As a young primary care internist, Joseph Frolkis, MD, PhD, routinely observed what he coined as the “Columbo phenomenon.”
At the end of each episode of “Columbo,” a well-known television show about a blundering detective played by Peter Falk that began in the late 1960s, Falk would deliver his famous line: “Just one more thing.” At this point, catching suspects off guard, the detective would perfectly deliver the incriminating information.
“The ‘Columbo phenomenon’ in primary care describes a decidedly more benign but equally pivotal interaction,” wrote Frolkis, vice chair of Primary Care in BWH’s Department of Medicine, in an opinion piece published in the Journal of the American Medical Association earlier this year. “It reflects the power of the trust that is developed between a provider and a patient as a function of the longitudinal, continuous relationships that are such a central, critical feature of primary care.
“It is this trust that allows patients to bring up symptoms or circumstances that are frightening, or embarrassing, or confusing and therefore enables the physician to respond, to investigate, to diagnose, to treat. Innumerable times in the span of my career, I have been at the door of the examination room, at the conclusion of the standard ‘15-minute visit,’ having dealt with the ostensible reason for the encounter (the hypertension, diabetes, URI) when it is the patient who says, ‘Doctor, just one more thing…’ It is then that I hear the actual reason for the visit: the rectal bleeding, the strange chest pain, the weird dizziness, the unusual shortness of breath, the devastating psychological impact of the just-discovered infidelity of his or her partner. The patients in the waiting room notwithstanding, I turn back into the examination room, and the real work begins.”
Frolkis says that as primary care continues to change and evolve, the relationship between primary care physicians (PCPs) and their patients remains ever-important. This unique relationship builds trust, which allows patients to feel comfortable discussing sensitive issues, leading to earlier diagnosis or intervention in some cases, and increases patient adherence to medications and a healthier lifestyle.
“As physicians, active listening prompts patients to feel comfortable enough to share their concerns,” said Frolkis. “This skill can be taught to anyone who cares about people and wants to help them, not just doctors. Whenever any of us goes to the doctor’s office, we’re nervous, often anxious about the potential meaning of a symptom and maybe in pain. We want someone who makes eye contact, listens to us and sits at our level. Over time, we get to know and trust them.”
Integrating Team-Based Care
Notwithstanding the foundational importance of the PCP-patient relationship, internal medicine is in the midst of the seismic shift toward team-based care. The current shortage of PCPs, the aging baby boomer population and the concurrent movement of more and more care into the ambulatory setting have catalyzed the emergence of a new model of care that focuses on care coordination, chronic disease management, prevention, scrupulous utilization of appropriate health care resources, and the comprehensive treatment of a population of patients.
“The number of people over age 65 will double between now and 2030,” said Frolkis. “We have to continue to move toward teams providing great medical care, with patients seeing the appropriate member of that team for the problem at hand. This is happening both nationally and in all of our BWH primary care practices. Patient and provider satisfaction increase in the studies that have examined this model, and quality does too. Patients can learn to trust all members of the team so that the power of the ‘Columbo phenomenon’ can be even further amplified, with outcomes rising accordingly. The bottom line? The care we provide our patients improves. That’s a goal we can all agree on.”