICHAEL is educated and smart enough, as well has posted other persons articles in the past, to know better to post the link crediting the article.

When ZSMiCHAEL has not given reference to the article then one is not wrong to assume it came from him. Common sense.

Either way, whether he wrote this article or not ... my feelings and posting regarding my daughter's kidney issues still remain true.

I would of dealt with this privately via eamil with ZSMICHAEL but he does not have an email listed in his profile.

At the end of the day, I still stand behind my posts. Persona non grata ?

quote:

Originally posted by 12131:
This is why I always post links to articles right on top of the post.

Thank you for that.

quote:

Originally posted by GT-40DOC:
I agree, this post was deceiving.....at least it was to me.

Apparently, exactly ... and someone like ZSMICHAEL, with his education and knowledge, should know better.

quote:

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.

This is the problem. Good care needs TIME, time to see the patient, time to talk with them, examine them, time to write up the note and order the meds and labs. The amount of time spent with a patient even impacts on the incidence of lawsuits.
But this is one of many things doctors have totally lost control of when they became employees. Employers determine the time alloted for the patient and doctor; employers determine the number of patients to be seen daily and the number of patients one is to have totally (the doctor's 'panel'). Employers determine how many overbooks one must endure, how late a patient can be and still has to be seen (30 minutes?, an hour?, no time limit?), and who is allowed to schedule regular and overbook slots (usually a clerk, who is also instructed by the employer to ignore the doctor having any say in the matter!) Employers determine how medical notes are written and what must be included/said in those notes, what meds can be ordered and when, and even what care plans must be followed and in what order.
These are just some of the things Employers do; I could go on...

The writer of that article is lucky as a physician; he gets to practice 'old timey independent private practice' medicine and make a living at it. It's pretty much gone for most current and up and coming doctors.

quote:

Apparently, exactly ... and someone like ZSMICHAEL, with his education and knowledge, should know better.

^^^^^^^^^^^^^^
I did not intend to present anything as deceiving. I used the orignal title. I am sorry you felt decieved, but if you read the article in its entirely you would know the author was not me. Thank you for the back handed compliment about my education and knowledge.

As noted at the end of the article: Daniel M. Horn is a primary care physician and director of population health and quality for the Division of General Internal Medicine at Massachusetts General Hospital and an assistant professor at Harvard Medical School. Twitter

quote:

Originally posted by ZSMICHAEL:

quote:

Apparently, exactly ... and someone like ZSMICHAEL, with his education and knowledge, should know better.

^^^^^^^^^^^^^^
I did not intend to present anything as deceiving. I used the orignal title. I am sorry you felt decieved, but if you read the article in its entirely you would know the author was not me. Thank you for the back handed compliment about my education and knowledge.

As noted at the end of the article: Daniel M. Horn is a primary care physician and director of population health and quality for the Division of General Internal Medicine at Massachusetts General Hospital and an assistant professor at Harvard Medical School. Twitter

Priceless. Got it.

Just curious is if you learned anything from the article, especially regarding your post to me on this thread that you still have glossed over :


https://sigforum.com/eve/forum...960082784#6960082784

What you don't know, and I will not throw anyone under the bus, but the numerous emails I received regarding your post in my thread surprised by both your non-reply as well as your lack of compassion.

From someone in your type profession I am shocked by this ...

Lack of words speak loud. Takes a man with real balls to admit made a mistake.

Just sayin'.