 I'm Dr. Louis Myers. Welcome again to Health Care Today. We are going to be talking today about one of the most important topics, I believe, in medicine. That is primary care and the changes that we've seen in primary care over the years and why it's important. And I'm honored to have with us Dr. Michael Johnson, who is the family physician and the managing partner of Evergreen Health Care in Williston, based in Williston. And I'm going to go over his CV and it's a fascinating CV. Dr. Johnson began college at the United States Naval Academy and served there two years and had an honorable discharge and then went on to get his truck driving certificate, as well as returning to Finnish College at the University of Pittsburgh where he graduated magna cum laude with study in the classics. He eventually went to Germany where he studied theology and also went to medical school in Germany, got his MD degree there, returned to the United States to do his internship in residency in family practice at the University of Vermont and also an additional year as their chief resident. He received an award as one of their top professors and he has been in practice since I believe 2005 and also is on clinical faculty at the University of Vermont helping teach the medical students. So Dr. Johnson, welcome. Thank you. And I usually don't go back to someone's CV but yours is one of the most fascinating I've seen in quite a while and I just have to ask you a couple of questions. You started at the Naval Academy in Annapolis and obviously left there after a couple of years with an honorable discharge and then learned how to drive trucks. Tell us about that transition and the skills that you transitioned from and to. I didn't expect those questions. It's real life, right? As a teenager in the era of the first Top Gun, it was a very appealing thing and still a strong supporter of people that serve our country in many ways and wanted to emulate that but after a couple of years really found it for me personally at that point in my life and at that point in the culture of the academy it was not the right thing for me and leaving the academy meant that I had to find a way to finance going to college. And so I got a truck driver's license and earned money so that I could go to a regular civilian school. A little bit of the real world. You went to Pittsburgh and then you went to Germany and I wanted to ask you about that. You certainly have gone through medical school in Germany and now you've been a faculty member and obviously done residency in the United States. How would you compare the medical education in Germany as opposed to the United States? The medical education is formatted very different and medical education has changed immensely since in the last 30 years here as well. When I see the medical students now coming through our office they don't have books, they don't have cards to memorize, they have electronic resources and so that's changed immensely but the content of medical school is very similar in both countries when I went to medical school there there was a lot of theory and a practice was kind of done later. The U.S. has traditionally had really excellent residency programs, very structured, very quality oriented whereas in many other countries like in Germany the residency training can drag on and be more haphazard and to be licensed in the country here you have to do residency here really and so I came here thinking I'd be here for three years and that was 20-some years ago. You also combined study with theology which I find fascinating and I can't think of something that perhaps might be more useful as you went through. Did you find it helpful to have studied theology and then along with your medical training? Yes, absolutely and I think in many ways I've told others, I'm just a little caught off guard because I wasn't thinking about all this but primary care in many ways is like a secular pastoral care. It's a scientific pastoral care we're really caring for people and their families and their whole situations using the science and education and the ethics and everything that we dedicate years to learning but there's a whole lot of parallels to people who are working in theology as caregivers there. Do you think that whether it's primary care or other aspects of medicine there's a role for spirituality? I'm a firm believer that you can't... I wouldn't even say there's almost nothing in medicine that doesn't have some aspect of mind, body and spirit and if the same person would experience the same broken bone differently depending on their social situation, their economic situation, their emotional situation and so I think if we ever try to treat a disease without looking at the whole person and all the aspects of that person we're going to miss something. I think it leads me into my next question which gets us back to medicine and that is what led you into primary care? Well, I think that's exactly it. It was a kind of a way to care for people as I had planned to care for people studying theology using science and education in a way that in primary care allows me to continue to care for the whole people and not be relegated to one aspect and of course specialists also look at the whole person but sometimes it's more difficult as a specialist with brief interactions in many specialties to get to know the whole person as much as in primary care. And speaking of the whole person, you went into family practice which is perhaps the broadest specialty of any field in medicine because you learned about adult medicine, pediatrics, child medicine, OBGYN, surgery, psychiatry, correct? You were training in all of those. Yeah, absolutely. Why is primary care important? I think in any country that studies their healthcare system and every country's healthcare system has problems. Pretty much every study I've ever seen comes to the conclusion that we need more primary care because primary care is when done right, when accessible is the basis to prevent so much of the other care and when primary care breaks down and isn't there for people then you end up with a lot more and less effective care. We hear that there's a primary care shortage in this country. You mentioned other countries, for example, Germany, where you had some training. Do we have a shortage of primary care in this country as compared to other developed or industrialized countries? The U.S. primary care traditionally did... Actually, it's one of the things that the U.S. system did better than other countries, having more comprehensive primary care. But over the years, we've invested less and less in primary care and more and more in procedural care. That's taken a real toll on our system and made medical care much less affordable for people here. What are some of the changes you've... You've been in practice since 2005, I believe. That's over 16, 18 years now. What are some of the changes you've seen in that period of time in primary care? Even your residency is three years before that, too. What changes have you seen? One of the changes that comes right to mind would be electronic health records for all the positives and negatives of that. But the day-to-day biggest change is maybe the cost plays a role. There's not a day that goes by where cost isn't part of the equation for my conversation with patients. Can you give me an example of a conversation where it might come up? A patient yesterday who was thinking about changing the medicine but couldn't afford it. Or a patient yesterday who didn't want to get x-rays done because of the cost of the x-rays and finally did get an x-ray done and had a broken bone. You know, it's... Every day on my computer, I've got a tab up with GoodRx and looking for coupons for people to see what, you know, knowing what the right medicine is and then knowing whether they can get it or not. Do you think that primary care providers and physicians who are in primary care in general, though, their patients are paying or what they're on the hook for financially? I think, at least in independent medicine, we do. I think that if in a larger hospital system you might be more separate from that, but I'm thinking back to my time, even after residency, working in the hospital system and trying to convince a patient to have a colonoscopy and they said, well, what does it cost? And I said, well, I'll call the billing department and said there is no cost. It depends on the person. It depends on the insurance. So there's no way for that person to make a decision. I can make a recommendation, but it couldn't make a decision. And I have many patients who refuse to get things done because they're still paying off bills from other things. So you've mentioned electronic medical records, which will come back. Do you mention the cost? What are some of the other general changes that you've seen in the practice of primary care? I think patients, and it's tied together, I think most everyone in primary care, whether they're at the Community Health Center, hospital-based, independent medicine, recognizes that patients are coming with much more complicated cases now. There's, you know, when a patient comes in, and that has a lot to do with the cost, but there's very few straightforward visits, you know, someone coming in with one issue, people come in when things are bad and when there's real problems and there's multiple problems to manage. So I think it's become a much more complicated system over the last 18, 20 years. And why do you think that is? I believe it's access. There's a barrier to people getting care. And that's, I think, why our emergency rooms get so much more full of care, because we all want to hope that we're not going to have to pay to fix something if... I've heard from a number of friends, others, that, you know, I called for a primary care appointment for initial appointment and I was told, you know, coming in nine months from now, or a year from now, is that what's sort of the happening out there? Well, we still get our patients in our office, but I think we run one of our economic challenges, we run much smaller panels. So I am strived to always be able to see my patient when they call, but I can't always do that, even though I haven't taken new patients on for years. Your panel has been closed. My panel has been closed, and I have 910 patients on my panel, and that's about half of what the U.S. average is. And I think that makes a frustrating experience for patients and for physicians. And it's one of the things that drives many physicians and many patients who can afford it into the concierge model, or they have, you know, half the panel size that I have. So that's a real driver of dissatisfaction. We'll talk about the concierge model perhaps in a minute. And I should note, your practice has expanded on, as you mentioned, your CV from seven providers now to 20, which I guess includes a mixture of physicians and middle-level providers. I think our MDs, DOs, PAs, NPs are all integral parts of our office, and all the colleagues are, you know, there's a role for everybody. One of the major changes that I've seen, too, having been in primary care over the last 25 years is the division between inpatient and outpatient medicine, where maybe 30 years ago primary care providers usually saw their own patients in the hospital. That's almost never happens now, particularly in urban areas like Burlington. They're now hospitalists, which are physicians who are only in the hospital, and then primary care tends to be only in the office. What do you think about that? There's really, I have very mixed emotions about that, up until, I'd have to look back, but I think about 10 years ago is when we quit rounding on our own patients in the hospital, and a few years after that, quit rounding on newborns as well. And part of that was the, initially at least the systems have gotten much more complex. So even if you know how to treat a patient with an acute inpatient problem, you don't necessarily know how to facilitate that in the latest iteration of the hospital software or the hospital systems. And I think talking to my inpatient colleagues, the patients in the hospital are much sicker than they used to be. Patients are only there when they're really desperately ill. And the kind of rule of thumb that I use in primary care, as you alluded to, it's a broad spectrum. When choosing whether I should do something, I think would I send my family member to myself? And if I don't feel like I'm the best person to care for a patient with a specific thing, I shouldn't do it. We got to the point with, for all of those barriers, that I didn't feel I was the best person to be caring for my patient in the hospital when I was in an office 20 minutes away. Do you miss her? I do, yeah, I do miss that, yeah. One of the other changes that I've seen is, I won't say it's a loss of collegiality among physicians, but a loss of communication, that people get siloed in their practices, they get siloed in the hospital, that they don't see each other as much anymore, have you noticed that? Yeah, I have, and it's the systemization of medicine. So there's messages, there's check boxes, there's all of that done rather than a phone call or rather than a discussion in the break room. Right, the personal touch is being lost. For patients too, sometimes patients will say that with this division between hospital medicine and outpatient primary care, that gosh, when I met my very sickest and possibly even life-threatening situation, it would have been great to see my own primary care person who's known me for the last 15 or 20 years, and that's sort of a loss for patients in a way, isn't it? Absolutely it is. I had advocated for maybe an unrealistic thing, but kind of a primary care consult service, because sometimes some of the inpatient hospitalists will give us a call and say, hey, I'm seeing your patient, does this sound normal or is this different? Because while I may no longer be up to date in the latest hospital systems or the hospital medicine like my colleague is, I certainly know that patient better and I know the context. You know their family. I know their family and I know that emotional implications having this condition will have because what they went through when their parent or others had it. And I think there's real value in that and would be well worth striving for more integration. Let's talk for a minute about, go back for a minute about the EMRs and I think everyone's aware that EMR stands for electronic medical record and it has affected every aspect of medicine. In many ways for the better. Very few doctors now have the old paper charts. So there's a lot of information at your fingertips and you don't have to wade through difficult to read handwriting, et cetera. But it's also at a downside. There are a number of studies that show that particularly in primary care, at least 50% or more of each visit, they've looked at primary care providers and they're actually looking at their computer rather than their patient for more than 50% of that visit. And obviously patients get that. They realize they're not necessarily being attended to. They're competing with the computer at that point for attention. What has been your experience? I absolutely feel the same way that the computers are a mixed blessing. Now that it's been part of our day-to-day life for so long, I'm thinking, we went electronic 15 years ago, it's unthinkable to me to not have all the interaction checkers or the lab flow sheets and all the things that we take for granted now. But the documentary burden has definitely increased. And the minutes that are required to type, to click, to do on the computer are many more than to scribble a few lines on a piece of paper. The question is, is that being driven by true clinical value or is it being driven by financial value? For example, billing. Is it being driven by medical liability? Certainly not by clinical value. The vast majority of documentation is not clinically necessary. It's semi-worthless. Yeah. You know, if I'm seeing a child for an ear infection and I say right ear drum, red, amoxicillin, 250 milligrams, three times a day for seven, that's all the information you need. You know, all the other information there is for billing, for liability, for whatever else. And all the minutes we spend doing that are minutes that are driving up health care costs. I saw a study recently that and we mentioned Germany earlier that in most European countries the notes are about 75% shorter in Europe than here in America. And they're probably communicating all the basic information. They're just doing it without all of the rest of the somewhat useless filler. My two oldest daughters were born in Germany and their pediatrician had a big index card and one line on the index card was per visit and it would be just that left ear, red, you know, whatever, or whatever, you know. And then that pediatrician could move on to the next patient, you know, or focus on the family, on the patient, and not on a chart or a record. Even before electronic, we were doing a whole lot more writing or we're supposed to be doing more writing in the chart. Let's talk about autonomy. You emphasize on your CV that yours is an independent practice and one of the relatively few in this community that's still independent, primary care, as we know, and this is not unique to Vermont, but across the country, whereas probably two-thirds of physicians used to be independent. Now it's flipped. Two-thirds are now, their practices are owned by large systems, hospital systems, private equity-owned systems, et cetera. You've remained independent. Why did you decide to go that route and what are the challenges of doing that? Well, the challenges are financial, of course, because as an independent, you get reimbursed at much lower rates and as a large entity. Wait a second. Explain that for our audience. So when they go in to see you or they go in to see a family practice doctor connected to UVM, you mean the UVM doctors getting paid more? If I have an independent cardiologist do a procedure on me in a hospital room or have a hospital doctor do a procedure on me in a hospital room, the bills will be drastically different, you know? And the hospital doctor isn't necessarily walking away with more, but the system is. The system has more financial leeway there. So it's a huge financial stress, but it's very rewarding in that practicing physicians can make the decision what makes sense for our practice and for our patients. Can you give me an example? Can you think of a situation where you had to make that decision in your office and you might have had to make a different decision? Had you been a systems physician? I loved working at the University of Vermont and being a faculty member there and being in a primary care office there. But it was very frustrating to not be able to do things that made sense to me in the office. So if I'm managing a diabetic patient to be able to have the result of their average glucose so we can talk about it and make adjustments face to face, really made sense. But in office, testing of an A1C reimburses much lower than testing done at a lab with a facility fee and everything, they weren't allowed to do that kind of testing in the office. And then when the result comes back later that night or the next day, I or my nurse would have to try to get the patient on the phone, try to explain the results over the phone, which was one more work but also suboptimal care. And so that would be an example of, I think that the practicing physicians, if they were the ones making the decisions, you know, they would say it is better to have the financial, less financial income for this but it makes our lives, makes the patient's lives better. And they may be doing in-house testing now. I don't know, but I was very frustrated not being able to do rapid testing like that. It must be frustrating for patients at times. Yeah. Another example was anti-coagulation, you know, monitoring how people who are on blood thinners and being able to have that answer right away, look at them, say what, we're going to adjust change, make sure they understand, make sure they leave with the changes highlighted and then it's just much safer, and makes for less phone calls unless you work afterwards. In terms of, let's say, making decisions for your practice, I guess as an autonomous practice, you and your partners can sit down and if you want to change the direction of your practice or something you're doing, you can make that change. Now, if you were, let's say at a University of Vermont practice, that would, I assume, would have to go up through multiple chains of decision making. Right. There are really good doctors and nurses at University of Vermont and... I agree. But I think that, you know, an example recently, we were redoing our paperwork for new patients and the people who should be deciding on that paperwork are the people who are seeing new patients, not me, because I haven't seen many new patients in many years. Our partnership is designed so that if someone is no longer seeing patients at least three days a week, they're no longer a partner. Because the idea is that if you're not, if you're not doing it three days a week, you don't, you're out of touch. You don't really know the implications of a few extra clicks or not being able to do this test or that. And I think that that is having decisions made by people in the trenches really makes a difference. Yeah. You see that in a lot of, you see that in the military as well, that sometimes the more chains of command you have, the further people are away from the actual situation that sometimes decisions are made very differently. Let's talk about mental health. You mentioned that patients seem more complex at this point. They're coming in with more problems. We hear a lot about the fact that primary care providers are having to take care of a lot of mental health issues that perhaps they weren't in the past. I'm not sure if that's true or not, but at least we're talking about it now. What has been your experience? Mental health is a huge part of my practice. And I think most primary care practices, the dearth of mental health referral options is just frightening. Having a patient from an inpatient psychiatric stay, not have any psychiatric follow-up, and that falls upon the primary care to do that. We're working with a couple local psychiatrists to work on collaborative care with them, and that's certainly great, and it's certainly better than nothing, but it's a real problem in our society that we don't have... Well, I guess unfortunately we're getting that in other specialties too. When the specialist can't see a patient for a year, it's kind of like not having a specialist. Yeah, just about. Now there's something called a medical home. People hear that term. What is medical home? A medical home was a political term that was rolled out, but the idea behind it is to have a place where the patient can get all their medical needs met. And so we've been officially certified as a medical home for 12 years, but I think rather than focusing on what that certification means and all the documentary hoops that you have to jump through to get that, just to focus on what does it mean? One of the things that we've strived for and are working to really re-establish is if a patient's sick today, they should be able to be seen today. And if a patient has various medical concerns, they should be able to be taken care of at their medical home rather than being farmed out to all different other entities. So medical home might include behavioral health? Right, we have behavioral health, we have sports medicine, we have various people that, among our primary care who specialize in different aspects, you know, if I have a women's health particularly complex issue, I might go to a colleague and say, could you do this? I no longer... Does your practice a medical home? Yes. Sounds like one-stop shopping to some extent. For most things, you know, certainly we need to have a specialist and that we can coordinate care with and having specialists who can get our patients. It's invaluable to me as a primary care physician to have a cardiologist that I can fax an EKG to and say, can you just look at this? It seems a little off. That is immeasurably valuable to me for my peace of mind but also for the patient rather than have the default send them to the ER. And so it does take a community even outside of our walls to provide that. How long have you been a medical home at Evergreen? Whenever that...it's got to be 2008 or somewhere when that certification came out. And when people come in, does it ever seem scattered to them or do they know that, for example, if you're their doctor that you're the one sort of quarterbacking the care? I don't think any of us are perfect. And so I think that what we strive to do is when one of my patients needs to be seen that they see me, if I am out or unavailable then they would see one of the other three people on my pod team. And for the patients with complex medical issues we get to know each other's patients who are very complex and at least it's not like walking in brand new. And then we can talk about the patient and not just have a note go back but say, oh, I saw Mr. Smith yesterday or I'm here today, I could come back tomorrow and my colleague could tell me, oh, I saw Mr. Jones and his wound looked really bad when you see him back on Friday, check that. And there's real value in that. Keeping it tighter knit like that. A team. While we're on team. Well, just a couple of minutes we have left. Are you still continuing to teach students? We have students that rotate through and what we generally do is we share them amongst ourselves and kind of having a student takes time and we're all rushing to see our patients and we can't. Before we started today you told me that sometimes and we, by the way in our last show we had two wonderful fourth year medical students who were getting ready to graduate and I was certainly encouraged to see and hear them but you've said that sometimes you see these young people and they give you hope. Why is that? Oh, I think that if we focus too intellectual on all of our problems, we forget the problems of the past that have already been solved and when I have medical students or nurse practitioner students or PA students come through the office, they're coming in with optimism, hope and energy and enthusiasm and we can get things better with that and that's having students keeps us sharp. You never know something as well as you know when you teach it and it also keeps us optimistic and reminds us what a privilege it is to be part of people's lives. Our patients let us into their lives and while that can be overwhelming at times it's also incredibly rewarding and really honoring to be... Well circling back to what we started with which is why you went into primary care when you talk to these students if they ask you, obviously they're trying to make their own decisions about what kind of residencies to do. What do you tell them about primary care today as you look at the changes that we've talked about in the future? Well, what I tell students is that they really should pursue their passion. You know, primary care is currently not reimbursed the way it should be, it's currently very hard but every medical student who comes out of medical school and is working hard is going to do well and in the big picture whether they get their student loans paid off in 15 years or in 30 years matters less than that they're having a rewarding life day to day week to week, month to month and so the financials are real but I really encourage them to pursue their passion and what's going to be fulfilling for them in the long term. I totally agree and that's some of the other things we've talked about in terms of making electronic medical records more user friendly for both the patients and the providers and improving communication between physicians making it feel like more of a community they're joining not just an isolated pod would be helpful and allowing them the chance to have some work-life balance which I think unfortunately and particularly in primary care has been going the wrong way. So I think all of those are things we need to work on but I'm encouraged, I'm glad to have you here I'm encouraged to see there's still some independent practices as well in the Burlington area and perhaps we'll have you on again in the future. Thanks so much for having me. Thank you and I want to tell our listeners if you have any questions or comments about this program or any suggestions for upcoming programs please get in touch with our station here and their information will be on the screen. Thank you and goodbye.