Disability and Progress-June 19, 2025 - Do you need a Primary Doctor?

[00:00:00] Speaker A: KPI.org. [00:00:57] Speaker B: And greetings and thank you for joining Disability in Progress, where we bring you insights into ideas about and discussions on disability topics. My name is Sam. I'm the host of this show. Thanks so much for tuning in. Charlene Dahl is my research PR person. Hello, Charlene. [00:01:12] Speaker A: Hello, everybody. [00:01:13] Speaker B: On this grand summer day, at least in Minnesota. Erin is my podcaster. Thank you as always, Erin. And I want to remind those listeners I appreciate you. And if you want to be on the email list, you can email me at disabilityandprogressamjasmond.com let me know what you'd like to hear and different topics you'd like me to cover. Tonight we are covering primary care. We have Dr. John Hallberg. Hello, Dr. Halberg. [00:01:45] Speaker A: Hi, Sam. Thank you so much for having me here. [00:01:47] Speaker B: Dr. Hallberg is joining us to talk about primary care. Do you really need a doctor, A primary doctor anyway? Yes. So can you start out by giving me. I know you've done a lot of things, a little bit of your history and how you got to the path you're on today. [00:02:06] Speaker A: Sure. So I'm a Minnesota kid. I was born in New Ulm. I had a chance to live overseas at one point in my life when I was a young person, but I've spent the rest of my life in Minnesota. I went to college here. I went to med school here. I did my residency just up the street. It was called Smiley's. Original location was right on Riverside Avenue. And then we moved over to Franklin Avenue for the duration of my training and now it's over on Hiawatha. When I finished my family medicine residency, I practiced in downtown for five years at a Fairview clinic. And then in 2000, that closed. And then I found myself over at the university. So I have kind of risen the ranks over the years. I'm now a professor of family medicine and community health. But my main identity is that I'm a family physician. I'm a primary care physician and I have about a thousand people in my practice panel. My youngest patient is 3 years old and my oldest is 102. So I love the fact that I have exactly. I have almost 100 years of the human condition that I get the privilege of seeing and taking care of and being part of. [00:03:13] Speaker B: I love that. That is so that's such a vast amount of knowledge you have to carry for each person. I'm wondering if you could talk about what does exactly a primary care doctor do and how they are different from specialists. [00:03:28] Speaker A: Yeah, let's start there. So I think that when you think about primary care, I mean, it's not exactly the same as being a generalist, but if you're a family physician, that is really true. You know, we often say that we're a jack of all trades, master of none, but I think we're really, really good at taking care of the human condition. Reading a room, reading people, understanding what makes them tick, their context, their community in which they live, their wants and desires. And so a primary care, we are the opposite then of a specialist. And I think of specialists, a nephrologist, for example, they take care of the kidneys. Exactly. Neurologists, the brain and nerves, cardiologists, the heart. You can even be more, you know, not just a GI specialist, but you could be a hepatologist, you could study just the liver. So, you know, and I kind of think like they're, they're not PhDs necessarily, but it's kind of a way of thinking about that. Like they've really gone deep. They really understand everything about the heart. Or even within cardiology, there's like electrophysiology, cardiologists, they just really focus on the, the electrical activity of the heart. So it gets really, really specialized. I'm the opposite. My colleagues in primary care, we are, I often say it's kind of the liberal arts approach to medicine. Like, we just sort of, we, it's, it's a life is an open book and we're, we're looking at things very largely and holistically. But at the same time, I, I need to know about the heart and I need to know about the kidneys and everything. So it's a, it's tough job. I mean, there's a lot to know and I know what my limits are. But yeah, I think, you know, generalist versus specialist, big, big picture, very small picture. And then primary care is also like, it should be where people start. You know, almost regardless of what your condition is, you should start with a primary care physician, a clinician. And I'm very careful about saying that, by the way. We'll talk, I think we'll talk about the difference between a physician and a PA or an mp. [00:05:28] Speaker B: Yep, yep. And so your idea is that somebody should have a consistent primary care provider. Why do you feel that is so important for long term health? [00:05:38] Speaker A: Yeah, I mean, I think anyone who's listening can probably say to themselves, like, well, you know, I've gone in to see somebody. I always feel like I have to start over. I have to tell my whole story every time. They don't know who I am, right? And it's not going to be cold, but I think it's not going to be like you're, you know, I mean, honestly, I've been doing this for 30. This is my 30th year of doing this. And some people I've known literally 30 years and some since literally they were born, you know, so now I have like 30 year olds who I've known since they were 2 weeks old, right? And we just pick up where we left off. You know, it's like, how are you doing? Oh, my gosh. I just saw a young man yesterday. He's 15, he's a high school freshman, and I haven't known him since he was two weeks old. And, you know, he talked about his soccer playing and is he on, you know, what's he doing this summer? What's the class that he likes the most? And it's just so fun because it's just like we. I know his family, I know what makes him tick. I've watched him grow up and just multiply that a thousand times. In my case, it's just a great privilege on my side. On the patient side, I think it's just, you know, that whole piece, like someone knows me. And I always think of this too. Let's say that we're sick, or let's say we go to the emergency room and anyone who's been in the er, they always say, well, I want you to follow up in one week with your primary care physician. And if you don't have somebody, how do you get your medication refilled? Or how do you have somebody help you interpret what that X ray showed? Or, you know, because let's face it, being hospitalized, having surgery, being in the er, those can be really scary situations. And I think that we in primary care, in a way, are like a guide. Not a guide through life, but kind of a guide to be at your side through life and help put things in context, help explain things. I can't tell you how many times people will say, like, oh, I'm so glad that I saw you. You put my mind at ease. I'm glad that, you know, we've got a plan. That's a big part of it, too, like just being rudderless, not having a plan, not having a direction. Right, we can help with that. [00:07:39] Speaker B: So let's talk about that. I wonder, you know, there's physician assistants or PAs, and I think that there's other generalists too. So what is the difference between them and you? And should we expect them to be as knowledgeable all across the board. [00:08:01] Speaker A: So let's start with pas. First of all, we talk about this term apps a lot, and that's advanced practice providers. So that can include PAs, physician assistants, but also NPs, nurses, practitioners. And that's kind of evolving quite literally as we speak, into DNP programs, which is a doctor of nursing practice. And the University of Minnesota has one of the largest programs of its kind in the country. So in historically we've said, well, these are physician extenders. And that's not really the way to think about it. I think that many. And I worked with, in fact, the clinic I'm working in now, we opened with a PA and an NP and me. And so it was like we were the three clinicians that opened that. A very holistic kind of way of doing it. So I look at it as not competition, it's complementariness. And I think the reality is that in primary care there have been fewer people going into family medicine, general internal medicine, general pediatrics. So we need other to help fill the gap. [00:09:03] Speaker B: And why do you think that is? [00:09:04] Speaker A: Well, okay, I mean, this is always embarrassing to say this, but medical school in the United States, you have to pay for it. So you pay up front. People are hundreds of thousands of dollars in debt just for the privileges that were to go to medical school, you have to pay that debt back. And the reality is in medicine, there's a hierarchy. If you want to become an orthopedic surgeon, an ophthalmologist, dermatologist, some of these, you know, you do stuff, you do procedures, you're paid much, much more than a primary care physician. So even though we do the most, in a way, like we do everything to some extent, right, we're at the bottom along with the psychiatrists. And so there's just that fact, and I hate to even bring that up, but it's true, there's that element of it. I also think that, you know, for example, people are probably watching Pitt on TV or watching these shows in er. It's exciting, it's dramatic. When you're done with your shift, you're done with your shift, you can go home, you can go to your family, you can kind of turn off that part of your brain. You're done in primary care, it never stops. You're not done, you're never done. And I think about that as I'm approaching my 60th birthday. I've been doing this for 30 years. It's heavy. I mean, I don't wanna say it's a burden, but it's a lot because every time I see a patient, it generates follow up with lab results or X ray results. And then typically patients have questions about those. And we're going back and forth. And so when we're feeling a little overwhelmed, we kind of say like, oh, it feels kind of like whack a mole. Like every time you hit one, nothing pops up. Or, you know, Greek mythology is Sisyphean, right? We're rolling that thing up and at the end of the day it comes back down. We have to roll it up the next day and start all over again. So that's the negative approach to it. Again, the positives for me, you know, in the best of my days, it's like, wow, I get paid to listen to stories all day long. If I think of it that way, what a privilege that is. So, you know, we have good days, we have bad days. But back to so PAs, historically would be a college graduate. They go to school for two years. And by the way, the origin of the PA program is fascinating. It started because of medics in Vietnam being really, really good at what they were doing. They really were good in the field saving people's lives. They had all this medical training, but what do you do with it? So they actually created the physician assistant program. And I believe it was either Yale or Duke that started. Those are the first two programs in the country that started it as a pathway then to becoming like sort of an actual licensed healer, you know, a caregiver, nurse practitioners evolved out of being an rn, you know, more advanced training, nurse midwives are, you know, one path you can go, you can become a certified nurse, anesthetist, another pathway. Others will be like family nurse practitioners. And so it's a different kind of training. Medical school historically was four years of college, four years of medical school. Historically, the first two years of medical school are like basic sciences. I always joke that the first full year is. It's like learning a foreign language. You're doing anatomy, you're doing histology, biochemistry. I think of like legos. Like you're learning all the pieces, all the parts, how it all fits together and how it all functions essentially normally, how drugs work. And then second year of med school, which is kind of overwhelming. And it was overwhelming for me as a young, what was I, 23, 24 years old at the time. You start to learn every single thing that can go wrong with every single part of the body. And so it's, it's like a lot. And many of us you know, get anxiety, get some depression, get overwhelmed. So that's a lot. And then you spend the next two years becoming like, you kind of getting more comfortable with, okay, this is my OB rotation. I'm going to learn how to deliver babies. This is my surgery rotation. I'm going to learn how to scrub in and assist in surgery. This is my pediatric rotation. I'm taking care of sick kids. And so we rotate through different specialties. Psychiatry, neurology, family medicine. And then your fourth year of med school is like, now you're kind of honing in a little bit more on what you think you want to become. Then you've got three years at least of a residency, three years to five years to seven years. So it's a totality and depth of training. PAs, it's two years, and now it's really turning into three years. DMP programs vary. Some of that work is done online. So it just, it depends on what you're doing, how you're going about it. But I think that in my own experience, when I've worked with PAs and MPs, I mean, we're colleagues. I mean, we're there together doing very similar things. I think a lot of times if you're in a clinic and you've got a physician and MPs and PAs, a lot of times a physician will be the medical director of the clinic. They'll be doing some leadership kind of stuff, helping to kind of guide the ship, as it were. But knowing that we just have other people that are kind of ultimately providing the same sort of care. We just have different titles. [00:13:58] Speaker B: You know, since we're on this, I'm going to ask you this now because I feel like I've observed different doctors and some just a few PAs, and I never feel like people are necessarily created equally. And when I say that, I feel like there are some that I feel put so much more time into knowing the vast. Because I realize you guys have to know a lot about a lot about a lot, a little about a lot. It's like. But you have to know enough that you know, I think, where your limits are and when you need to tell the person to go for something else. Right? [00:14:38] Speaker A: That's right. [00:14:39] Speaker B: So. But I feel like there are some that just aren't as top rated. I'm wondering, like, do you have expectations like CEUs you have are required to do? Are they required? Do you just choose to do them? Are there levels that you are required to keep up with? [00:15:00] Speaker A: Absolutely. So I, in fact, I just got an email Before I came over here today saying that I'm on this five year cycle with my accreditation and honestly, I have to be not just board eligible, but board certified in order for insurance plans to cover me. So I have high incentive. I can't practice without that certification. So I sit for a BIG exam every 10 years. We have to do at least 50 CEUs, or we call them CME credits, Continuing Medical education credits every year. But I think what you're getting at is maybe less about. I mean, because honestly, I think that almost every physician or NP or PA that you'll encounter, they're like technically competent, right? That we've all passed our exams, we all have certain level of smart. And I think that that's taken for granted. What I think it's really where it really comes down to where the changes are. It's personality and it's. How do I say this? I mean, I think it's like love of what you do. And I mean, I know I was drawn to family medicine, primary care, because I'm really interested in people. I'm interested in their stories, I'm interested in what makes them tick. And I hope that that comes through when I'm in a patient visit, even if it's for a sore throat or a urinary tract infection, I just have to take a couple minutes just to kind of get to know somebody a little bit. But not everybody has that degree of curiosity. Not everyone really frankly cares. You know, they just want to kind of get through the day. It's a little bit more of a job than a calling. I mean, it's always a calling, but I just think that. And then we're people too. And so I think that sometimes, you know, let's face it, we have bad days, we have good days. People are going through stuff. It's the classic story of like, you never want to assume anything because you don't know what's happening in that person's life, you know, behind the scenes. [00:16:44] Speaker B: Right. [00:16:44] Speaker A: But that does get a professionalism though. And I do instill this when I have medical students with me. It's like, look, if I don't, you know, not that I don't care that you're having a crappy day, but you've got a job to do. You've got to take care of these people who are scared and they're sick and they want reassurance. And when we knock on that door, it's like curtain up. I mean, it's not that we have to act, but you just have to you have to be professional about it. And if it's, if whatever's going on in your life is so affecting you that you cannot do that, then you need to take a leave, you need to back out and get some help yourself. Because it's just so critically important that we have an on day, that we have to be there, present, listening fully there. [00:17:28] Speaker B: You talk about patients having needs and being scared or maybe they're coming in for something that's difficult. And sometimes you have to coordinate with other specialists. How do you do that and to make sure that that goes well across the board. [00:17:46] Speaker A: Yeah. So I kind of look at my life and career almost in two parts. So when I was in training residency for three years and then when I was in my first five years of practice, that was all in the 90s up to about 2000, we would kind of do it all. I would round to the hospital in the morning, rub shoulders with my specialty colleagues, go through the quote unquote doctor's lounge, say hi to a few people, then head to clinic, see patients, and then I might come back to the hospital and see somebody that got admitted and write some orders. There was a very hands on kind of approach at that point. Like you had your friends, I mean, my friend the infectious disease specialist, my friend the cardiologist, my friend the surgeon. And so it was very collegial, very, not chummy, but very small town in a way. And I think that my colleagues who practice in the, you know, greater Minnesota, rural America, a lot of the smaller hospitals are probably still like that, the bigger hospitals. Well, what's happened is that we've, we've shifted now so that we have hospitalists, so we have like, like I don't go to the hospital to see my patients anymore. Like, I turn them over, they go through the emergency room, they're admitted to the hospital. There's a team, a wonderful team, really skilled team, but they don't know who this person is generally unless they are there all the time in a more commonplace way, like in the outpatient settings. That's where I live. If I've got somebody in the clinic who has high blood pressure, they're on three medications, four medications. I can't seem to get their blood pressure down. I know when it's time to call on the specialists and so I will place a referral. I mean, it's a little, it seems a little anonymous sometimes, but I just write it in the electronic medical record. I will give the patient the number to call if they haven't heard from the people. But as a primary care physician who's been doing this for a long time, who's grown up in this area, I have all my favorites. I have all my favorite specialists. And I do like to think that there's sort of an art to a good referral. And if I have the opportunity, I'll say, okay, you have a hernia. I want you to see Dr. Grandja, for example, because he's my favorite, favorite general surgeon. I know he's going to take good care of you. Or if you need a knee done or a hip done, I've got my specialist there, my favorite electrophysiology cardiologist. So I would bet that all of my primary care colleagues have that sort of bench, that lineup, to use the sports term. You know, they kind of know who they like to refer to. [00:20:11] Speaker B: Yeah. [00:20:11] Speaker A: And then part of our job as a generalist, too, is to. I always think part of the art of a good referral is to have, like, look, I know they're going to want to have that test done. Why don't I go ahead and order that? So when you go to that visit, it's all there. They have all the information. They've got the lab results, they have the imaging studies. They can see everything. They can weigh in. They can make a really good, informed decision, rather than, I'm just going to send you this person, and then they have to order a bunch of stuff. Then you have to go back. It just drags it out. [00:20:38] Speaker B: Right. [00:20:39] Speaker A: So I think that it's incumbent upon us as primary care physicians to be. And I don't like people often refer to us as the quarterback or the captain of the ship. That's too big. I don't think the metaphor quite works, but there is something about that. I am there to be the patient advocate to help guide them through, and often this is scary. We saw something on your mammogram. We saw something on your CT scan. I need you to see this person or see this oncologist. But we are the home or the safe harbor for people to come back to. [00:21:11] Speaker B: And I do feel like. I know it's really hard. I mean, I've been in a position where I've had to do this, where I got referred to somebody, and I just. They rubbed me the wrong way, so to speak. It's just. I don't. It was either bad bedside manner or bad communication with me as a person with a disability. And I was like, whoa, I don't ever want to. So if. If you have it in you, I Just want to say, because I think sometimes it can be so exhausting. It's difficult to reach outside and do this. But if you have it in you mentally seek a second opinion. Like I don't ever try. I feel like I don't ever trust the first. I nod my head at the first referral that, you know, a doctor might give me but then I say, okay, I want some other ones because I'd like to do, you know, research them if you can and, and see who's out there because sometimes somebody might do procedure X and the other one won't. So there is a difference, right? [00:22:21] Speaker A: Oh, absolutely. And I, you know, just, and I'll go back to primary care too. I mean if you, if someone's establishing with a clinic and it's like, oh my gosh, I did not hit it off with that person. Well don't, you don't have to stick with that person. I mean there's other options within the clinic or of course there's other clinics to go to because I think that's, and that's maybe. And personally I think that's even more important is to have a really good relationship with a primary care provider provider because that's long lasting, that's like, you know, potentially years in the, in the making. But I agree with you, if you feel like you've seen a specialist and you do not click that you need a second opinion. Absolutely. [00:22:54] Speaker B: Dr. Halberg, I want to touch on something you said because I mean I actually am sort of at that, that crossroads personally. I will say I had a doctor and it was not, it was a different PA and I just felt like they either, either they weren't kept keeping up or they were always kind of bored of me or whatever. You know what I mean? There's just this feeling of oh, they didn't take me serious with my, when I was telling them something I didn't feel heard, the list goes on and I felt like I need somebody different. It just wasn't gelling anymore. And I'm sure things changed in their lives too. But so I go back to how do you find what's going to match you? Sometimes I've gone into a doctor and feel like where they will totally miss the whole how to deal with somebody with a disability. Depending on the disability you have, it really is, I think a dance that you have to do between doctor and patient. So what would your thoughts be on the best way for somebody with or without a disability? Because just because you don't have a disability doesn't mean that you don't have special emotional needs of something you want to have in a doctor in regards to, like, somebody with really good bedside manner. That's not a given, by the way. So give me some ideas. [00:24:38] Speaker A: Well, I would say the absolute first thing I think of is if you're lucky enough with family and friends, you know, like, who do they see? Because, like, for example, our clinic, we basically don't do any advertising, and we're seeing, you know, a bunch of new people every single month, and almost every single new patient we see, there's a connection. You know, they've heard from somebody that it's a good clinic or that my mom comes here or my brother comes here or my neighbor comes here. And I think that that counts for a lot. And, but. And so maybe a corollary to that, I would encourage people not to rely too much on what they see online, because, let's face it. [00:25:15] Speaker B: Yeah, I was wondering about that. I was like, okay, did you just have all your relatives fill this out? [00:25:20] Speaker A: Well. Or the opposite, you know, like a terrible Yelp review or something, you know, because you sort of figure that the people are going to go online. They're the extremes, right? They're like the people that had a horrible experience. [00:25:32] Speaker B: Absolutely loud. [00:25:33] Speaker A: Exactly. So I think that, I mean, that can be a helpful place to start. You know, the Minneapolis St. Paul magazine just came out. There's a Time Top Doctors thing. I'm just here to tell everyone that if you're listed, it's wonderful. It's an honor. It is, quite honestly, a bit of a popularity contest. It's not a sign of truly who. Especially in the primary care world, there's hundreds and hundreds of people who are wonderful clinicians that are not listed. And so I think that not relying too much on that, not relying too much on the surveys and reports online, but. But thinking about who you've heard from, who you trust, and then they'll say, oh, my gosh, this person was wonderful. They were patient and kind and accommodating and smart and insightful. I mean, maybe that sounds like a unicorn clinician, but people like that are out there. And so I would encourage that. And then part of it, let's be quite honestly that some people have. Getting to a clinic is difficult just through transportation. So it has to be on a bus line, or it has to be on a light rail, or it has to be something that is a bit more accessible, and people don't have time to go too far out of their way to find a Clinic. So looking around, you know, where. Where do you live? You know, what are the clinics? What have you heard? It's. I liked your way of putting it, though. It's like a dance. It's choreography. There's a little bit of a courting, as it were, that goes on. You know, that. Just trying to, like, oh, that didn't work. Let's, you know, it's not speed dating, but there can be a little bit of that at times. Like just trying to land and get the right person. So you don't have a perfect answer for that. But I do think listening to family and friends is right at the top of my list. [00:27:12] Speaker B: I'm going to touch on one more thing with this, and then I'll move on. But I do feel, I guess I wonder. Somebody gave me this idea. Call the clinic, explain. Get a nurse to call you back and explain to the nurse what you want. This is what I need from a doctor who, you know, I need a doctor who really listens, who is really attuned to people with disability issues. Are they attuned enough to do that? To separate that out? [00:27:47] Speaker A: Sure. I mean, I think of our clinic, for example. We have three triage nurses. They know us really, really well. And if someone like you were to call a clinic and say, like, hey, I had a. I'll be honest, I had a not great experience with, with so and so. But here's kind of what I need. Could you make a recommendation of who might be a better fit for me or who might kind of fit that description? They would give it to you. They'd be honest. They would share that with you for sure. [00:28:14] Speaker B: The only thing that is sad to me is that, you know, and I realize there's complexities with this, but once you've seen your doctor for your annual visit, let's say it didn't go well, for whatever reason, you know, insurance only covers so much. So then you gotta wait till whenever to go to the next doctor. So that. That does get tricky. But. [00:28:34] Speaker A: Well, let me. Let me add to that. So that's a. I'm really glad you brought this up because I find that. So I'll see patients and they're coming in for their annual wellness visit, preventive care visit, checkup, physical exam. We kind of use the same terms that mean the same thing. And, yeah, we all have health insurance that pays for one annual wellness visit that's typically free. There's no copay or anything like that. But I think that people make the mistake of thinking they can only see Their doctor like once a year. And what I encourage people, because what they'll do is they'll come in and then technically speaking, if they have three or four things to talk about that are new concerns, we have to do what's called split billing, which means that we end up like having to do almost like two visits in one, and then the patient's responsible for paying for part of the other one. So I encourage people like, you don't have to wait a year to come back. Just come back with other concerns as they come up. Or, you know, if there's two or three things you want to talk about. Yeah, there might be that copay. And I don't mean to downplay this, but typically it's in the 25 to $50 range, but it's worth it because I think that that sometimes when people sense an irritation from their primary care. [00:29:38] Speaker B: Clinician, they don't talk about the other stuff. [00:29:40] Speaker A: Well, right. They'll say, oh, I'm sorry, I can't talk about that today. And then as a patient, you're going like, wait, what? Like, I've been saving up these things for nine months and now we can't talk about them. So it's very off putting. And I think we do a terrible job of explaining that. I will tell you that even though I'm the medical director of my clinic and I should know better, I always deal with everything just because this is who I am. It's how I deal with things. But I probably should do a better job of parsing these things out. But it's just, it becomes like, contractual. And that's the part of healthcare I hate is the billing and all of that. And I will be honest, I think that gets in the way sometimes of good care, good, honest conversations. We have people who come to our clinic from 300 zip codes. So some people have like, I'll even ask them, I'll say, like, can you remind me, like, where did you drive in from today? And they'll say, oh, I drove in from Elk river or Hudson, Wisconsin. And it's like, okay, let's try and do that cortisone shot today in your knee. I don't want you driving back here just for that, you know, So I try and accommodate, and I know a lot of people do, but I do think that that leads to some of that tension that people feel is like, if we save up all our concerns for one visit and the clinician has to go through a whole checklist of wellness stuff, you know, and like, you just can't get it all done in 20 minutes or 30 minutes or 40 minutes even sometimes. So I think that's sometimes part of the problem. [00:30:55] Speaker B: So what kind of preventative screenings or tests should a person kind of be aware of and ask for, regardless of their ability? [00:31:06] Speaker A: Sure. So, yeah, I think that all humans, regardless of ability, disability, gender, there are, as we age, certain things that are kind of expected. And I think these days, just so everyone knows, I mean, we clinicians pretty much know what they are. When adults hit 45, we now talk about colon cancer screening. Regardless of anything we should, that's when we start. We don't have to do it every visit, but every so often. We want to check glucose for diabetes, we want to check cholesterol. Men, it's a conversation about, when do you get prostate cancer screening? For women, it's mammograms, Pap smears, all these things. So the good news is that patients don't really need to worry about that because all of us now are on these electronic records, and when we pull them up, there's a list of all the to dos. I mean, it's right there. They call them care gaps. And so it's like, oh, this age and this gender. Like, let's. We need to do these things. Or I recommend that we do these things. We always talk about immunizations, like, which ones might be due. Everyone knows, like, kids, you know, it's lots of potential shots in their early on, but it just. [00:32:13] Speaker B: One would hope. [00:32:14] Speaker A: One would hope. But, you know, yeah, again, that's a conversation we have, and that's part of our job is to talk about that and why this is important to get. But in children, it's really about growth and development. Like, are they mentally developing as expected? Are they growing physically as we expect? We watch for those things really, really carefully. That's why kids come in so often when they're in the first two years of life. As we get older, it's, you know, we start asking things like, are you falling? Have you tripped? How's your memory? How's your hearing? What's your vision? Like, there's just lots of things. So good news is, I don't know that patients really need to worry about that because that's our job. And we kind of know when people come in for that preventive visit, what they need to do. And I take. I just will say this as an aside. Most people in healthcare, we're all a little bit obsessive compulsive. I mean, like, we're, you know, not diagnosed. But we're all a little bit on that spec because we really like to. We check off boxes, we have checklists, we are very careful. That's a good thing, you know, so that I think patients should realize that, yeah, we're kind of detail oriented folks and we will make sure that they get everything done that they need to get done. [00:33:22] Speaker B: I want to ask a question. [00:33:25] Speaker A: How do you feel about the. A lot of organizations are using my charts now. How do you feel about that? So as we speak, I think I have 16 messages waiting for me that I need to respond to tonight or tomorrow. And I am using all these Greek metaphors, but I kind of feel like I'm atlas. I have the weight of the world on my back sometimes because again, it just always. I'm never caught up. I'm never done. [00:33:57] Speaker B: Right. [00:33:58] Speaker A: Mycharts are a great communication tool because let's face it, a lot of times we can take care of things you don't have to come in for. You know, if someone has recurrent UTIs, urinary tract infections, and it's like, oh, I got another one, we can just treat it, you know, we don't have to go to urgent care. I use it, you know, every time I get a lab result, I'm sending a patient a message about, you know, putting that result in context. Any X ray, any imaging I'm doing, we send messages. Some of my patients, unfortunately, they probably think it's almost like instant messaging, which becomes a little much because it really should be like minimal correspondence just here. I want to share this information with you. Unless I say what do you think of that? Or would you be willing to start this medication? Not everything requires a response back, but it becomes a lot sometimes. So it's like the art of mark my chart. [00:34:50] Speaker B: Yeah, there needs to be some kind of cultural education in regards to that. But I realize that it's all different. I'm wondering, I'm sure it's changed since the 30 to 40 years that you went to med school, but you obviously have people who come in and that you are educating current doctors. Do you feel like the med school trains doctors on knowing how to address the needs of a patient with disabilities? Well enough. [00:35:31] Speaker A: Well, that's a good question. So I'm going to tell you something, and I know this for a fact, that the University of Minnesota Medical School has one of the highest percentages of its student body who identify as having a disability. Now that can be apparent and non apparent disabilities. And in the case of medical students, it's a lot of mental health issues, depression, anxiety, adhd, dyslexia, a number of things. So I think that there is, from the student body itself, a certain sensitivity and awareness that probably didn't exist when I started. I mean, the diversity of our classes increase. More women going to medicine, more people with disabilities, more people from all kinds of backgrounds, first generation students, so all kinds of things. So there's a diversity in the med schools now that never existed before. It's amazing. But as always, the med school curriculum is so crammed with. I mean, everybody wants a piece of it. And there's the pies. The pie isn't getting bigger. It's almost like the pie is getting smaller, but the pieces are being divided up into smaller pieces. And so to do sort of like disability education per se is tricky. But I will say that when we teach the medical students how to do an interview, how to do a physical exam, there is more attention paid to that. Like, how do we work with folks with disabilities, sensitivities, different cultural backgrounds? I mean, this is all part of the, part of the training. And, you know, is it great? Probably not. Is it better than it was when I was starting medical school in 1988? Absolutely. [00:37:21] Speaker B: How often should someone see their primary care physician if they're not sick and if they are, how does that change? [00:37:31] Speaker A: Yeah, when people are young, let's say I've got somebody in their 20s or 30s, they're totally healthy, they have no conditions, they're on no prescription medications. You know, we'll often say, like, hey, I don't need to see you every year. I can see every two years. Just for folks to know, though, that if we don't see somebody for three years, and this is almost a universal thing, a clinic doesn't consider that patient, an active patient anymore. So if they kind of disappear for a while and then they'll say, like, oh, I want to see Dr. Hallberg for my annual exam. It's like, oh, you haven't been here since 2020. They'll say, oh, no. And then they'll say, well, yeah, he's, you know, you're considered a new patient. Let's see if he can take you. I mean, just as an aside, of course I'll take that patient back. But people may have had that experience, like, look, I don't need to go in very often. And when I do, they say, I've got to be a new patient. So that's why. But I think on average, so if people have diabetes, for example, even if it's well controlled. We want to see that patient two times a year, once for a wellness visit and kind of weave into that some diabetic care, but six months later, a diabetic visit. [00:38:33] Speaker B: And does insurance cover those two times? [00:38:35] Speaker A: Oh, absolutely. In fact, it's expected. I mean, there's certain quality measures that we're measured on. And so for a diabetic, they should have an A1C level done for their sugars biannually. There are certain other things that should be done. But I would say that anyone who takes a medication, and let's say it's a stable medication, if it's an antidepressant, we generally want to see people back in two to four weeks to see how they're doing and then decide what the cadence is for follow up. But let's say people are like doing fine. They might have high blood pressure, might have high cholesterol. They just need a mammogram or colonoscopy or whatever they need once a year generally suffices for that. And then the door is open for when acute things come up, you know, things that are unforeseen. And, you know, we're all, as we say, like, you know, you're one infection or one accident away from life changing quite dramatically. [00:39:29] Speaker B: Right. [00:39:29] Speaker A: And so that's again, another reason to have a primary care home because, you know, you might be healthy, healthy, healthy, and all of a sudden you're not. And Susan Sontag many years ago wrote a book called Illness is Metaphor. And I always misquote the opening paragraph, but it's something to the effect that all human beings have two passports. We have a passport to the world of the well, and we have a passport to the world of the unwell. And sooner or later we will all use that other passport. [00:39:55] Speaker B: That's fascinating. I actually like that metaphor because I feel like that is so true. I wonder. There's a. I feel like a really touchy situation that can happen where, you know, I think we all either were good or not so good or bad at advocating for ourselves. But now I think there's become this whole tricky privacy stuff where let's say you have an older, like a teenager, 15, 16, 17 year old, there becomes this whole HIPAA thing. And if, if there's any mental illness or whatever, or any types of unstable, let's say it doesn't even have to be a diagnosed mental illness if there's any trouble with that. It gets hard to have the doctor communicate with the family when the teenager maybe doesn't want that or doesn't want the parent in the room. How do you maneuver around that? Because there are times I feel like the parents need to know what's going on. But then there's all that privacy stuff. So how does that work? [00:41:09] Speaker A: Well, the best scenario, the best case would be that let's say I, as a family physician, I take care of the parents, I take care of the children. I do make it very clear, for example, I've got a teenager and we're going to talk about sexual activity. And they don't want the parents in the room. I'll have them leave and we'll have that conversation. And typically, as long as no one's life is in danger, what we say in that room stays in that room. Right? We're not obligated to report anything. And frankly, we really can't. We have to have that trust. Now. It's tricky when it's a minor. When it's an adult, it's very clear cut, right? Like, there's just no way. Even, even if I'm taking care of two spouses, you know, like the two people are married to each other, living together, I have to be very careful about, like, oh, I can't say that, you know, they're not. [00:41:53] Speaker B: If there's an STI involved, well, that's. [00:41:56] Speaker A: A whole different thing. And so, yeah, so, I mean, but kind of with that, I mean, I think that what you. The ideal situation is that I know everybody so well that I'll talk to somebody and say, you know, it would be so helpful if I could, we could bring your mom back in the room or your dad back in the room and have them hear this because I think it's really important that they're part of this conversation. That would be great. But if they say no way, and you know, again, this is not a suicidal situation, it's not a homicidal situation. There's nothing being shared that that is to that degree, then we will honor that privacy. And it can be tricky because parents are like, but I want to know, like, what are they watching on their computer screen or what do they tell you? And it's like, well, I can't share that. It's tricky. And I mean, I'm a parent of, well, now two adults, but I've been a parent of teenagers and young people. And my perspective is different, of course, because I'm in the business and kind of know how that goes. But yeah, I know how frustrating that can be. But we have to, because again, like, we don't want to lose the trust of the minor. Right. And that's a big problem, is that if they feel like adults aren't listening, they're not going to honor my privacy. They're just telling my parents everything. Then we've lost their trust, and then they're going to lose their trust in healthcare. [00:43:20] Speaker B: I want to step back to something you started talking about a little bit, and that was trust. And I think sometimes patients can lose trust if an appointment didn't go well in many ways, or if a doctor was rude and maybe they were just responding to how they felt the patient was acting. So how do you. Do you ever. If you were to consult or tell doctors how to better establish trust with their patients or tell patients how to rebuild trust after a negative experience. You do, what would you say? [00:44:01] Speaker A: You know, I. I personally have very thin skin, so if I ever get. And then this has happened to me, I mean, I can tell you right now that there were things that I learned in my first two, three years of practice through, like, patient satisfaction surveys where I would read the. For example. Let's give you an example. I remember one time somebody said that I was very cursory in my examination. Like, they come in with a cold, and I probably listened to their lungs and just wanted to make sure it wasn't pneumonia, but they felt like the visit was too quick. And I have to tell you that ever since I read that, even if a person sees me for something that's obvious, that it's just a cold, I check their ears, I check the nose, I just look at the throat, I feel their neck, I listen to their lungs. It might be a little performative, but it's a match. The patient expected something to make sure that things are okay. And I'll even say, like, hey, your ears look great. Your sinuses aren't tender, your nose looks fine. Your throat, I'm not seeing big tonsils. They're not red. There's no pus. We can get a throat culture if you want, but I don't think it's necessary. Your lungs are clear. I'm not hearing pneumonia. That takes me, what, 15 seconds to say all of that, but it's, like, really reassuring. So I would say from a patient standpoint, number one, be honest. If you've had a bad visit and you're asked about the visit, say that it didn't go well because that will make it back to the clinician. And I will say that if a clinician has. And part of professionalism in medicine is self reflection. And if you get From a boss, from a colleague, from a nurse, from a patient. If people are saying something, we need to listen to that. And I hope we pivot and we try and become better. I mean, I've been doing this for a long time, but I know I can still be better. And I. And I really strive for that. But there are times too when I know every once in a while a nurse will say, like, okay, so and so is in the room. And I can tell they're really irritated, like they know this person like I do. And it's like, okay, I'm ready, because I kind of think I know what this is about. Or. [00:46:02] Speaker B: Yeah. [00:46:02] Speaker A: I remember once again, first five years of practice, I had a patient who kept insisting on something. I can't remember what it was. And in my note, I shouldn't have done this, but I was dictating my notes. And I, like, the patient simply doesn't seem to understand or doesn't seem to get it, or, you know, I'm going in circles or something. You know, I shouldn't have put that in the note. But he went to the Mayo Clinic for a second opinion and he made, he got copies of all of his notes that I had done. [00:46:26] Speaker B: Oops. [00:46:27] Speaker A: Yeah. And he came in and he was just, literally, his face was red. He was beet red. He put himself between me and the door, by the way, so I couldn't get out. And he went line by line with all the things he disagreed that I had written. But there again, that's like, that's what, 25 years ago or more. I still remember that. And I now know how careful I need to be with what I put in the patient chart for that reason, you know, like, just, I don't want to put disparaging things. It's no place for, you know. And by the way, too, I also said that he was at baseline when I saw him. He thought that I was implying that he was like, somehow not functioning normal. And at baseline means, like, you're just functioning at your normal level. That's all I meant. But he misinterpreted that. You know, there's some words we just, we can't get around. [00:47:11] Speaker B: So that's an interesting perspective because. Well, first of all, I just want to touch on the example that you gave to begin with about going through and maybe being, I would call it more thorough. I didn't see that as thin skinned. I saw that as you taking something and saying, how could I better that? But this, the example that you gave in regards to charting that is something I think that doctors do need to think about, like how they chart the things they write in their notes and what they put in their notes. How they say them sometimes can mean just everything. And also, I feel like maybe that could even make a difference in how other doctors see them. Right? [00:47:55] Speaker A: Oh, sure. [00:47:55] Speaker B: So that is an interesting thing that you bring up now, that it used to be that you guys just saw the notes. Now with. Everybody can see the notes, everyone gets. [00:48:07] Speaker A: To see them, let's say. What's funny, this is sort of a silly example, perhaps, but I've got. I know my patients really well. Some of my patients, most of my patients are absolutely wonderful human beings. They're lovely. Some are not. And then I'll refer somebody to a specialist, and so many of my specialists will say things like, like, dear John or dear Dr. Hallberg, thank you so much for referring this lovely patient to me. And it's like, don't use the word lovely. They're not lovely. You know, But I think they're doing it because they're trying to make me feel good about my patients. Like, look, I know they're tough as nails, and that was not an easy appointment. You don't have to make it sound like that was. [00:48:41] Speaker B: Maybe there was some sarcasm that you didn't read. [00:48:44] Speaker A: Yes, but to your point, though, I think that, like, you know, if the patient saw that, they'll want to see that they're lovely. [00:48:50] Speaker B: That's true. [00:48:51] Speaker A: But you can also just say, like, I saw Mrs. Johnson and, you know, thank you for the referral, and here's my thoughts, you know, or something. But it's. It's always so funny. Like, there's this sense that they need to, you know, kind of flourish the way that they're communicating with us. But I think that. But back to this idea, though, like, what do you do? If I know, and people, if they're really honest with me, and I'll say. At the end of the visit, they'll say, can I mention something? And it's like. And then I go, okay, here we go. I know this is like they're going to say something that's going to hit hard. It doesn't happen very often, but every once in a while it does. And, you know, you're right. I mean, I feel like I have thin skin, but I'm also very, very attentive to wanting to better myself. And so if a patient says to me, like, hey, that didn't go well last time, or I wish you had called me to tell me about that rather than sending me a MyChart message, you know, I'll say, like, I totally get it. I am sorry. I will make sure we don't do that the next time, you know, and that's probably how we should respond, right? [00:49:52] Speaker B: I think that's a lovely way to respond, but I do like that. I think that's very human, very personable and very human. [00:50:02] Speaker A: And so from an empowerment standpoint, I think that patients should feel if they know their, especially their primary care physician or maybe it's a specialist that they see all the time, and if they feel something didn't go well, I hope that they feel empowered to share that. And I hope that they realize that, that most of us will take that to heart and we'll try and better ourselves and be better humans and better doctors. [00:50:25] Speaker B: Can you tell me how, if a patient is coming to their primary care appointment, are there things that they would be really nice if they would prepare for or have or know? [00:50:40] Speaker A: I will answer that question, but I will also kind of start with almost like the negative corollary of that. [00:50:45] Speaker B: Okay. [00:50:45] Speaker A: So for years, people have been told, like, when you go to the doctor, make sure you have a list so you don't forget things you wanted to mention. So 100% agree. However, if it's a 20 minute appointment and there are 14 things on the. [00:51:01] Speaker B: List, they're not gonna get all addressed or at least not properly. [00:51:06] Speaker A: Exactly. That's the big key. Because I was saying to my rooming staff the other day, like, someone came in and it was literally the, like, left knee pain. So often that's one of six things that people want to talk about. Or it's the wellness visit and it's that. But to do a really good job. Like, I had this great visit. It was like, got a great history, had the patient demonstrate how they were walking, did a really thorough knee exam, decide if any imaging was necessary. We talked about PT and whether to get a cortisone shot or see a special specialist. And that took up the entire time. But it was so satisfying. And. And yet I think that patient actually apologized to me for coming in with just that complaint. And it's like, no, no, no, you don't understand. I love doing things like that. It's like, very focused. So. So I think just keeping that in mind, being reasonable, you know, how thorough can I be if someone has 10, 12, 14 individual complaints? And, you know, it's like headache, fatigue, back pain, visual changes, chest pain, like, oh, my gosh, like, every one of those is a Thorough visit in and of itself. So, and just so people understand too, if that happens for sure, if we do our job right, we'll probably say like, okay, of those things, what are the two that are really bothering you today? And then let's address those other ones in more detail, depth, like, you know, in another visit or two and handled well, I think people understand that and realize that they've been heard, but we just can't get into it as much as we would like if there's a ton of things to go. [00:52:43] Speaker B: So do you have a time constraint? What is the general time they expect for you to spend with a patient? [00:52:50] Speaker A: It completely depends. There is a, we just had a really great conversation the other day with my department colleagues about what is that appropriate time? So in some private practices it can be a 15 minute appointment for everything, which, like you can't do things. I mean, you can do a sore throat in 15 minutes, but you can't do a wellness visit or a full physical exam in 15 minutes. I don't care how good people think they are, you just can't. So time slots are everything from, and this is, I'm talking primary care, not like ophthalmology where you could maybe be 10 minutes with the ophthalmologist, but this is primary care. Typically it's 15, 20, 30, 40 minute video visit slots depending on where you go. I do all 30 minutes. And so some visits don't take 30, some take 40. It all kind of comes out in the wash. 30 minutes is becoming a little bit more standard now for primary care throughout the community. My colleagues, if they're listening to this, might say, like, what are you talking about, John? It's like I only get 20 minutes. Or some people, like most of my colleagues at the clinic get 20 and 40. I just decided to go for 30 because frankly, it makes scheduling so much easier. Everything gets, you don't have to worry about, oh, I can't get you into the three weeks because John doesn't have a 40 minute appointment, you know, available. [00:53:59] Speaker B: Gotcha. [00:54:00] Speaker A: This just makes it so much easier. [00:54:01] Speaker B: I have about two minutes. What are your feelings on telehealth and do you think it falls short? [00:54:07] Speaker A: Well, I'll tell you, this gets back to the fact that if you have a primary care physician who knows you, I think telehealth can be fantastic. Especially like I just put someone on an antidepressant. I want to follow up with them. In two weeks we're going to get a score of kind of how they qualitatively Feel I know them really, really well. They live in Hugo. They live in, you know, wherever it's snowing. Oh, my gosh. A telehealth visit is so nice to do because. And I think frankly, there's an ecological piece there. Right. People don't have to drive and burn fossil fuel to get to the clinic if we can do it. That's true. So I think there's a green element. [00:54:41] Speaker B: To it, but there's no weight check, blood pressure check. So many things that could. Even looking just kind of at them face to face, I would think it might be trickier. [00:54:54] Speaker A: Yeah. So it depends, like medication, follow up, mental health stuff is a really good example of that. Frankly, as a family physician, I find the house call aspect kind of fun because I can see people in their environment and it's like, oh my gosh, look at that bookshelf over your shoulder. Or, you know, tell me about that painting. Or, you know, are you in your basement? Or, you know, tell me where you are. I feel like it's kind of almost like a little bit of a privilege to kind of see where people live. [00:55:17] Speaker B: Thank you so much, Dr. Helberg, for coming on. We really appreciate it. I feel like I could have gone another 30 minutes with you easily. So thank you so much. I really appreciate your time and good luck with everyone. [00:55:29] Speaker A: Thank you. It was my pleasure to be with you. Thank you. [00:55:35] Speaker B: You've been listening to Disability and Progress. The views expressed on this show are not necessarily those of KFAI or its board of directors. My name is Sam. I'm the host of the show. Charlene Dahl is my research PR person. Erin is my podcaster. Tonight we were speaking with Dr. John Hatch, talking about primary care and primary care Doctors. This is KFAI 90.3 FM, Minneapolis, and KFAI.org if you want to be on my email list, you can certainly email me at disabilityandprogressamjasmond.com tell me your thoughts and what you'd like to hear. Next week I will not be here because it's 24 hours of pride, but I'll be back after that. Thanks for listening. Take care.