I was struck by the difference between my care and that of the rest of the system as I cared for a patient recently. She was complaining of a strange pulsating noise in her ear that had started a few weeks before. We chatted for a while, as I asked about any sinus symptoms: If she’d ever had anything else going on like this, what other significant symptoms she was having (headache, other sensory changes), and just general medical questions. The diagnosis remained a mystery as I went to examine her. The exam was not really helpful. She had no foreign bodies in her ear canal (something I was guessing I’d find), no fluid behind her eardrum, and basically a negative exam.
The diagnosis was “pulsatile tinnitus,” which is basically a description of her symptoms: a loud whooshing symptom in her ear. I’ve said in the past that one of the best tricks a doctor can do to bullshit patients is to use fancy words to describe exactly what the patient says to you. So when a person has a rash, you call it “dermatitis.” When they have a loose cough, you call it “bronchitis.” And when they hear their heartbeat as a “whooshing” in an ear, you call it “pulsatile tinnitus.” It offers absolutely no help to the patient, but it perhaps impresses them with your grasp of medical jargon and distracts them from the fact that you don’t know what is going on with them.
Not satisfied, I chatted with her some more, talking about tinnitus, something that I’ve had for the past 15+ years. It came on suddenly in my 40s and was associated with the sudden inability to hear words in a crowded room. This is one of the few bad things I’ve inherited from my now 92-year-old dad. I talked to her about the frustration of this condition and how certain things make it worse. One of the main things is when other people mention the ringing in their ears. It makes me so aware that the volume of my tinnitus is turned up to “high” (it is very loud as I type these words). Another thing that makes tinnitus worse, I mentioned, is aspirin therapy.
She interrupted my rambling. “Wait. Aspirin makes it worse? I just started on aspirin therapy for my knee a couple of weeks ago.” And that is pretty much exactly when her pulsatile tinnitus began. This was about 20 minutes into my time in the room with her. Let me clarify: She had spent 25 minutes in my office, 20 of which was spent discussing her situation with me. She didn’t wait to see me, and I didn’t spend my time staring at a computer screen making her answer questions to satisfy data quality measures. I just talked to her, and this fact came out at minute 20 of that discussion. That’s a moment in the exam room that doesn’t happen often: after 20 minutes of discussion.
This is one of the reasons I believe this practice model is clearly superior to the “care as usual” with the assembly line/hamster wheel care that is done by most primary care doctors. I have time. I can listen. I can chat with people until important information emerges. In many, if not most, primary care practices, this patient would’ve been referred to ENT for a workup that may have possibly resulted in lab testing and likely CT scans or other testing.
Having the time to listen was superior to an ENT consult, labs, or a CT scan. Time is something, even after growing my practice to 800 patients, I have for them. I give patients 30 minutes of my time for normal visits, and 60 for complex care or new patient visits. Often the time I spend is shorter, but that time is available. This is exactly the opposite of what happens in most primary care settings. I used to have only 15 minutes set aside for people, much of which was devoted to documentation, and had to stretch that out to 30 or more minutes to get in the basics of care for complex problems.
With so much attention to physician burnout and the high cost of care, the discussion spends far too little time talking about the lack of time most primary care docs have for their patients. Before I left my old practice (nearly seven years ago!), I was increasingly burdened by the fact that I was increasingly being robbed of the time necessary to give good care. I was spending too much time dealing with red tape from the insurance companies and from the rules from the government aimed at “improving care.” Since quitting, I’ve yet to see more than 15 patients in any given day, and am often reminded how much my patients appreciate the time I can spend with them.
It doesn’t matter to me how we accomplish it — whether by the direct care model or another — but we must fix this problem. Primary care just had its worst year in matching residents from medical school, this at a time when we need more primary care doctors and fewer specialists.
My decision to practice this way has saved my career, has healed my heart, has saved money for my patients, and has given me the time to listen, the time to care for them.
Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.
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