I was happy when I looked at today's schedule.

Two husband and wife pairs were on my schedule, both of whom have been seeing me for over ten years.  Their visits are comfortable for me; we talk about life and they are genuinely interested in how my family is doing.  They remember that I have a son in college and want to know how my blog and podcast are doing.  I can tell that they not only like me as a doctor; they see me, to some degree, as a friend.

Another patient on the schedule is a woman from South America.  She has also been seeing me for over ten years.  I helped her through her husband's sudden death in an accident.  She brings me gifts whenever she goes on her trips, and also brings very tasteful gifts for my wife.  Today she brought me a Panama hat.

I know these people well.  I know about their past illnesses and those of their children.  I know about their grandchildren, having hospitalized one of them over the past year for an infection.  I know about the trauma in their lives as well as what they take joy in.  They tell me about their trips and tell me their opinions about the health care reform bill.

I spend a large part of their visits being social.  I can do this because I know their medical situation so well.  I am their doctor and have an immediate grasp of the context of any new problems in a way that nobody else can.  This is not just in the context of their own medical ecosystem, it is in the larger family context.  This means that I know how to read between the lines when they say something - knowing what I can ignore and what subtle things are out of character.  This also means that I don't have to practice defensive medicine - as I not only have a low risk of lawsuit, I also can rely on my intimate knowledge of them to keep excessive ordering of tests and referrals to a minimum.

That is the joy of primary care that doesn't get talked about as often as it should: I have a genuine personal investment in my long-term patients.  I know them and am known by them.  It is also a much more efficient way to practice medicine.  I don't have to order tests to get information when my personal information is so great.

A 21% cut in Medicare may have put an end to it.  When we were staring down the barrel of losing that much revenue, we seriously talked about our threshold for dropping Medicare.  The political game of chicken was not only played at the expense of physicians, it put great fear into many of my long-term patients that they would lose me as their doctor.  Yes, many of them would probably ante up and pay cash to maintain that relationship, but a new negative dynamic would definitely be thrown into the mix.  Some just couldn't afford to pay me out of pocket (even with a discount).

We need a system that encourages relational medicine rather than discouraging it as our system does now.  Getting a bunch of mid-level providers in Walgreens is not the same as having an adequate primary care workforce.  I cherish my relationships with these people and they are, to a very large extent, the reason why I haven't seriously contemplated dropping Medicare until recently.  I am a very important part of their lives - a stabilizing force that helps them deal with the difficulties of getting older and getting sick.  But they are an important part of my life as well.  I have a personal stake in their health because they bring me joy and connection.

After the visit, I gave the woman a big hug.  I was wearing my Panama hat.

My nurse says it would look good with my Jimmy Buffett shirt.

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