Primary care visits are never quick; we don’t give much advice over the phone or online; and we prioritize the government’s and insurance companies’ public health agenda over our own patients’ concerns. Imagine health care as a retail customer experience for a few minutes: Imagine you’re going to Walmart to buy a bag of dog food, a new coffee maker or to equip a small kitchen in your newly built mother-in-law apartment. 1. ...

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There are many days in primary care when you feel like you are treading water; nobody gets substantially better as time and disease progression seem to always win over your own and your patients’ efforts. But sometimes you hit a winning streak. The past few weeks seemed to bring me one diagnostic or therapeutic coup after another. There was the depressed man who came in smiling and said: “I’m shaving again.” There was ...

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After a Harvard endocrinology course several years ago, I walked out into the weak afternoon spring sunshine and crossed the street to the Boston Public Garden. Among the multitude of faces of the other flaneurs I was certain I saw scores of people suffering from endocrine diseases -- probably undiagnosed, I thought to myself: I saw tall men with big jaws, typical of acromegaly; stout women with skinny extremities and ...

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For many years, I’ve held a brief huddle with my team every morning to make sure we are ready for the day: Anybody with complex problems coming in today? Anybody who’s been in the ER? How is Mrs. Jones’s husband over at the nursing home, is she worried about his condition? Where can we squeeze in more add-on’s? Now other people have tried to hijack the word “huddle” for a completely ...

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Brilinta, at $6.50 per pill, twice a day, reduces cardiovascular events more than generic Plavix, which costs 50 cents per pill, once a day. But only a little: 20% relative or 2% absolute risk reduction. The event risk was 10% with the more expensive drug and 12% with the one that costs 82% less. Put differently, if 100 patients were treated with Brilinta for a year, at a cost ...

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I can’t help myself from telling patients how things really work in health care. But I feel they have a right to know. When I see new patients their jaw usually drops when I sit down with them next to the computer with a stack of papers held together with a rubber band or a gigantic clamp and with yellow sticky notes protruding here and there with words like LAB, ER, ...

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One of the ways a doctor can document the value of an office visit is by keeping track of the number of symptoms the patient has and the number of items included in both the review of systems and the physical exam of the patient. This way, for example, we can get paid more if we do an extensive evaluation of a dizzy patient by looking for both inner ear, cardiovascular ...

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“Any recent antibiotics? Steroids?” I asked my last patient of the day, a healthy looking young woman with what she described as a yeast infection that was driving her crazy. She’d had many of them, and they were always coming back, but she had only used over the counter topicals. I knew she needed oral medication, but I asked one more question: “Any trouble with high blood sugars?” Her answer eliminated any ...

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I don’t regularly make any New Year’s resolutions, but this year I am tossing around a couple of ideas. One reason is that I have so many things going on that I need to be clever about how I use my time. I work four days a week at my regular clinic, and I also work two long days at a clinic in far northern Maine. In addition, there are many ...

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Four and a half years ago I read an editorial in JAMA, the Journal of the American Medical Association, that etched a short phrase into my memory. These five words seemed so profound and poignant that I really think they almost define primary care medicine today, perhaps with the alliterative addition of the word “teach”. Dr. Abigail Zuger wrote of how the computer had changed the dynamic in the ...

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“I made myself a hypodermic injection of a triple dose of morphia and sank down on the couch in my consulting room ... I told her I was all right, all I wanted was twenty-four hours’ sleep, she was not to disturb me unless the house was on fire.” – Axel Munthe, MD, The Story of San Michele (1929) When people in this country mention the opioid epidemic, most of the time it is ...

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It’s just after six o’clock on a Sunday morning in December. The barn animals have fresh hay and warm water. My wife and the dogs are asleep. The cats are gathered around me as I sit down to write. One of them has jumped up in my lap and is pawing and clawing my jeans. The fire is roaring in the wood stove, but the 1790 room is still cold. I ...

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Primary care doctors don’t usually have scheduled blocks of time to read incoming reports, refill prescriptions, answer messages or, what we are told the future will entail, manage their chronic disease populations. Instead, we are generally expected to do all those things “between patients.” This involves doing a little bit of all those things in the invisible space between each fifteen-minute visit, provided we can complete those visits, their documentation and ...

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A couple of years ago I saw a young man with pain in his lower right abdomen. I sent him for an urgent CT scan with a “wet read” to check for appendicitis. It was afternoon, and things were crazy at the office. I forgot all about the pending CT report. I have learned this about myself: I am efficient because I have the ability to hyperfocus, but that has made ...

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Many physicians have become world famous writers, and in Greek mythology, Apollo was the god of both poetry and medicine. I can personally think of many prominent physician writers I have come across in my reading over the years: There was the 12th-century rabbi Maimonides, Copernicus in the 15th century and the poet John Keats in the 1700s. In the late 1800s to early 1900s, there were Anton Chekhov, Sir Arthur Conan ...

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It is not unusual to see a patient for a timely transition of care visit after a hospital admission and within a minute of entering the exam room know with all the bones in your body that this person needs to go back into the hospital. The funny thing is that when that happens, if the patient has Medicare, we may indirectly suffer financially from such “avoidable readmissions.” We belong to ...

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How would you like to double your chances of winning the lottery? Just buy two tickets! Statistically, this is true, but is that a reason to spend more money on something that most likely offers no return on investment? Yet, in medical research, study after study shows impressive improvement in relative risk for this, that and the other intervention but a small or even negligible effect on absolute risk. For example, I just ...

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I’ve finally found my groove with our EMR. Maybe I’m even starting to like it. A few weeks ago I got a new iPad, this time a Mini, which lets me type with two thumbs the way some people text on a smartphone, and the voice transcription is good enough as long as you avoid fancy jargon and unusual generic drug names. Yesterday as I sat next to a patient and ...

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“Jag ska bli doktor,” a four-year-old boy announced to his family sixty years ago. Somehow, everything he did after that moment seemed to move him in that direction, even when, on the surface, his path through life seemed to be meandering. As a student, he was just as interested in literature and philosophy as he was in scientific subjects. He even failed his first quiz in organic chemistry just after receiving the ...

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One cold winter night many years ago, someone dropped off a calico cat and her two kittens in our snowy driveway, and we went from a two cat family to a five cat household. I learned a few things from that. When I was a resident, two thirtysomething family docs had an office upstairs from the residency program. Ned and Peter precepted us, and they sometimes ran downstairs to ask the ...

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