He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.
He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here. He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like. First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits. Then there is my guitar just behind me. He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music. Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person. He seems intrigued.
He owns a business, which is a service type business like mine. Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it. I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine. He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report. Spin happens. But as we talk, there is much to find in common, and he warms up. His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.
He explains to me how he is a “bad patient,” wanting to spend as little time in the doctor’s office as possible. He tells me about other doctors he’s seen who have “forced” medications on him (which he refused to take). His wife gives him a scowl as he explains this to me. I describe my approach to care and how it has been changed by this new practice style: how I used to focus on problems and treatments, but now focus on assessing and reducing risk and improving quality of life. My job is to keep him as healthy as possible, and I point out to him that I am actually more happy for the business when the office is empty than when it is full. After all, I get paid the same amount either way, and the empty office allowed his waiting time to be the usual one: 30 seconds.
He’s not begging for medications or quick-fixes. He knows that back pain doesn’t go away magically. I explain that his poor sleep due to the pain probably keeps his back in spasm, and that a muscle relaxant at night might help. I reassure him that this is not a slipped disc, and discuss the merits of avoiding 250 pound sacks in the future. He laughs, and his wife shoots me an appreciative glance, impressed by the fact that he’s actually comfortable seeing the doctor.
We move on to a discussion of prevention, with the disclaimer up front that “when the house is burning down, we don’t cut the lawn.” In other words, I am totally focused on his back first, but the heart disease and cancer prevention will need to be addressed at some point. I explain that our goal is not to treat the disease, but prevent them in the first place. We talk a bit about exercise, with me admitting my struggle with doing it on a regular basis. I explain that I hope eventually to set up an online community of patients to encourage each other to exercise, using something like the Foursquare badges to reward, and perhaps even having a drawing for a gift card or something. I know I need that community to help motivate me to exercise, and he agrees it would help.
By the end of the visit he’s talkative, bemoaning the fate of small business as it is in the crosshairs of the Affordable Care Act. He uses a few choice words for the president, and I explain how I want to work on this problem, combining a wrap-around high-deductible plan with my services to meet the criteria for the ACA. The ACA is totally confusing for me and my wife, I explain, and I hope to offer something not seen much in health care: simplicity. I work for you, I tell him, not the insurance company or the government. He nods and smiles.
As the visit finishes up, he tells me how much he appreciated the visit. He is genuinely excited about the visit. It’s as if he’s found a gorgeous woman who likes to hunt, drink beer, and watch football. After he’s gone, I talk to my nurse Jamie and we conclude that this is one of our target demographics: men in their 40’s who hate going to the doctor. I am, to them, the un-doctor. I don’t act much like a doctor (which is a good thing in their mind), and I focus on keeping them where they want to be: away from my office. It’s a win-win, as a practice full of guys like this would be easy to manage. They don’t want long explanations, they just want to be listened to and answered in English.
Contrary to what some think, I’ve not done any “cherry picking” of patients — choosing only healthy “easy” patients over the complex chronic disease patients. In reality, my message of risk management, minimizing medications and tests, focusing on education, and having open communication plays just as well in that demographic as it does for today’s patient. I was at a meeting for local small business and was greeted (by a middle-aged man) with the exclamation, “you are that doctor doing the thing that makes so much sense!”
I like that. Maybe it should be the tagline for direct primary care: that thing that makes so much sense.
Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).