Every year, as winter approaches, I look forward to big snowstorms. Not just because I love Nordic skiing - though I do. Not just because the individually tiny flakes and their accumulation into deceptively gentle drifts are such a useful reminder of the importance of soft power. Not just because of the quiet, or the magic of moonlight glistening on fresh powder, or even the knowledge that the piles of snow against the foundation will help insulate the basement and protect our pipes. These are all perfectly good reasons to enjoy snowstorms, but I particularly look forward to snowstorm epiphanies.
Every significant storm results in a flurry of cancellations in our family practice office, proportional roughly to the intensity of the storm. Mainers are hardy folk, and significant begins around 12 inches; anything less than 5-6 inches is considered inconsequential. Several days during a typical winter our schedule is less than half full allowing us to comfortably spend 30-40 minutes with each patient. We love these days.
The slower pace engenders flexibility. The sense of adventure brightens the mood. The nurses have time to catch up on prior authorizations, logging immunization data into the state system, and completing QI and other projects. The providers have time to call consultants to discuss challenging cases or touch bases on a shared patient. We know we will spend time at the end of the day working as a group clearing off our cars and digging each other out of the parking lot. Someone invariably brings in a tasty treat to share in the break room, and there is actually time to enjoy some conversation as well as the snack. But the biggest and best change happens in the exam room.
With more time, we can let the visit evolve more naturally. Instead of directing attention to the official agenda (“Good morning, Mrs. Jones. Nice to see you. How have you done with your diabetes and cholesterol since we saw you three months ago?”) we can take agenda items from the floor (“Good morning, Mrs. Jones. Nice to see you. Before we review your diabetes and cholesterol, is there anything else on your mind that you’d like to talk about?”) The slower pace affords us the luxury of listening both better and longer, and pursuing hints and clues we might otherwise have been forced to defer or ignore: “You made a face when you mentioned your brother. Is there a problem there?” There is time to review previously addressed issues, which often turn out not to be as fully resolved as we thought: “That shoulder, Bob. The one we treated two years ago. Does it ever keep you from doing anything you want to do?” He had given up kayaking with his wife, but was able to resume after a steroid injection and a course of physical therapy. We have time to explain more slowly and review in more detail our assessment, with the diagnoses we are considering, and the possible approaches with their implications. The front desk tells us the patients are happier on the way out.
Every one of us agrees: these days are special. We go home feeling much better about the value of the personal contacts we made with patients and the quality of the care we delivered. We have a sense of ‘this is what I signed up to do.’
All this would be enough to make snow storms something to look forward to, but there are also what we call the ‘snowstorm epiphanies.’
With every major storm, at least one (and often several) of us solves a problem that had resisted our efforts over sometimes not just several visits, but even years. Sometimes is it small but important, as with the patient who didn’t realize she shouldn’t take vitamins or supplements containing calcium at the same time as her thyroid and other medications, and whose hypothyroidism was suddenly easier to control. Sometimes it is major, like the patient with the unexplained and mild but chronic neurologic findings on exam that had been resistant to multiple diagnostic evaluations, who confided during an unhurried 45 minute discussion that he had begun hallucinating as a graduate student, had had multiple hospitalizations and complex drug treatments (one of which caused permanent neurologic symptoms), that he still hallucinated but was able to recognize and ignore what he called ‘my extra dimensional reality’ and function as a lawyer, husband, and father, and who had kept it a secret for fear of social and legal stigma. It can be a diagnosis that is made only because the additional time resulted in follow-up questions, better listening and more information, like the patient whose recurrent vaginal infections turned out to be local allergic reactions to the sulfa-based antibiotics her husband took intermittently for flares of his prostatitis. It can be a better understanding of the social context that is preventing a patient from adhering to our agreed upon regimen, like the generally very motivated and conscientious patient who said he would exercise by going for walks but inexplicably never did, who described the night when he was 11 and his father went out for a walk after dinner - and never returned.
The benefits of being able to spend more time with each patient, and spend it in an atmosphere that is more personal because it is less hurried and that gives the patient more control, are obvious. I can’t count the number of times patients have said to us or to our staff: “Thanks. Today was a great visit. Next time there’s a big storm, I’m going to call for an appointment.”