Family Practice – The Cornerstone of My Team

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I love my family doc. If you’re not happy with your primary care doc, find someone you trust to help you find another one. She’ll be your cornerstone. Interview with Dr. Laura Zucker.

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Credits

Music by permission from Joey van Leeuwen, Boston Drummer, Composer, Arranger

Sponsored by Abridge

Thanks to these fine people who inspired me for this episode: Danny Sands, MD, Bruce Russell, MD, Coalition for Compassionate Care of CA, Tony Baron, MD, Alan Hirsh, MD,

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About the Show

Welcome to Health Hats, learning on the journey toward best health. I am Danny van Leeuwen, a two-legged, old, cisgender, white man with privilege, living in a food oasis, who can afford many hats and knows a little about a lot of healthcare and a lot about very little. Most people wear hats one at a time, but I wear them all at once. We will listen and learn about what it takes to adjust to life’s realities in the awesome circus of healthcare. Let’s make some sense of all this.

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The Show

Introducing Dr. Laura Zucker

Living with a progressive neurodegenerative disorder is seriously annoying at best. I’m blessed to have a pathologically optimistic disposition and the drive to manage manageable stress. When my stress is up, my symptoms are worse – a direct correlation. Challenges with my health team would put me off my feed and send my stress levels through the roof. Welcome to the third episode in the series with and about my fantastic health team: my chiropractor, physical therapist, and now, Dr. Laura Zucker, my primary care physician. Dr. Zucker keeps the wheels on the bus. She co-leads my team and routes me to specialists that fit me. She goes to bat for me when there’s a hiccup in the system. I’ve been to an office visit from two to six times a year for more than ten years – maybe only 40 times. We often communicate by text message on the patient portal, sharing reports from other doctors, reviewing symptoms, meds, tests, whatever. That can be not at all between visits or ten times, depending on life and fates. She responds within a day – almost always. If she’s sick or away, a colleague responds – fabulous care and service. I’m fortunate, and I work at keeping a good relationship with Dr. Zucker and her office. If I feel like crap, I don’t need to work at it. The goodwill’s in the bank.

Health Hats: Good morning. I am with Dr. Laura Zucker, who, besides my wife and me, is the most essential member of my health team. You have the most robust knowledge and understanding of what’s important to me, what’s happening with my many specialists, my journey. I appreciate that. Thank you for joining me this morning.

Laura Zucker: You’re welcome.

Health Hats: How do you introduce yourself in a social situation?

Laura Zucker: Usually, just by my name. I usually don’t say doctor. If people are curious as to what I do, I certainly tell them, but I often don’t volunteer it.

Health Hats: Where were you when you first realized that health was fragile?

Laura Zucker: That’s been a process or a journey for me. I did grow up with an ill parent. From a young age, I was aware that health is fragile because my mother had multiple hospitalizations. That was the start, but really as I became a parent. In residency training, we were engaged with a lot of very fragile and extreme situations and realized how difficult things are for people and how people’s health can be quite fragile.

Behold, a doctor

Health Hats: Did you always know you wanted to be a doctor or was that something that also evolved?

Laura Zucker: I never thought about being a doctor until late in college. I’d always been interested in exercise, exercise physiology, and physical therapy. I thought I was going to become a physical therapist. Towards the end of college, I thought about medicine. I didn’t like the competitive nature of my classmates. This course of study wasn’t for me. I thought I’d do something else and got very interested in public health for a while and did get a public health degree. After that, I decided to pursue medicine.

Health Hats: Wow.

Laura Zucker: I started medical school when I was 26, 27, something like that.

Health Hats: I remember when I decided to go to nursing school. I had a second mother, the mother of my best friend. She tried to talk me out of it and said, ‘if you’re going to go into healthcare, you should become a doctor.’ I said that I didn’t want to do that because I wanted a life. It didn’t seem to me that being a doctor and having a life and a family and whatever were compatible. But you managed that. How has that been for you? It’s so demanding. Medical school is crazy.

Laura Zucker: You should probably ask my family. That’s how I managed it. It was demanding, I delayed a few things, mostly having children. I did have my first child in residency, so that was not so easy. Then when I was looking for a job, it was hard to find a job. I wanted a so-called part-time job. For a physician, that was not so easy to find. It took me almost a year to find someone willing to allow me to practice three days a week instead of the typical five. There was lots of negotiation involved with that. It has since become the model of our practice that none of our clinicians work what would be considered a full-time schedule. We’ve managed to make it work. I don’t think it’s been easy. The job still takes you away from things at times. But, at the time- 22 years ago, Dr. Sagov, who owned our practice, was one of the few people willing to negotiate around a fraction schedule. He said, ‘well, if you think you can make it work, here’s the platform to make it work, and we’ll see how it goes.’ He was probably one of the first persons to be open to the idea all those years ago.

What does a family doc do?

Health Hats: Tell our listeners about the role of a primary care physician?

Laura Zucker: We wear different hats. I’m a family physician. We take care of adults and children and families. In addition to providing basic preventive health care, we treat acute conditions. But increasingly, as I have aged with my patients, my role has expanded to helping people manage their chronic illnesses, but also to negotiating through the healthcare system. That’s finding the best individuals for their care and helping to answer questions as they waltz through our healthcare system. Answer the questions that come up that they’re not getting answers to through their specialists or what have you. There’s a significant degree of care coordination, not just with other medical specialists, but other aspects of their care, be it physical therapy, occupational therapy, home health, and so on.  I also tell patients that I am one of their strongest advocates through the healthcare system. If they happen to find themselves hospitalized almost anywhere or having something that’s happening that they need help with, there are many ways to reach me, not just by phone, but through messaging. You and I communicate a lot through our patient portal messaging system. I like to work with families, so I invite family members to join when things get difficult or not going well at home or sometimes before that.

Something is seriously wrong

Health Hats: Working with you, first, was figuring out what the hell was going on with me.  I remember having this conversation with you, saying, ‘Dr. Zucker, something is wrong.  I do not feel right.’ I realize in hindsight that for 25 years, I had been treated for heart disease because my father had died of a heart attack when he was 45. For 25 years, every time I had an episode, I would get a cardiac workup, which would always be negative, and the episode would pass. But that happened twice a year.  You kept dogging it – another specialist, trying to nail it. Then I think, as we were getting into different specialists, you would come out with a list, and instead of just giving me the list, you’d be saying, ‘I think this one’s for you.’ You’ve been right. It’s been docs who are comfortable with my style. I don’t know that I’m always the easiest patient.  I’m paraphrasing, and you might not have said it this way, but something about, ‘you may have MS, and you may need to see these specialists, but you’re still an old white man with old white man problems, and we’ve got to deal with that. I appreciate that. You work hard to get the reports you can get through your system, and when you can’t, I send them to you. You have a handle on the big picture, which is such a relief.

Laura Zucker: I do see myself as someone who’s going to try and match individuals with appropriate specialists, not only for medical expertise, but for personality when we can, and the way people like to work. I very much remember that I was trying to figure out what was wrong with you. I agreed with you. I knew something was wrong with you. Your symptoms were not necessarily particular to MS, but there was a moment where I was like, “Ugh, I’ve been looking at the wrong thing. I need to look at your brain.’ I remember getting your MRI results back, exactly where I was, and when I called you.

Health Hats: I was working at Boston Children’s Hospital, and I was in the Prouty Garden. You said, ‘Can you talk? Can you sit?’ I told somebody that story, and they said, ‘she told you on the phone?!’ I said, ‘yeah, it was the right thing to do. I needed to know.’

Laura Zucker: I was at a conference all week. I was pacing in some empty ballroom at a large conference somewhere. I wasn’t going to be in at all that week, but I thought you needed to have your results sooner rather than later.

I love my work – mostly

Health Hats: What do you enjoy the most in your work?

Laura Zucker: I enjoy a lot of things. There are a few things I don’t enjoy, but in general, I enjoy the people. I get to learn about individuals, their lives. I like to help get people the answers that they need about their health concerns, whatever they might be. I do like a good diagnostic challenge. I do enjoy figuring things out for people and with people, more importantly. It’s mostly doing intellectual work and personal engagement with individuals. There’s a lot not to like about our system. Every day it’s clearer and clearer that our system is quite challenging and the frustrations that clinicians feel navigating through it wearing thin on everybody.

Health Hats: I was on a call yesterday with a gig that I have related to developing clinical decision support apps for managing chronic pain. I’m the patient expert on this initiative. I was trying to orient them to that the beginning moment is not getting ready to go to the doctor to deal with chronic pain. That people have lives, and they have life flow. How is this going to fit into their lives? When I get a message from the portal, I get a message that says, ‘you have a message from your doctor, or you have a message about an appointment. Do Not Reply is also in the subject line because that’s on the first line of whatever message there is.  I was saying. ‘why would somebody go into the portal to get this app that would help with decision support when it says do not reply? Then we got into a conversation about the challenges of working with a medical record, and they didn’t want to start down that road. How can you not start down that road? You want to use the medical record.

A scribe changes how we practice

Laura Zucker: The electronic record is powerful on many levels. I work with a scribe, which makes it easier. The scribe began with a grant, an experiment, for us to see what the patient’s experience would be with a scribe in the room. Although scribes have been used throughout the medical system, usually not in primary care. We have yet to give up our scribes

Health Hats: Tell us what a scribe does.

Laura Zucker: A scribe as an individual who sits in the exam room with us, sits at the computer, and transcribes the entire visit as it’s happening in real-time. They type in the complaints and update the medication list as I review that with you. They’re usually present for the exam, also serving as a chaperone, but also typing in exam findings, the assessment, and plan for us. Then I review it at the end of either the visit or the day and sign off. It streamlines the process of note-taking and getting tasks done quickly.

Health Hats: I noticed that when you say something that sounds longitudinal – over time – she’ll pull that up so that you can use it with me, I find that helpful, too.

Laura Zucker: We can look at image findings and so on. Everything is happening in real-time. It streamlines your time with me, and it’s efficient. It cut down my time after seeing patients by about two to three hours each day.

Health Hats: Wow. That’s huge.

Laura Zucker: There’s a lot of clicking and tasks in the record that take time to create a complete encounter. When we have a busy day, I can see between 16 and 20 people on that day. Anyway, I would say that the number one complaint of providers is how much time they’re spending on records outside of their workday.

How can we make the best use of our doc?

Health Hats: How can your patients make the best use of time with you.

Laura Zucker: It’s a good question. If it’s for a routine visit or followup visit, having a list or an agenda of what they would like to discuss. Some people now use the portal and send me a list in advance. These are always helpful. Then we can just follow that agenda or list. That’s the best piece of advice I can give anyone about seeing their doctor. I usually have an agenda too, but I typically like to hear yours first.

Health Hats: I like that too. We do that together: this is what I want to cover, and this is what you want to cover. Our visits are short, but I feel like we get it done. And we have three minutes to shoot the shit.

Laura Zucker: We always talk about healthcare together. You can always get me talking about that.

Health Hats: I think we expect too much of our doctors like we expect too much of our teachers. It’s not our teacher’s job to raise our kids. It’s our job. What do patients expect of you that’s outside the bounds of either your capabilities, your resources, or your skills?

Laura Zucker: That’s such a good question, and it’s hard to answer. Given our digital age and how we’ve moved in medicine from these paper records to this electronic experience, and people’s experience of information and communication is an expectation of rapid review of information and getting it back to somebody. It can be unrealistic for us. Some individuals might have an X-ray done, for example, and within hours or less are expecting their results. I can’t do that, even though there’s a lot of things that are now automated with results. Some things just aren’t. People don’t necessarily appreciate that. It does take us a little bit of time to think.  There’s this expectation that we can be available 24/7 at a moment’s notice and give them the information that they want when they want it. Honestly, our systems don’t support that. People forget that we are caring for not just them. I don’t know exactly what my patient panel is, but certainly well over a thousand patients. So, that’s an unrealistic expectation. Sometimes, in visits, there’s not always time to think.

We’re dealing with some complex medical issues that take time for us to think about. Sometimes people have lost that notion that it does take a little time. That’s been a detriment with our electronic systems. I had this happen today. An individual saw a specialist; the specialist ordered a test; the test was done. But the specialist hasn’t seen it because they might be in the operating room for a given day or two consecutively, and they’re not doing outpatient work. The patient’s anxious for their results, and they’re frustrated, and they’re angry because they don’t have it. And it’s been 24 hours. If I can see it, I will give it to them. But I can’t always see it, or I can’t always do that.

Now a word about our sponsor, ABRIDGE.

Use Abridge when you see your primary care or family doc. Push the big pink button and record the conversation. Read the transcript or listen to clips when you get home. Check out the app at abridge.com or download it on the Apple App Store or Google Play Store. Record your health care conversations.

Keeping up with research

Health Hats: Research evidence in medicine is so fluid. How do you keep up with it?

Laura Zucker: It’s hard. One of the advantages of our electronic record, we do have access to resources where if we have a clinical question at the moment, we can look that up directly in the electronic record. We use a resource built into our record called UpToDate. That reviews the evidence for any given topic, usually within the year. We can do that as a shared experience with patients often if it’s appropriate. It keeps us up to date. It informs the patient of what is the evidence. I still do a fair amount of reading when I can. There are email services that provide summaries of the latest in journals. I try and keep up on those. It’s not always so easy.

Applying guidelines to the individual

Health Hats: No, I can imagine. It’s apparent to me, being involved with PCORI, The Patient-Centered Outcomes Research Institute, that it’s different looking at evidence of what’s recommended for populations – A is more likely than B to be effective – but doesn’t say anything about me, the individual. The last time I saw you, you were sort of talking to yourself out loud, saying, ‘okay, I have to remember that you often don’t present typically.’ That made me think, ‘okay, wow, that’s a challenge.’ You’ve got to take this onslaught of information and guidelines that are changing and then apply them to the individual, which may or may not apply.

Laura Zucker: When I’m working with patients and talking about guidelines – screening guidelines in particular – what a guideline really is. And I usually say the following, ‘the guideline is not a mandate. They are just guidelines. They are meant to guide us.’ We have a choice through a shared decision-making process. We can decide what to do if you’re aware of both the risks and the benefits of pursuing whatever we’re discussing. Yes, you have to consider the individual. There are lots of factors to consider with the individual. You might present atypically, but are you a worrier? That’s going to drive a lot of their decision making versus individuals who are less worried and who maybe want them to be a little more worried, who tend to the opposite end of the spectrum. We strive to find that balance for any given individual. Sometimes we’re dealing with a more controversial guideline where the evidence isn’t as good as it could be. That’s how I negotiate that. I try to match or find the individual where they are and then guide them through that process. I want people to be engaged in their decisions around healthcare. Not everybody wants to be, however.

Pay for Performance – holding a dollar in front of health and wellness

Health Hats: As you and I have talked about, I’m sitting on a couple of panels with CMS (the Center for Medicaid and Medicare Services) and with NQF (the National Quality Forum) in the area of measurement. Often these guidelines get translated into measures. The focus of those measures is not communities or teams, but clinicians. People really want to get an A. They want to be 100% or close to 100%, whereas maybe a guideline applies to 75% of people. Then getting to 100% is unreasonable if it only applies to 75% of people. As we’re getting more into value-based healthcare where you’re not paid per episode but based on outcomes and measurement. How does that affect your practice?

Laura Zucker: We have a lot of feelings about this. We are beholden to what’s referred to in Massachusetts as Pay for Performance. It frustrates a lot of clinicians. We don’t all agree that these are the right metrics. We don’t all agree that the targets are appropriate, and the clinician being the sole individual responsible for the outcomes.

Health Hats: I have a team of clinicians.

Laura Zucker: It all falls to the primary care provider about Pay for Performance. We have about 33 different clinical metrics that we can be measured or paid on.  Some of them are fine. Should women have pap smears? We should be screening women for cervical cancer. Some are not. Blood pressure targets are controversial, as is A1C for people with diabetes, aspirin use. So, we don’t agree with some of the metrics. But we are held accountable to them for payment. Because of the way we’re structured in medicine, we are all part of these physician organizations. We are collectively responsible as a physician network. If one person doesn’t agree or doesn’t want to engage, it can hurt everybody else. Primary care doesn’t get paid probably as well as specialists. Then to be held accountable to something that’s not always attainable and has no patient responsibility involved. We’re going to pay you a little less up front, and if you meet your metrics, then we’ll pay you the rest that we think you should be paid. It’s the incentive. I don’t know why we keep holding a dollar out in front of people’s health and wellness in our system. It’s not right. We do lots of outreach to patients. We try and convince them they should get the metrics that we think are valuable done. But you can only bring a horse to water.

Health Hats: I’m on a panel about cost measures. Why does anyone think that we’re going to bend the cost curve by measuring physicians? I pointed out that the most significant expense or cost in healthcare of people with chronic illnesses is caregivers. What would we do if we didn’t have all these family caregivers? Why aren’t we thinking about supporting family caregivers so that they can continue to provide their free care and not overwhelm the system?

Laura Zucker: You’re correct. An engaged family member primarily controls cost. Home care is often better than what we do in other facilities. We cannot provide good care without strong social infrastructure, which we do not always entirely have for individuals. We see that every day. As much as the bean counters complain about home care costs, be it in terms of VNAs or what have you. If we could make those systems more robust, we could probably keep people out of the hospital. I think they often measure the wrong thing. You may not know this, but I do a lot of work around advanced care planning and end of life decision making. Those are difficult conversations that many people don’t want to have, including doctors. I’ve been working on getting clinicians to have difficult conversations with patients well before the crises happen – not trying to make difficult decisions when facing a life-limiting illness or situations.

Managing an independent practice

Health Hats: Not only are you a primary care physician, but you’re the lead doc, right?

Laura Zucker: I’m technically the medical director, but also an owner of one of the owners. We essentially four owners, three clinician owners, and our office manager who are involved in management decisions and so on. There’s technically four of us at the helm.

Health Hats: What does that entail?

Laura Zucker: We address higher-level issues: hiring, staffing, pay, payment. We manage the 401k business, health insurance for employees. We handle the business aspect of the practice, trying to make sound financial decisions in a complicated, financially challenging business in general. We’re an independent practice, so we are fading away rapidly. Most practices like ours have been sold to larger organizations run because it’s challenging to be successful financially. When I say successful financially, I mean pay the staff, pay our doctors and pay the clinicians, and have a little at the end of the year to give back to the staff and clinicians working for us.

What do you think of us?

Health Hats: What should I have asked you that I haven’t?

Laura Zucker: You’ve covered a lot. I’m curious about what your experience has been as a patient in our practice.

Health Hats: You have a good practice. I’m grateful for it. Your staff, the front desk, and the support staff in the back and you and when something comes up, and you’re not around, it all works very well. Over the years, I’ve made a couple of suggestions, and I feel like you’ve heard those, and when I come back, I can see evidence of something’s a little bit different. I appreciate that. I certainly appreciate your availability, that we have a way to communicate using the portal and that we make good use of that. When my neurologist left, and I was shopping around for new neurologist, one of my criteria was portals. I went to somebody, and they didn’t use portals. I told them I couldn’t work with them.  I don’t want to come to see you all the time. I would rather deal with what we can deal with offline. I think your office is exemplary.

Laura Zucker: It’s a hard process to manage the practice with so many people and try to get consistency and make sure everyone’s on the same page. For us, the overarching goals are to have a warm and inviting place for people to come into, feel like they have a home, where they can feel comfortable and feel cared for and in ways that I don’t think we experience in health care these days.

Health Hats: And safe.

Laura Zucker: That’s my goal – capable, competent individuals who do their job and do it consistently. That’s not always so easy.

Health Hats: Thanks for taking the time. I appreciate it. And thank you for what you do for me.

Laura Zucker: You’re welcome. I enjoy doing it. I love working with you. It’s been great.

Reflections

You can see why I rave about Dr. Zucker. I didn’t have to search her out.  We moved to Boston. I got health insurance with my employer and found her as a doc close to my house – first shot. As Dr. Zucker and chatted about, I knew something was wrong, and it was getting worse. I didn’t want to say anything to my family until we moved, settled down, and I had a job with insurance. I didn’t say anything to Dr. Zucker until our second or third visit together. The rest is history. We’ve been tested as a team, and I trust her. It’s a gift. When I tell people my story, they often wish they had a Dr. Zucker. I tell them to shop until they find one. I’m full of BS. I didn’t have to shop. There’s many to choose from where I live, I have good insurance, and I’m a good-natured old white man of means. When I get a recommendation, I mostly follow it unless I say I’m not going to, and I do the work. If you’re not happy with your primary care doc, find someone you trust to help you find another one. She’ll be your cornerstone. This week I also interviewed my acupuncturist, Valerie Smith.  We’ll hear from her soon. Next, I’ll speak to my massage therapist and optometrist. Thanks for joining me today!