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Tuesday Oct 15, 2019

Stop and Listen: Why We Need More Time With Patients

Kathy came to me complaining of exertional shortness of breath. She lived in a third-floor, walk-up apartment and she was having a hard time climbing the stairs.

[hello good listener name tag]

Kathy, who was in her early 50s, had a history of severe anxiety, which complicated her care because other physicians had stopped actually listening to her. She was misdiagnosed for at least two years, allowing continued progression of her disease. I was able to ascertain her problem -- recurrent pulmonary emboli -- but it was too late.

Kathy ended up on a transplant list, and she died waiting for the cure to her disease.

Our patients' stories shouldn't have to end this way. Too often, people -- especially those with mental health issues (including anxiety) -- have their other health conditions dismissed or overlooked. A significant part of the problem is the time constraints facing primary care physicians. When we have just 10 to 15 minutes to take a history, address a patient's chief complaint, create a treatment plan and refill prescriptions -- all while checking the boxes we have to check for payers and employers -- how much time is left to make eye contact and truly hear what people are dealing with?

When we have time to listen to our patients, it can make all the difference.

Take, for example, my patient Linda. Instead of 15 minutes, I gave her 45. And although that visit was three times longer than what has become the unreasonable norm in our health care system, it saved the patient and the system thousands of dollars.

Linda, who was in her mid-60s and recovering from surgery to repair a leaking abdominal aortic aneurysm, also was suffering from repeated syncopal episodes. She had a workup with a neurologist, who recommended seizure medications and a five-day, inpatient electroencephalogram evaluation after her initial EEG came back normal.

She was reluctant to go back to the hospital so soon after surgery and came to me for a second opinion.

I listened to her, and the solution was simple. Her episodes were clearly postprandial.

"Do I really need all this?" she asked.

My answer was, "Absolutely not."

It turned out that during her recovery from surgery, Linda wasn't eating well and was becoming hypoglycemic. When she ate regularly, she was fine. Problem solved.

A $90 visit with me saved Linda (and her insurance company) thousands of dollars.

And yet our health care system continues to overvalue subspecialty care, focusing on treating disease rather than preventing it.

Need another example?

Meet Jennifer.

A patient in her 40s, Jennifer has anxiety and occasional panic attacks. She was suffering from symptoms -- including shortness of breath -- that appeared consistent with panic attacks. However, Jennifer knew what she was experiencing recently was not typical of her anxiety. She told this to the team of subspecialists -- cardiologist, neurologist and pulmonologist -- who examined her, but they each dismissed her without an in-depth workup. They also were only able to tell her what she did not have and failed to make a diagnosis.

When Jennifer came to me, I did reasonable testing to rule things out and found her underlying issue, which was a carcinoid tumor. Her surgical outcome was good, and the symptoms that other doctors had attributed to her anxiety resolved completely.

We need more time with our patients. The 15-minute visit is a disservice to our patients and to us. And it all comes back to payment. If there is no more money for primary care in our $3.5 trillion a year health care system, then we should be pointing out overutilization and inappropriate utilization so we can eliminate waste and redirect funds to things that actually matter, like listening to our patients so they can be diagnosed correctly the first time.

A recent JAMA study(jamanetwork.com) estimated annual waste and misuse in U.S. health care at $760 billion to $935 billion. The authors postulated the system could recoup one-fourth of that amount (excluding potential savings related to reducing administrative complexity), but my question is, why aren't we aiming for a figure closer to 100%? If we paid primary care appropriately, dollars currently wasted downstream could be saved. Start with robust funding, in the straightforward manner suggested by the AAFP's Advanced Primary Care Alternative Payment Model,(38 page PDF) for both public and private payers.

Too often, our employed family physician colleagues are told by their health systems to refer work that we are trained and capable of doing. A family physician doesn't need to send a patient to a dermatologist for a biopsy. We need to protect our broad scope because we are the most cost-efficient place for care, and there is no need to feed the system with care we can provide ourselves. In fact, data already exist that show larger systems provide higher amounts of lower-value care.(www.healthleadersmedia.com)

If the system actually valued primary care appropriately, imagine how much money and stress we could save the Lindas and Jennifers of society.

More importantly, we could save the lives of people like Kathy.

Doesn't anyone else see the data?

Is anyone listening to our patients?

Is anyone listening to us?

Erica Swegler, M.D., is a member of the AAFP Board of Directors.

Posted at 04:00PM Oct 15, 2019 by Erica Swegler, M.D.

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