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Tuesday Jan 15, 2019

Beat the Clock: Why I Chose Direct Primary Care

For whatever reason, being 35,000 feet in the air makes me reflective. During one flight, I had a flurry of thoughts, and the reason I decided to get into this whole mess of direct primary care spilled out of me. I want to share it here because if you don't know why -- or you can't convey why -- you're doing something, what's the point in doing it?

Here I am discussing medication with a patient. I opened my own direct primary care clinic two years ago because I wanted to ensure that I had enough time for patients.

In line with my desire to have a career that served others, I had the opportunity to do my residency in family medicine at a federally qualified health center in Denver that also served as that metro area's international refugee intake clinic. We saw people from all walks of life and tended to each and every person in the same way, under the same constraints and system that dominates health care.

As I advanced in my training, more and more patients were added to my schedule. At first, I was expected to see 12 patients in a day. Then it crept to 16, 18, 20 and peaked at 22 at the end of my training. A schedule like that meant I was starting a new patient visit every 20 minutes. If I wanted to place any orders, coordinate care, look up the best medical evidence, seek advice (I was, after all, in training), or simply document the visit, that face-to-face time with the patient was squeezed to 12 minutes or less. This time crunch was further complicated by the fact that more than half of our visits were translated -- leaving half the amount of time to realistically care for and communicate with someone.

This was my reality: If I wanted to help a vulnerable population, I needed to figure out how to learn about their concerns, ask clarifying questions and communicate a plan of action back to them in six minutes if they were non-English-speaking, 12 minutes if they spoke English. It didn't matter that patients had taken off work, navigated several bus lines, waited all afternoon as I slowly became more and more delayed in my schedule, and had multiple issues to discuss. None of that mattered. The 12 minutes mattered. Because if I ran late, people would get angry. If I ran late, people would cancel. If I ran late, fewer patients could be seen. And if I ran late, ultimately, the clinic lost money.

So, I created a routine for getting through each visit: I'd enter the exam room, flip on the computer, pull up a timer in the bottom right corner of the screen -- 12:00 exactly -- and explain, "We only have 12 minutes, so please prioritize the most important concern you came with today." Then I’d click "start," and the timer would tick away -- 11:59, 11:58 ...

During my last year in training, the behavioral health professor scheduled a visit where she'd record my interaction with a patient and we'd play it back to review for pluses and minuses after the session. Days in the clinic were always exhausting, so when we finally sat down at the end of the day to review my visit with an Iraqi refugee, I was actually grateful to be excused from the onslaught of patient visits. The professor explained how this would work: We'd watch the video together, either of us could pause it to reflect on what was happening, and we'd come up with things that I did well and things that could be done better.

She hit "play" and the screen buzzed to life, showing me -- seated, back turned, hair a little unkempt and creased in ways that made me cringe, hunched over the computer, explaining my timer and my spiel about prioritizing -- and the man. He sat, facing the camera, his view cast just to the left of the screen. His skin was a chestnut brown, his hair dark and groomed nicely, his frame carried a little more weight than it should have, and his clothes were generic and clean. Arms crossed, he began his story in fluid Arabic.

His story was the story of the refugee: He had fled due to war and violence. As he spoke, the interpreter would interject to fill me in, and even before she could finish interpreting, he'd begin again. He had lost siblings, children and friends. He lost his home, his profession, his identity. He was suffering intolerable pain -- abdominal pain, pain from bones broken during torture and joints that no longer worked.

The timer on the video showed that a little more than four minutes had elapsed since the start of the visit. Had I been able to see it in the video, the timer on my own computer screen would have told me we had about seven and a half minutes left. And I knew -- both as the doctor in the video, listening, and now as the person watching the video and being reviewed -- that the clock was ticking down. In the video, I sat, not speaking, nodding and intermittently making noises of understanding, not interrupting.

My professor clicked pause and asked how I thought the visit had gone so far, seeing as a third of it had transpired.

I don't think I managed to say a word before I realized I was swallowing hard, gazing toward the ceiling, feeling my eyes well up.

Everything -- everything -- about that visit was terrible. It was terrible that this is the world we live in. It was terrible that this man had so much hardship. It was terrible that I didn't have the skills to do the "right thing" -- interrupt and reorient the patient. And it was terrible that on the video, I sat there, feeling simply impotent. And I felt impotent all over again watching it unfold.

What I wanted to say was this: "I know medicine can't solve all this man's problems, but I -- as another, caring human being -- want to sit with him and hear his story. I want to be present and empathetic and bear witness. I want to nod and make him feel heard. I want him to know that he is the most important person to me right now. And yes, we'll talk about his high blood pressure, his pain, his debilitated joints in good time. And I don't really know if we'll ever truly cure any of them, but we'll work on it. But the only thing I can offer this man in this moment is to be with him. And everything about the system is keeping me from offering the most basic elements of being human: compassion and love."

But instead, I probably mumbled something bland about not being focused or missing the opportunity to agenda-set or whatever nonsense and let the tears flow.

At the end of my residency, months after this encounter, I realized I couldn't keep being a doctor and care -- truly care -- if I stayed, so I left the system. Because it is a broken system.

And it was breaking me, too.

So, I set out to work for my patients -- and only my patients. I wanted to take the third parties out of the room. I wanted to return the control of the health care industry to physicians, who, in turn, are responsive to patients sitting in front of them. I wanted the opportunity to be present with patients.

To care.

This is why my staff and I ask ourselves on a daily basis, "How can we show those we serve that we care -- in all our actions?" More tangibly, how can we bring the patient back to the center of the health care experience?

January 2019 marked the two-year anniversary of Kansas City Direct Primary Care. We've been through a ton in the past year. I've started to understand many aspects of business, and although we've done some pretty amazing things in the past two years, we've also made people frustrated and mad while trying to care for them. And so, I still reflect on these basic questions frequently, like checking the vitals of one of my patients. Are we still meeting that goal? Are we still steadfastly patient-focused? Do we still show patients that we care in all our actions?

And that's usually all I need to remember. After all, it's why I did this in the first place.

Allison Edwards, M.D., founded and cares for patients at Kansas City Direct Primary Care;(www.kansascitydirectprimarycare.com) provides locums coverage at rural hospitals with Docs Who Care in Missouri, Kansas and Colorado; and is volunteer faculty at both the University of Colorado and the University of Kansas. You can follow her on Twitter @KansasCityDPC.(twitter.com)

Posted at 02:16PM Jan 15, 2019 by Allison Edwards, M.D.

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