What Solomon Taught Me About Delivering Old-fashioned, Futuristic Care

The day I was born, I established care with a family physician. He delivered me. I moved a few times and changed doctors, but I cannot remember a time during my childhood when I did not know the name of my family’s doctor. He or she was always a trusted member of our community, serving on the school board, working at our wilderness science camp, and raising a family in our neighborhood. I developed a great respect for the contributions that primary care clinicians make to their communities. These early years shaped my desire to become a family physician, with the ultimate goal of being someone’s long-term doctor.

So, you can imagine how loudly my heart sang when our family medicine inpatient service team was rounding on a patient in the hospital last year, and he introduced me to his nephew: “I’d like you to meet Dr DeVoe. She’s my doctor! She has taken care of me forever—since 1964!” Except for the minor fact that I was born in 1971 and became his primary care physician in 2003, it felt wonderful to hear someone proud to call me his doctor and to have him feel that I had cared for him for over 50 years.

The trusting relationship that Solomon and I had built over 15 years enabled me to help him navigate complicated diagnoses during that hospitalization and to base our decisions on his preferences and health goals, which I knew extremely well. When he was faced with the dizzying feeling of receiving multiple recommendations from several different specialists, he trusted me to sit beside his hospital bed and help him prioritize which tests he would complete, which ones he would postpone, and which he would forego completely. When he confided in me that he did not want to be discharged to a skilled nursing facility and preferred to go directly home, we worked together on a plan for him to get home safely and engaged our outpatient care management team to stay closely connected with him and his family. I also agreed to make home visits to check on him. On the day of his hospital discharge, he emphatically announced that he never wanted to be hospitalized again.

Despite our team’s best efforts to keep him out of the hospital, his condition deteriorated over the next 6 months. When he presented for an urgent clinic visit with a gangrenous toe, Solomon and I both knew it was time for him to be readmitted to the hospital. He promised to go if I promised that he would not have to stay very long. Knowing his wishes and goals, I was able to join the inpatient team for care conferences, help to obtain a palliative care consult, participate in a family meeting that facilitated a transition to home hospice, and ensure a continued connection with our primary care team.

During this same 6-month journey with Solomon and his family—being present at extended clinic visits, in the hospital, and at his home—I have also been treading a different path, in what feels like a parallel universe. I have participated in a number of national meetings about the future of primary care, hearing people say “primary care physicians are too expensive,” “patients only want easy access to urgent care centers,” “in the future primary care will be delivered by computers,” and “continuity is a vintage concept that has gone out of fashion.” Certainly, we need to invest in making major improvements and updates to our primary care system,¹ but I cannot fathom a world without having or being a primary care physician.²

I have tried to imagine how different Solomon’s experience might have been without our primary care team’s involvement in his care. I asked his family members if they would have welcomed a home visit via avatar, or if they would have discussed Solomon’s advanced directive and portable orders for life sustaining treatment (POLST) at a retail urgent care clinic with someone they were meeting for the first time. “Nope,” they said.

When I am asked at national policy meetings about why primary care matters, I think of patients like Solomon and how an individual family doctor’s contributions to the health of a patient, family, or community are often too numerous to count and nearly impossible to accurately measure using the metrics in existence today. Solomon’s story reminds me how the work we do in family medicine is usually behind the scenes over years, strengthening relationships, building trust, relieving suffering, healing the soul, and preventing ills.^3-4 Spending years caring for Solomon and getting to know his family has helped me better understand the population-level statistics showing that interpersonal continuity of care is associated with improved patient experiences, improved health outcomes, lower health care costs, and physician well-being.^5-9

As a family physician, I am fortunate to have opportunities to care for patients like Solomon and to go to national policy meetings about the future of primary care. I will continue to think about Solomon and his family when I am challenged to answer questions about the relevance of primary care physicians in today’s health care system or asked the question: “If primary care physicians and teams disappeared, would anyone notice that we were gone?” Solomon’s family would notice. I imagine that millions of others would also mourn this loss. Solomon’s story inspires me to continue working to shift the national conversations so that we talk less about robot avatars and more about transformative primary care delivery models and fair reimbursement practices that will enable family physicians and primary care teams to deliver the old-fashioned, futuristic care that patients, families, and communities want.