Primary Care Among His Primary Concerns

Heading into retirement, longtime local physician fears he may have been part of a vanishing species
By Judy Benson
http://www.theday.com

For 30 years, Dr. Robert Linden has been taking care of his friends and neighbors from offices in a modest, gray ranch house on Main Street a few miles from his home in another part of town.

Nearly all of his 2,200 patients have been with him for two decades or more, since the only new patients he’s taken in the last 20 years are the husbands, wives or grown children of his current ones.

As his patients have aged and their maladies grown more frequent and complex, Linden has been there for their hospitalizations, bouts with cancer, blocked arteries, painful falls and routine check-ups, and to make sure medications are keeping high blood pressure or diabetes under control.

“I like taking care of my friends,â€? he said during a break one afternoon last month from reviewing and updating patient charts. “My kids went to school with their kids, at East Lyme High. They’re not scared to bring anything up, because I’m one of them. A lot of doctors have become so aloof and are scared to get close to their patients because of medical malpractice, or they’re getting so caught up in all the insurance codes they forget about treating the patient.â€?

As a primary-care doctor, Linden is one of what health-care experts say is one of the most essential — and besieged — kind of physicians.

On Monday, he retired from his daily practice, a casualty, he admits, of his own intensity and insistence on doing his job the old-fashioned way.

“I’m a bit burned out,â€? said Linden, 59. “I’ve seen 25 to 30 patients a day for 30 years, and you take their seven or eight problems and each time they come you add two to four more problems. By three or four in the afternoon, you’re an hour behind, and you get problemed out.â€?

•••••Linden and the other four doctors who share the practice insist on caring for their patients themselves in the hospital, a rarity in an age when physicians known as hospitalists have freed primary-care doctors from those responsibilities.

Any time a patient calls and asks for an appointment that day for a sinus infection or aching shoulder, Linden makes room in his schedule, a policy he set because, he said, he’s found patients are seldom wrong about the urgency of their illness. Typically he sees patients until 7 p.m., he said, and works on charts and other paperwork until 9. The workday begins with hospital rounds at 7 a.m.

“He’s old school, quite an advocate for his patients,â€? said Dr. Joseph Gadbaw, chairman of the department of medicine at Lawrence & Memorial Hospital in New London. Gadbaw has known Linden for 25 years. “His passion is taking good care of his patients,â€? he said. “He does whatever needs to be done for his patients, no matter about his schedule or his time off. He’s just there.â€?

Among the doctors who practice at L&M, Linden is known as an outspoken, opinionated activist for ensuring that decisions are made based on what’s best for patients, Gadbaw said. He recalled Linden raising concerns at medical staff meetings several years ago that wait times for X-rays and ultrasounds were too long, and warning fellow doctors to be wary of Big Pharma’s growing influence on medicine.

“He’s incredibly incisive, and about as caring as anyone I’ve ever seen,â€? said Dr. John Urbanetti, a New London pulmonary specialist. Over the past three decades, Linden has referred several of his patients with lung diseases to Urbanetti, and the two have consulted about their care.

Specialists like Urbanetti, Dr. Michael Daren, a New London thoracic surgeon, and Gadbaw, an infectious-disease physician, agree that the role of the generalists — the primary-care doctors, internists, pediatricians and family-practice physicians — is undisputedly critical to quality health care and seriously undervalued.

Insurance and Medicare reimbursement rates that pay disproportionately higher rates for procedures and diagnostic tests rather than routine office visits have made primary-care doctors, with salaries of $150,000 to $200,000, the lowest-paid private-practice physicians, they note, while malpractice and overhead costs continue to climb.

Deren, a chairman of the Council of the Connecticut State Medical Society, said a 10-percent Medicare rate decrease that will take effect in January is likely to hit primary-care doctors the hardest, possibly forcing some to leave.

“In primary care, we’re facing acute shortages,â€? Deren said, adding that there are just 290 primary-care physicians statewide. “Specialty care can’t work without them. We need them.â€?

In a 2006 report, the American College of Physicians warned that primary care is “on the verge of collapse� as demand for their services grows with the aging population, and fewer medical students enter the field. The U.S. Department of Health and Human Services estimates there are already at least 7,000 too few primary-care doctors to meet current need, and that demand will increasingly outstrip supply at least through 2020. Nationwide, there are about 300,000 primary-care doctors.

Don Goldmann, senior vice president at the Institute for Healthcare Improvement in Cambridge, Mass., and a professor of pediatrics at Harvard Medical School, said that without a strong base of primary-care doctors, the entire health care system suffers. Care not only becomes more expensive, but the quality declines, too. And patients without a primary-care doctor — also called a “medical home� — tend to get lesser quality care and have poorer outcomes.

“It all begins with primary care. It’s pivotal,â€? Goldmann said. “But primary-care physicians are under a lot of pressure and stress, because of the way they’re reimbursed. They have very little time to see a patient, and yet they’re asked to do more and more.â€?

As part of its work on health care reform, IHI is exploring ways to improve primary care and ensure doctors’ time is used most effectively, Goldmann said. Many of the problems in health care, he and others at IHI believe, can be traced back to shortages of primary-care doctors, their lack of prestige and lower salaries compared to specialists, and the pressures put on those currently in the field.

Linden is quick to agree with IHI’s analysis, and eager to add some of his own. He plans to spend the first six months of his retirement writing a book he plans to call “The Rise and Fall of the American Medical System.â€? The outline he’s written calls for four sections, one of which will be titled “The Death of Primary Care.â€? The others will cover health care costs and advocate for a single-payer system; Big Pharma “and the bad things they’re doing with their infiltration into medical school educationâ€?; and trends such as hospitalists and so-called “shift medicineâ€? — the increasing numbers of doctors, especially recent medica-school graduates, seeking to work a 9-to-5 schedule.

“Every change takes them farther away from the patients,â€? he said. “You learn from medicine based on what happens with your treatment, and if there’s no continuity of care, you never see the results, and no one’s responsible for the outcome.â€?

He’s not expecting to make money on the book, he said, but wants to write it because “this is something my patients want. They’re confused.â€?

•••••

But up to his last day, Linden kept trying to keep health care as simple as possible for his patients, including Ralph and Julie Curtis of New London, who’ve been coming to his office for care for the last quarter-century. Told of his pending retirement, the Curtises said they would miss his thorough care.

“We trust him,� said Ralph Curtis, who was hospitalized for a blocked artery a few years ago.

“What can I do for you today?� Linden asked Julie Curtis, obviously in pain as she gingerly eased herself into a chair in his office as her appointment began.

“I fell yesterday afternoon,� she said.

After learning more about her injury, Linden led her to his examining room for a closer look at her aching shoulder.

“I can get you an X-ray today,� he told her, back in his office. He wrote her a prescription for pain medication and a muscle relaxer. “Put some cold on it for today, and then some warm soaks.�

Next in was Ernie Sunega of Niantic, whose father was also one of Linden’s patients. They talked about Sunega’s diet, his blood pressure numbers and whether the current dose of his anti-hypertension medications is enough.

“I hate to see you go,� Sunega told him.

Bob Ashley of Niantic, a patient for 20 years, came next. The district manager for a pipe-sales company has had surgery to remove a portion of a kidney that was cancerous, and was now having chemotherapy for lung cancer. Ashley said Linden was the first to notice a spot on his lung after a CT scan and referred him to an oncologist.

“I’m very upset he’s leaving,â€? Ashley said. “He knows me so well. He knows if I’ve had a cigarette.â€?

Linden asks Ashley how the chemotherapy is going and reviews his medications. Just because he’s referred a patient to a specialist for a specific illness, Linden said, doesn’t mean his involvement ends. If anything, he gets more involved, talking with the other doctor and checking to make sure the patient’s diabetes or heart disease is still getting attention.

“Primary care has to be the captain of the ship,â€? he said. “That’s how I’ve always done it.â€?
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