30 Years of Innovation, Healing: Longtime Family Physicians Decide Time Is Right to Step Aside

  • Peter Mason explains the cold-related symptoms of Paramjit Kaur, left, of West Lebanon, N.H., using her daughter Parminder Kaur, 12, as a translator, while David Hernandez, a second-year student at Geisel School of Medicine, observes at Good Neighbor Health Clinic in White River Junction, Vt., on January 17, 2014. "It's about patient education," said Mason, explaining how he spends time building relationships rather than just delivering quick diagnoses. (Valley News - Will Parson)

    Peter Mason explains the cold-related symptoms of Paramjit Kaur, left, of West Lebanon, N.H., using her daughter Parminder Kaur, 12, as a translator, while David Hernandez, a second-year student at Geisel School of Medicine, observes at Good Neighbor Health Clinic in White River Junction, Vt., on January 17, 2014. "It's about patient education," said Mason, explaining how he spends time building relationships rather than just delivering quick diagnoses. (Valley News - Will Parson) Purchase photo reprints »

  • Mark Nunlist, who recently retired from his general practice in White River Junction, Vt., poses at his home in Lebanon on January 17, 2014. Retirement for Nunlist will bring more time to pursue hobbies like photography and music. (Valley News - Will Parson)

    Mark Nunlist, who recently retired from his general practice in White River Junction, Vt., poses at his home in Lebanon on January 17, 2014. Retirement for Nunlist will bring more time to pursue hobbies like photography and music. (Valley News - Will Parson) Purchase photo reprints »

  • Peter Mason discusses sinus diagnoses with David Hernandez, a second-year student at Geisel School of Medicine, before seeing a patient  together at Good Neighbor Health Clinic in White River Junction, Vt., on January 17, 2014. (Valley News - Will Parson)

    Peter Mason discusses sinus diagnoses with David Hernandez, a second-year student at Geisel School of Medicine, before seeing a patient together at Good Neighbor Health Clinic in White River Junction, Vt., on January 17, 2014. (Valley News - Will Parson) Purchase photo reprints »

  • Mark Nunlist, who recently retired from his general practice in White River Junction, Vt., poses at his home in Lebanon on January 17, 2014. Retirement for Nunlist will bring more time to pursue hobbies like photography and music. (Valley News - Will Parson)

    Mark Nunlist, who recently retired from his general practice in White River Junction, Vt., poses at his home in Lebanon on January 17, 2014. Retirement for Nunlist will bring more time to pursue hobbies like photography and music. (Valley News - Will Parson) Purchase photo reprints »

  • Coach Perry Seale jokes with his daughters Phoebe, left, and Rachel during a practice at the Mid Vermont Christian School in Quechee, Vt., on Jan. 21, 2014. (Valley News - Sarah Priestap)

    Coach Perry Seale jokes with his daughters Phoebe, left, and Rachel during a practice at the Mid Vermont Christian School in Quechee, Vt., on Jan. 21, 2014. (Valley News - Sarah Priestap) Purchase photo reprints »

  • Peter Mason explains the cold-related symptoms of Paramjit Kaur, left, of West Lebanon, N.H., using her daughter Parminder Kaur, 12, as a translator, while David Hernandez, a second-year student at Geisel School of Medicine, observes at Good Neighbor Health Clinic in White River Junction, Vt., on January 17, 2014. "It's about patient education," said Mason, explaining how he spends time building relationships rather than just delivering quick diagnoses. (Valley News - Will Parson)
  • Mark Nunlist, who recently retired from his general practice in White River Junction, Vt., poses at his home in Lebanon on January 17, 2014. Retirement for Nunlist will bring more time to pursue hobbies like photography and music. (Valley News - Will Parson)
  • Peter Mason discusses sinus diagnoses with David Hernandez, a second-year student at Geisel School of Medicine, before seeing a patient  together at Good Neighbor Health Clinic in White River Junction, Vt., on January 17, 2014. (Valley News - Will Parson)
  • Mark Nunlist, who recently retired from his general practice in White River Junction, Vt., poses at his home in Lebanon on January 17, 2014. Retirement for Nunlist will bring more time to pursue hobbies like photography and music. (Valley News - Will Parson)
  • Coach Perry Seale jokes with his daughters Phoebe, left, and Rachel during a practice at the Mid Vermont Christian School in Quechee, Vt., on Jan. 21, 2014. (Valley News - Sarah Priestap)

Lebanon — The doctors arrived in the Upper Valley just two years apart during a time when computers were novel and the crest of the hill along Route 120 was mostly wooded land.

At that time, the early 1980s, Peter Mason and Mark Nunlist could not have imagined the changes that would occur in their family practices over the course of their careers — physicians punching keys on laptops during patient visits and working as part of a team of professionals, some of whom might have no medical training, to provide care. Electronic records. A shifting focus on the health of entire populations rather than individual patients. An expansive federal law aimed at overhauling the nation’s health care system.

Mason, 66, and Nunlist, 65, were two generalists who did a little bit of everything in medicine and who were looking for a community to serve. In the decades since they settled in the Upper Valley, they have become innovators who helped transform the way primary care is practiced in the region, say their colleagues.

“They’re both wonderful doctors who dedicated themselves to their profession, their patients and their organizations,” said Brian Lombardo, the medical director at Alice Peck Day’s community care clinic in Lebanon.

“Both Peter and Mark have made many contributions to health care, and medical education in the Upper Valley and beyond,” said Allen Dietrich, a professor of community and family medicine at Dartmouth-Hitchcock. “They are both notable for their creative, forward-thinking approach.”

Now, Nunlist — who last year was named physician of the year by the Vermont Medical Society — and Mason have stepped away from the practices they helped build over the past three decades. Nunlist retired from White River Family Practice at the end of last year and Mason, who won’t use the “r” word, stopped seeing patients in his family practice in mid-January.

They are leaving at a critical moment in health care, and especially for family physicians, as health reformers advocate for primary care to play a central role in lowering costs and improving overall health for people in the United States. A driving goal of the Affordable Care Act was to expand access to primary care.

Mason and Nunlist share a few things in common beyond being longtime family doctors in the Upper Valley. They were both medical residents at the same Pennsylvania hospital, Lancaster General, and are neighbors in Lebanon. They are leaders in their field who are recognized for their commitment to patients and mentoring of young doctors. Yet they have different ideas about some of the changes happening in their profession, particularly when it comes to technology and the effect it is having on their relationships with patients.

Medicine has changed significantly since they began their careers. But as they reflected on the past 30 years, Nunlist and Mason said the most radical shifts have not necessarily been in the treatments they prescribe, but in how they organize their practices and interact with patients.

The current moment is an exciting one, Mason and Nunlist said. But this is also a fragile time, and the decisions being made now could lead either to improved health in the U.S. or further widen gaps in care.

Doctors play an important role addressing social inequities, Mason said, perhaps now more than at any other time.

“I think there’s more understanding of how important (health care) is,” Mason said, “and more young physicians who see themselves needing to be agents of social change.”

Doctor-Patient Relationship

Coming of age in the 1960s, Mason embraced the idealism of the period and it guided his training and professional development. Education, jobs and housing were the three legs of the stool that President John F. Kennedy’s administration, and Lyndon Johnson after him, emphasized in addressing poverty. Mason, a medical student at Boston University, saw health care at the intersection of them all.

“What was very clear to me was, while you worked on all three of those things, people’s health was really fundamental to their ability to work, to study and just to live,” he said. “All three of those were impacted by health care.”

But the role of the doctor in providing that care has shifted radically in the time since Mason was setting up a free clinic with the Black Panther Party in Boston and going to street demonstrations.

At that time, doctors and patients had one-on-one relationships. Together, they would work through whatever the problem of the moment seemed to be. The patient would leave and return when she got sick again.

That model is being replaced in many hospitals and medical practices with a health care team. It is not just the doctor and patient, anymore, but also a nurse, social worker or even a “health coach” attending to different patient needs. In some places, including White River Family Practice, it’s not just the patient’s health that the team is thinking about. Those providers are trying to assess the patient in the context of a larger community of patients, with all the attendant social and demographic factors that affect health.

“That’s a watershed,” Nunlist said one recent icy morning at his home in Lebanon. “Words fail me to describe the enormity of the difference in outlook.”

Such a notion never occurred to Nunlist during his medical education at Brown University, nor even when he arrived at White River Family Practice in 1983. But he has come around to the idea of team-based care over the past 12 years, beginning with the day he realized he was failing his patients on one important, though basic, standard of care.

It happened when a New Hampshire insurance company sent some of its people to White River to do an audit. After several hours, the insurance officials said they were pleased with what they saw. But they had one suggestion: Nunlist needed a system to update his patients on their tetanus shots.

Nunlist thanked them and politely sent them away. He was pretty sure they were wrong, however, as he kept patients’ vaccination records at the front of their charts. There was no way that he was overlooking tetanus shots, he thought. Still, he put his system to the test. He issued a standing order to his medical assistant to vaccinate any patients who were not up-to-date on their tetanus shot, regardless of why they came in, as long as they were willing. If his system worked, then it shouldn’t be a big deal. Nobody should need a shot.

Several hours later, his medical assistant buzzed him and said they needed to stop giving tetanus shots. They had run out.

“We let them down,” Nunlist said. “(Patients) are entrusting us with their primary care and a tetanus shot is sort of a very simple, flagship element of primary care. What are we doing?”

Nunlist’s practice wasn’t as good as he had assumed. That realization eventually led him to enroll in classes at what is now called The Dartmouth Institute for Health Policy and Clinical Practice, or TDI. While studying there, he learned about the potential for team-based care and developed a new appreciation for how he should be thinking about his practice. It was no longer just about him and his patient. It was about his team of caregivers and the entire community they cared for.

Why, he wondered, should there be just two people — doctor and patient — involved in that patient’s care? Why weren’t all 25 people in his office involved in trying to make sure all his patients were up-to-date with their tetanus vaccination?

The model has been adopted in a growing number of medical practices around the nation, including at Dartmouth-Hitchcock.

“When I started to view primary care through that lens, if you will, it opened up an exciting, profound different view of how primary care should function in the community to advance the public health as well as the individual health,” Nunlist said.

Balancing Technology, Personal Touch

Mason has not been as eager to embrace the team model, believing that however efficient it may be, it sacrifices intimacy that is helpful in addressing a person’s health problems.

His experience these past few months has convinced him of the importance of personal relationships. As he wound down his practice, patients stopped by and thanked Mason for how he has helped them. The majority of these conversations had nothing to do with his scientific medical knowledge, Mason said. Rather, they touch on the ways in which he talked patients through difficult times and helped them sort through problems.

“That’s what upsets me about what’s happened to medicine. … The ability to have the kind of relationship that allows a physician to have a healing relationship and to help patients make decisions and get through difficult times,” Mason said. “You can’t do those things unless there’s trust and you can’t develop trust unless you’ve seen somebody over a long period of time.”

That is why Mason continued to do house calls long after his peers abandoned the practice. House calls may be inefficient, he said, but they allow him to see how people live, how their disease affects their lives, and to understand “what is practical, what you can really do to make things better.”

His desire for personal relationships extends beyond patients, to his colleagues as well. And it is also behind Mason’s skepticism about the use of digital technology in medicine, which he believes is the most significant and troubling change in medical practice since he began.

Technology has separated physicians from their patients and professional colleagues, Mason said. He used to talk with surgeons and specialists often, either over lunch at the hospital or over the phone. Now, those conversations happen electronically, via email, and get buried under a growing pile of other emails that are difficult to prioritize.

New software allows doctors to manage patients in ways that were not possible 30 years ago. But Mason said it has also brought additional burdens.

“A computer makes it easier,” he said, “but what happens as a byproduct of all the need for documentation and the use of a computer was a lot of unnecessary stuff gets entered into the chart at every visit.”

Doctors now spend three-quarters of every visit staring at a screen rather than the patient. Plus, much of the digital medical record is “boilerplate” in form, making one patient appear like the next. The demands for digital documentation are not just about patient care, Mason said. They also are driven by incentives to bill insurance companies for more stuff because that is how doctors are paid — quantity of care, not just quality. Somewhere beneath the pile of itemized charges for lab tests and minor, often unnecessary, procedures lies the hidden story about what is happening with that patient, he said.

“We’ve lost a lot of the soul of the medical record,” Mason said. “We’ve lost the narrative of the medical record, which used to be so important in knowing who somebody was as an individual when that person walked in.”

While Mason has been skeptical of using technology in his practice, Nunlist has embraced it. White River Family practice was an early adopter of an electronic prescribing system to reduce medication errors. He and his colleagues were exploring the potential for an electronic health record system years before the federal stimulus legislation and Affordable Care Act encouraged medical practices to use them.

Now, Nunlist said, the practice is looking at analytic software that would allow physicians to study patients with chronic diseases more effectively, to help doctors figure out which diabetics, for example, would benefit from more regular visits and which ones are doing fine on their own.

More advanced software allows family practices to keep track of medications, vaccinations and all the little details that might get lost in an inch-thick paper file of a patient’s record. It also could improve communication between separate health care providers.

Nunlist compared health IT to air travel. A person flying from Manchester to Chicago will check his bag in New Hampshire and expect, when he gets off the plane at O’Hare, to find his luggage waiting for him. Sure, a few bags get lost, but for the most part, the system works. Not so in medicine.

“Patients have assumed that, of course, that’s happening in medicine,” Nunlist said. “But let me tell you, it isn’t.”

Family physician, specialists and hospitals don’t coordinate on care nearly as much as patients believe they do, he said. Electronic records can improve access to patient information when it is most needed.

But the transition hasn’t been easy. Even Dartmouth-Hitchcock has struggled with electronic health records. The learning curve was steeper than many expected, taking months for Dartmouth-Hitchcock physicians and nurses to get comfortable using the new system when it was rolled out in 2011. That created patient backlogs in many areas, including at Norris Cotton Cancer Center, where patients were delayed in getting chemotherapy.

White River Family Practice hasn’t struggled nearly that much, Nunlist said, but staff members have worked hard to ensure its success. They looked at every work area — billing, nursing, scheduling, care providers — and created a list of the “must haves” and “nice-to-haves.” Then a team of about eight visited other practices in Vermont, looking for a system that would work best for them. After they settled on one, White River providers spent months figuring out how they would work in a digital world. They made tweaks to the software when it arrived and continue to meet weekly to assess how it functions.

“We were committed to picking the right system and to making it work throughout the office before we even committed to doing it,” Nunlist said. “We felt this is going to happen and it better happen correctly the first time.”

It still isn’t perfect. Every hospital and small practice has its own electronic records system and they don’t always function well together. White River doctors can see on their computers whether one of their patients has been treated at Dartmouth-Hitchcock Medical Center. However, the reverse is not true. There is an interface that White River could purchase that would fix the problem, but at $25,000, it is too expensive for a small practice.

Still, Nunlist has encouraged his colleagues to keep investing in technology to develop better ways of caring for patients. And there has been total commitment among all the physicians to do so, he said.

More investment in analytic software would allow White River to do more, Nunlist said, to take a lot of information, break it down and identify the best ways of treating individual patients.

“We’re poised to be able to do that,” Nunlist said. “We need maybe $15,000 or $20,000 of investment in technology and some money to support somebody not doing that for free on Sunday morning. And we could take it to the next level.

“And I regret stepping away when that seems to be so close within grasp. So close.”

A Time of Transition

Now, at the end of their careers, Nunlist and Mason appear ready to move on with their lives, even if they have mixed feelings about leaving their colleagues and patients.

Nunlist will spend more time with his wife, Cappy, who recently retired from her job at Vermont Law School, where she was assistant director of the general practice program. Together, they will travel and see their three children and one grandson without having to worry about how it affects his office schedule.

“It opens up space and time in my life when I still have health to think about doing other things,” Nunlist said.

Meanwhile, Mason intends to stay as busy as ever practicing medicine, just in a different way. He will shift his attention away from his family practice and work instead to help people with opiate addictions. Mason also intends to keep teaching students at Dartmouth’s Geisel School of Medicine and spend more time volunteering. He travels to Honduras twice a year to help run a health clinic there and, when in the Upper Valley, Mason intends to see more patients at Good Neighbor Health Clinic, the free clinic he helped start with his colleague, Paul Manganiello, in White River Junction in 1992.

Mason does not even like to use the word “retire.”

“I’m not stepping away,” he said. “I’m transitioning.”

Mason will have more personal time with his spouse, Laurie Harding, a New Hampshire state representative who is vice chairwoman of the House Health, Human Services and Elderly Affairs Committee. But Mason is eager to keep practicing medicine, and with greater flexibility and freedom in his schedule.

Nunlist is excited about the next phase of his life, too, but became wistful when he talked of leaving his colleagues.

It is a group of people — the practice has nine providers in total — with whom he has worked “extraordinarily closely for most of my waking hours for 30 years,” he said. Together, they built a progressive practice that was innovative and used technology in ways that few other small family practices could. Nunlist’s colleagues will continue that work, he said, but it is difficult to imagine not being a part of it.

It brought to mind a moment when his friend, a Marine, passed the anniversary of his discharge date, which meant that he was no longer as likely to get called up for a troop deployment. Nunlist congratulated his friend that day, but his friend wasn’t rejoicing.

“He said, ‘No Mark, you don’t get it. Those are my buddies. Those are the people I went to battle with. Literally,’ ” Nunlist said. “This group that I just retired from were people that I was in the trenches with. We were trying to solve (problems), day-to-day, month-to-month, year-to-year and looking out in to the future. … How are we going to advance the peanut, as they say? How are we going to make progress?”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.