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He came in for his regular blood pressure and cholesterol check.  On the review of systems sheet he circled "depression."

"I see you circled depression," I said after dealing with his routine problems.  "What's up?"

"I don't think I am actually clinically depressed, but I've just been finding it harder to get going recently," he responded.  "I can force myself to do things, but I've never have had to force myself."

"I noticed that you retired recently.  Do you think that has something to do with your depression?" I asked.

"I'm not really sure.  I don't feel like it makes me depressed.  I was definitely happy to stop going to work."

I have taken care of him for many years, and know him to be a solid guy.  "I have seen this a lot in men who retire.  They think it's going to be good to rest, and it is for the first few months.  But after a while, the novelty wears off and they feel directionless.  They don't want to spend the rest of their lives entertaining themselves or completing the 'honey do' list, but they don't want to go back to work either."

He looked up and me, "Yeah, I guess that sounds like me."

"What I have seen work in people, especially men, in your situation is to get involved in something that is focused on other people.  Volunteer work at the food pantry, work for Habitat for Humanity, or anything else that lets you help other people.  I think the reason people get depressed is that they turn their focus completely on themselves, which is not what they are used to when they are working." (I knew that this man had a job that helped disadvantaged people).

"That's great advice, doc." he said, with a brighter expression on his face.

"It's from experience," I responded.  "I've seen a lot of retirees start to feel like they are on a hamster wheel, just entertaining themselves until they die.  I know I wouldn't want to retire that way.  Knowing you, I wouldn't imagine you would either."

We talked for about 15 minutes about the various groups around town that would need someone of his skills.  I told him about how my parents went to Africa for a year after Dad retired.  He actually taught physics over there, but that is what they needed.  Of all the time I spent with him, over half of it was regarding his post-retirement "blues."  He wasn't clinically depressed, so I couldn't charge for depression as a diagnosis.  The code I used?  99214 for Hypertension and Hyperlipidemia.

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I saw her name on my schedule.  She's a dear woman whose husband passed away recently.  I have cared for her and her husband for many years; they would always come in together - he with his dry wit and she with her motherly hugs.  I was both happy and sad that she was coming in.

When I walked into the room she looked at me with bloodshot eyes and said, "I am doing OK" with a wavering voice.

I didn't say anything; I just went over to her and hugged her.  She hugged me tightly and neither of us said anything.  Her visit was officially listed as a recheck of her hypertension, but we spent the vast bulk of the time talking about her husband.  She laughed because her blood pressure was actually lower now than it had been before.  "I guess I know who was causing my blood pressure to go up," she quipped with a hint of tears still in her eyes.

I laughed, did my documentation as we talked, and scheduled her to see me back in a month.  She didn't need to be rechecked in a month for a medical problem, but I knew she would want to see me soon.

I coded it as a 99214 for hypertension and grief reaction.

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With the debate about our healthcare system heating up, I think we lose focus on the point of the system in the first place: care.  I knew both of these patients well, which made these special interactions possible.  I didn't have to do the extra stuff as a doctor, but the human side of me made it impossible not to spend the extra time.  Primary care is about relationship - about doctor knowing patient and patient knowing doctor.  It is an opportunity for people to get help and to get care.

I am not unique in my relationship with my patients; this is why most people go into primary care in the first place.  But I do think the pressure to become an E/M coding machine, for focusing on the business over the patient, is getting progressively stronger.  To the system, each of these encounters are simply codes and numbers.  But they were obviously so much more than that.  They were about the humanity, the contact, the care that is becoming a scarce commodity in our system.

Some people may not want a doctor who spends extra time with them, but most people do.  Our system is progressively snuffing this out by belittling the importance of relationship and stressing drugs and procedures.  Both of these patients are Medicare, and so the idea of my practice dropping Medicare bears their faces along with many others.  Yet I can't really afford to take a 21% pay cut, so we'll have to figure out something.

Medically, these visits were routine and uninteresting.  But those moments are the pearl at the center of any system we set up.  We need to value that pearl.  We need to encourage medical students to go into primary care, so that when I get to the age of these patients, I will have someone to care for me - to really care, not just code and document.  Right now, encouraging students into primary care is like encouraging them to stand at the muzzle of a loaded gun.  We are endangered.  These visits are what is really at stake.

Does Washington realize this?  Does Washington care?

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