(Extended Cut) Vital Signs: Finding a medical home

CATHY WURZER: Hey, we're starting a new monthly segment on Minnesota Now called Vital Signs. Each month, we'll be talking about topics that are important to your health and take a deep dive into medical news or what's on top of mind at the doctor's office. Joining us will be a familiar voice to longtime NPR listeners, Dr. Jon Hallberg.

Dr. Hallberg is a family medicine physician at Mills City Clinic in Minneapolis and a professor at the University of Minnesota Medical school. I can't tell you how excited I am to have you back in studio.

JON HALLBERG: Oh, Cathy. This is so fun for me to be back. We were just talking. I haven't been here in about four years.

CATHY WURZER: Wow.

JON HALLBERG: And it seems like such a long time, and yet it seems very familiar.

CATHY WURZER: Nothing ever changes, really, in the newsroom.

JON HALLBERG: It's very comfortable to come back. Thank you so much for the opportunity to do that.

CATHY WURZER: Oh, I'm so happy that you're here, and there's a lot to talk about. But first, I want to introduce you to listeners, just those who, of course, hear your voice. And they're like, yes, oh my gosh. He's back for those who don't know you, you're a family practice physician, family medicine physician.

JON HALLBERG: That's right.

CATHY WURZER: And that means what?

JON HALLBERG: So family physicians, we are trained-- going back to residency, so you graduate from medical school. You go into family medicine. Though it's very general by definition, it is a specialty. Back in the day, in the 1960s, people would do like a year of internship, one year, and then they'd be ready to practice. And those were general practitioners.

But starting in the late 1960s, family medicine became its own specialty. And we specialize in the human condition and everything from preconception to the end of life, so truly, truly cradle to grave. My practice, I have focused-- so I'm just an outpatient doctor, so I'm just in clinic.

But many of my colleagues, especially those in outstate greater Minnesota, do everything and do everything that they were trained to do, including delivering babies. And they might do an ER shift. They'll probably round at the nursing home. They really, really-- we can do everything.

CATHY WURZER: So by the way, are you like an internist? Or is that a different specialty?

JON HALLBERG: Right. So internal-- so think of-- if we break up life span into two major chunks, at the beginning, you've got pediatricians. So that's from birth to generally, 18 but a lot of times, pediatricians will extend that through college just because people haven't found a new doctor yet. So they'll kind of take-- it depends on the pediatrician.

Internists, they have kind of a tag that is specializing in the care of adults. So they take the second half, or not really the second half, but from the end of adolescence onward. Family medicine takes care of the whole range. So we don't make that sort of demarcation.

And many times, I will get adults because they've graduated from their pediatrician, and they'll want to have a family physician that can take care of them. But my personal practice is very much, yes, internal medicine because I'm doing mostly adults and, frankly, these days, mostly geriatrics.

CATHY WURZER: Not to diss my mother here, but she's a medical professional. And I remember she said-- because I was seeing our family practice physician until I was probably about, what, 40, I guess. And she said, isn't it time to grow up and get an internist? And I thought, I don't know what that means. Does family practice get the love it really deserves?

JON HALLBERG: Oh, probably not.

CATHY WURZER: [LAUGHS]

JON HALLBERG: Things have changed, and I think that there is a growing conversation about the primacy, the importance of family medicine. And when you hear these arguments in these conversations and needs for more primary care people-- and let me be clear, too. I'm very holistic in my thinking. I always want to acknowledge that we've got nurse practitioners.

And around the country, that's shifting slowly into a DNP program, a Doctor of Nursing Practice. PAs, physician assistants, are many times functioning as primary care clinicians. And then, of course, family medicine, there's a joint specialty called med-peds, which is internal medicine and pediatrics. So they're doubly board certified, so they basically are family physicians.

But there's one way I often think of this, that internists, for example, they're training heavily, heavily inpatient, heavily, heavily really sick adults. And so they have rotations in oncology and critical care. And pediatrics, the same thing, really sick babies and really sick kiddos who are in the hospital.

Family medicine, by its very nature and from its inception, really focuses on outpatient care. We do everything but realizing that so much of what we do is going to be in the clinic. So we're trained from the beginning to really spend a lot of time in clinic, and our panels grow as we go through our training program.

And this is just my own sort of way of thinking of this. But I think also my internal medicine colleagues often are not "cup is half empty" kind of people, but they've seen such bad disease in people. They're really great diagnosticians. They can really figure out complex conditions.

And I'm, by nature, probably a little bit more of a "cup is half full" person, not thinking that when someone comes in, they've got some grave disease, certainly being aware of the fact that they could. But I generally think most people are going to get better, and most people are going to be healthy.

So a lot of what I do is focusing on prevention, and coaching, and interpreting of lab results, and test results, and coordinating referrals, and then providing contextualization around that once the patient comes back from seeing the specialist, and now what are we going to do? So it's just-- and obviously, I'm generalizing to some extent.

Many family physicians can be "cup is half empty" people. And many internists might be-- their cups are half full. And so anyway, that's just kind of the way I frame it in my own head.

CATHY WURZER: So thanks for the backgrounder on all of that. I appreciate that.

JON HALLBERG: Oh, thank you.

CATHY WURZER: I'm wondering here, because we've been following the closure of two rural Minnesota clinics ending labor and delivery services-- one's in Boston, which is in Northwestern Minnesota. The other one's in New Prague, south of the Twin Cities. As a family practice physician, does that worry you?

JON HALLBERG: I think as a citizen, it worries me, being in Minnesota. This is happening-- I think I saw a statistic that Minnesota led the country in the number of rural hospitals that stopped providing OB services, partly because we have such a rich history of lots of rural hospitals that are very strong.

And just as a side note, I tell patients when they're up at their cabin or they're traveling around the state, we are so lucky in Minnesota with the quality of health care that we provide, it doesn't really matter where you are. And in fact, when I look at a map over your shoulder, Cathy, on the wall of Minnesota, I can think of former students, classmates, colleagues, mentors, who are basically all over the state of Minnesota, practicing.

And I just know how smart they are and how good they are. And these are my family medicine colleagues that I know. So when hospitals decide that they need, for lots of reasons, malpractice, overhead, training--

CATHY WURZER: Is there a lack of OB doctors, though?

JON HALLBERG: Well, for sure, and in fact, I think that people are going to be really surprised to know that many, if not most, of those deliveries that you're hearing about in these small hospitals, family physicians are doing those deliveries.

CATHY WURZER: What?

JON HALLBERG: Yeah.

CATHY WURZER: Oh.

JON HALLBERG: So that's part of our training. And so there just aren't-- it's going to be hard for an OB-GYN to want to be in a small town with little backup, call coverage. I think that gone are the days where you've got physicians who are willing to just do it all themselves, just be there, be on call 365 except for the few times they're away on vacation.

That just doesn't happen. Same thing in ERs, rural hospitals now are not just relying on the local family physicians to cover the ERs. They often are contracting with companies that provide ER docs. They may kind of rotate through, but it's a quality-of-life issue. Working in the ER, that's a complicated, scary thing to do.

CATHY WURZER: Oh, yeah.

JON HALLBERG: And I think of the shifts I had when I was in training in ERs in Red Wing, for example, where I did nine months of training. That's a scary prospect, and so you need-- rural hospitals, just like urban and suburban hospitals, need experience. They need depth. They need coverage.

And it's just getting harder and harder, I think, to be on call and get enough-- if you deliver babies, you want to do a lot of that. This is not an episodic thing. You don't want to do it every so often.

And so if the numbers are dwindling, fewer people are pregnant in rural areas, fewer deliveries. You're not getting as much experience. The malpractice rates may go up. If there is a complication, it can be not good for all kinds of reasons.

So yeah, it's a multifactorial problem. And it's a sad thing. Suddenly, you're 30, 45, 60 minutes away from the next closest hospital. And if you're a pregnant woman, and you're going to labor, and things are progressing quickly, and it's snowing, you're going to end up in the local ER and delivering there. And that's not ideal.

CATHY WURZER: No.

JON HALLBERG: So it's really-- yeah, it's very complicated.

CATHY WURZER: Say, as a physician, and I recall you talking in the past about this concept. Maybe we can dive into that right now. You talk about everyone should have a medical home.

JON HALLBERG: Absolutely.

CATHY WURZER: A medical home, what does that mean?

JON HALLBERG: So I think that every one of us needs a landing place, needs a home. I love the idea of a home. In the best of all possible worlds, everyone has a clinic that they love, that they have a primary care clinician who they love.

I know that's hard. And let's say you're a young person. You've got a super high deductible. You're healthy. Why would you think about trying to establish care with somebody? What do I need that for?

If I get sick, I'm just going to try and do something online. Or I'll go to--

CATHY WURZER: To the urgent care.

JON HALLBERG: Yeah, urgent care.

CATHY WURZER: Whatever.

JON HALLBERG: Emergency center.

CATHY WURZER: Sure.

JON HALLBERG: Emergency room, even, that matter, although co-pays are high there. It's just the absolute wrong place to go for an earache, for example. And the longer I'm in this business-- and now this is my 28th year after residency of practicing-- the more I realize that people need a place to land. They need someone they can trust.

Scary things happen. Scary things, frightening things happen when we least expect it. And what do you do when something like you've been given a diagnosis or you're not getting better? And you did go to the ER. You did go to the urgent care center.

How do you follow that up? And I've just found that the wisdom, the context, the reassurance, the care that we can provide is essential. So I think that everybody needs to think about this and establish care with someone that you can have a conversation with, that you can trust. I can't emphasize that enough, how important that is.

CATHY WURZER: So if you find a medical home-- and I understand the concept, what you're talking about-- how could that-- could that result in better communication between you, as provider, and other specialists, coordination, better coordination, that kind of thing? And does that help keep down costs, perhaps?

JON HALLBERG: Oh, absolutely. And I will say this. I'm-- this seems like maybe an odd thing to bring into this. But most of the health systems in Minnesota are part of Epic, which is electronic medical record. And as much as I visually don't like Epic-- I'm sure many of-- any physician, any health care colleagues listening to this conversation will probably feel the same way. But there's just-- it's more is more.

There's so much information on that screen. It is really hard for me, who doesn't type very well, to navigate it at times. But that being said, the sort of interoperability of it is amazing.

So if I have someone who, over the weekend, they went to an Essentia clinic and then now they're following up with me, I can see all the labs. I can see the x-ray report. I can see what the thoughts were of the person that they saw there.

Mayo, a number of years ago, went to Epic. And oh my gosh, I've got a lot of patients that go to Mayo for various reasons. And they can see my notes. I can see their notes. So that shared information is just incredible.

It wasn't that many years ago charts were manila folders with pieces of paper inside. And we'd have shopping carts that would take charts from clinic to clinic at the university. And like, where's the chart? And who knew? And oh my gosh. I mean, just, that's amazing.

That was the early 2000s.

CATHY WURZER: Not that long ago.

JON HALLBERG: Yeah, early 2000s.

CATHY WURZER: I know.

JON HALLBERG: And now it's a game changer. So that part's important. But yes, I think that having-- my specialty colleagues are great. My ER colleagues are wonderful. But patients are often very confused by the information that's been shared, or they're overwhelmed.

And we kind of joke that many of my patients need my blessing on things. And it's not a blessing. It's the contextualizing of things. They trust me, and they really want to get me to weigh in on it.

And then there are times, it's like, guys, you have cancer. I'm not going to be able to weigh in on the different kinds of chemotherapy that are being proposed. But sometimes they just need to hear that, too. You're seeing a great oncologist. Please, trust what they're saying.

It's really important that you just follow through. And I'm going to be here for you if you need me. But for right now, you've got a care coordinator. You're getting this care. I'm going to step back, but I'm here for you when you're on the other side of this, and you're doing well, and we need to monitor things. So it's just dozens and dozens of reasons why it's important to have that landing home, that landing place.

CATHY WURZER: Does that mean also, then, because of the coordination, are you able to reach out to your colleagues? And it sounds like communication between specialties, then, is potentially better than it was or not so much?

JON HALLBERG: Yeah, I think it is. So we have a staff message option, so we can send direct messages to our colleagues for things. But there are times when nothing beats a phone call.

I'm kind of isolated. I'm at the University. I'm off campus. I'm downtown Minneapolis.

So I'm not bumping into people the way I used to. I miss that. It's amazing how much you can gain by just those spontaneous ideas of bumping into people. Anyone who's been working from home and they used to work in an office, you know that. There's something that's really invaluable about that and really special about that.

But yeah, staff messaging, calling one another, it does-- communication is critical, of course. But the notes are-- they're there instantaneously.

So that's something we couldn't do before. You have to wait for transcription. And then you print it off on a piece of paper with a sticky back, and peel off the back, and put it in the chart if you could find the chart. None of that happens now, so it's much better communication.

CATHY WURZER: This must, then, be-- this must be quite helpful if someone's having a dire emergency because--

JON HALLBERG: Oh, absolutely.

CATHY WURZER: --with a medical home and if I'm having a really awful time, you, as you say, are my landing place, in a sense.

JON HALLBERG: Yeah, and kind of that juncture point. So you've got something going on. You have a clinic that you trust. You call that clinic.

In our case, we've got three incredible triage nurses who will field that call. And they're really smart. And they'll know like, OK, Cathy, what you're describing, we can't take care of that in clinic. You really need to go to the emergency room.

And so there's that. Then the notes document it. And I call the ER ahead of time, say I've got this patient coming over with this condition. I've done that many times.

Or I'll call and speak to one of my colleagues. And many times, I know them personally and just say, hey, I'm sending over this person, just FYI. This is what I think is going on. And then they work that patient up and either admit them to the hospital, or observe them for a short time, or send them back home. And then they follow up with me.

And yeah, no, it's-- and I think every time I've got someone who's been hospitalized, pretty much for anything, they will see me. The discharge instructions are always like, follow with your PCP, your primary care provider, in seven days or in the next week. And then you have a chance to review things and go, oh gosh, your hemoglobin was 7.4. Your iron is really down. Let's check your complete blood count again today and see if you're bouncing back.

And oftentimes, people are. And yeah, when it works well, it's really a beautiful thing. It doesn't always work like that. But generally speaking, it's pretty amazing when it works

CATHY WURZER: I wonder how COVID-- I wonder if COVID has underscored, then, the need for a medical home.

JON HALLBERG: I think it has. And I think that when we were in kind of those early days-- my little clinic, we're seeing about 100 new people a month that are establishing care with my colleagues. And that picked up in that summer of 2020 into 2021.

I think people realized like, holy cow, I don't have anyone. If I get COVID, who am I going to talk to? Where am I going to go? And I think that-- yeah, I think it underscores the importance of that and has.

And now that we're seeing more RSV and we've had influenza-- and there, too, if people want to be in for COVID, they want to be on paxlovid. Yes, there's a state way. You can go through MDH, Minnesota Department of Health, website to get treatment.

But still, we know your medications. We've got the list right in front of us. We can see if there's any contraindications or something, a med you should hold while you're on it. So again, yeah, one more underscoring of how important it is and why it's so important to have a health care home or a medical home.

CATHY WURZER: So speaking of COVID, you mentioned RSV, the flu. I see they're all trending downward in Minnesota according to the Department of Health. Viruses, I understand, don't do as well in warmer weather. So is this weirdly warm weather that we're having and are forecasted to have into this coming week, is that doing anything maybe to tamp down the cold and flu season?

JON HALLBERG: It's really hard to say. And I think just to be clear. I think that it's not that the temperature itself does anything with the viruses. It's people. It's us.

And so I think what the hypothesis is is that, when it is really cold and when it's cold in Minnesota, the air is really dry, and then our mucous membranes are, in turn, dry, and fragile, and crusty, it's just so much easier for a virus to land, whether it's in the back of our nose or in the back of our throat. And then it's nice, and warm, and humid, and dark, and just perfect culture medium to make millions, billions, trillions of copies of yourself.

CATHY WURZER: Ugh.

JON HALLBERG: So it's really not the temp, per se. It's more probably what it's doing to us. And also human behavior, like the winter, we're all indoors with one another. We're not outside playing.

And so I think that's why there's a seasonality to it, to some extent. At least that's what we think. So who knows? It could just be that it's just this weird little blip. Maybe it's going to peak again.

We've had-- it's been very hard to predict things the last few years. It was in fall of 2022 that we had that huge spike of RSV. It was totally thrown off. Usually February is the big month for respiratory syncytial virus infections in little kiddos and babies. And it got totally thrown off because our patterns were different, and it was-- so I think it's hard to predict right now what's happening.

CATHY WURZER: Is it still too late to get vaccinated against all those diseases?

JON HALLBERG: No and never. [LAUGHS] I'm going to wear a pretty strong pro-vaccination hat for that. So it might be-- like we don't even have the flu shot anymore, so we've kind of run out. And we're probably not going to replace that. If you want to get that, you can still get that at your pharmacy.

We've got COVID vaccines. A number of people got sick, and then we have them wait a while before-- they've had natural immunity if you've gotten sick with COVID. So we wait a period of time, generally about three months or so, and then potentially give that.

RSV, kind of brand new for various folks in various populations. But that's going to be evergreen, as we say. It's like, whenever you want to get that is going to be fine because it's kind of a maybe not a one and done but for adults, for sure.

It's like, for right now, it's like get it. And then we'll see down the road if and when you need a booster. But that's an easy one to get.

CATHY WURZER: We've covered a lot of ground, just a few minutes.

JON HALLBERG: Yes.

CATHY WURZER: Oh my goodness. We've run out of time. We'll have you back next month. Next month. Is that OK?

JON HALLBERG: Oh, it sounds great. I would love that.

CATHY WURZER: OK. Dr. John Hallberg, family medicine physician at Mill City clinic and a professor at the University of Minnesota Medical School.

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