Rooting for Routine - Annals of Internal Medicine: Fresh Look Blog


Wednesday, January 31, 2018

Rooting for Routine

“You got this, Rono!” I screamed at the top of my lungs. My friend, confused, asked how I’d met the elite runner who was maintaining a top-10 place in the Houston marathon with 2 miles left to go. “Oh, I don’t know him. I don’t know any of them.”

Six of us had gone to the race to cheer on a bunch of strangers. We arrived at the 10-mile mark of the half-marathon just before the first runners. We had met up to stroll, spectate, and sip coffee leisurely in pajamas. However, as the first runner came flying down the street, I jumped up and started to holler. (My Southern upbringing has endowed me with many skills, of which hollering is one I am most proud.)

Within 5 minutes, I was deep in the throes of a coach’s high. I have never run anything close to one of these races, but I had volunteered at 2 of them before, handing out water and encouraging runners to “Stay strong!” and “Stay steady!” With a grin as wide as the elite runners’ lead on the main pack, I joked with my friends that I was made for this.

Jokes aside, I also realized that this was a great illustration of what I do for a living. As a primary care physician, I often assume the role of a coach. I coach in the clinic, on the phone, and sometimes even in letters to patients (“Your sugar number is higher than it was last time we checked. I know it’s tough over the holidays. But we really need to get that number down because high sugars can hurt your eyes, kidneys, nerves, and sometimes even your heart. It sounds like you don’t want to go on insulin, and I’m OK with that. But only if we get that number down. And I think you can do it. You got this.”) Yes, I write letters that say, “You got this,” because I mean it.

The value of coaching patients consistently over time to achieve incremental successes—described by Atul Gawande in a New Yorker article as “incrementalism”—is well-known among physicians. Yet, although the engine for this incremental change is the patient–provider relationship, the medical community finds itself engaged in active debate about the utility of the routine visit.

A 2016 commentary in Annals of Internal Medicine addressed this issue, noting that those who argue against routine visits belive there are no data demonstrating positive effects on morbidity or mortality (1). Although thoughtful and reasoned, these views seem blind to the fact that such measures as morbidity and mortality do not fully capture the benefits of the patient–provider relationship. In addition, given the incremental success that often defines primary care, the payoff from relationships built between patients and their physicians often isn’t seen for years.

Eventually, my friends and I walked toward the marathon finish line, where my primary care instincts were piqued again as I identified several runners about to pass out. I started to holler, “Take your time!", "Take a break!", "Slow and steady!”, or sometimes even, “Grab some water!” Eventually, the crowd of runners got so thick I couldn’t distinguish those in danger of passing out from the rest of the pack. “Wow,” I said to myself, “This really is like primary care.” If my patient panel is bigger or sicker than I can manage, I can’t see which ones are in danger zones. The burden of care often falls on the patients. The premise of orders like “return to clinic in twelve months or prn” is that my patients will let me know if they need me. Or will they?

For most, the task of finishing a marathon is achieved in part by incremental support provided by co-runners and friends who help manage your pace, encourage you up even the small hills, ensure you get enough water, and counsel and catch you before you fall. This is what the routine visit affords many patients. At those visits, I am able to coach my patients in ways that are personalized, specific, and incremental. I am able to tell them that, like coaches and encouragers at a marathon, I am there to support them. That’s me. Your primary care doc. We got this.

  1. Himmelstein DU, Phillips RS. Should we abandon routine visits? There is little evidence for or against. Ann Intern Med. 2016;164:498-9. doi:10.7326/M15-2097


  1. Great opinion piece Dr. Chandler. I'm a mostly retired Endocrinologist so I know the concept of incrementalism very well whether with my patients with obesity, diabetes, dyslipidemia, etc. The problem in this day and age of rush them thru the office to see as many pts as you can is why, in part, I retired. This rush, rush, rush does not breed the necessary relationship you describe and what pts want and NEED. So I commend you for holding up the ideal of personal medicine, person to person, one at a time. Thank you for showing that there still are some compassionate physicians still out there, people I would classify as REAL DOCTORS.

    1. Thank you, Dr. Ettinger! The rush you describe is pervasive and does indeed drive many excellent physicians like yourself from the clinical world. However, I do think as long as some of us, who still have the energy, can keep the dream alive while we sort out the changes that will sustain it, we may be able to continue to serve our patients with the care they (and we!) deserve.


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