Primary Care (22/30)

     Primary care is an odd duck.  It's certainly not the most glamorous part of medicine. Patients come in complaining of colds and acid reflux, not trauma wounds and surgical emergencies. It's not exactly the stuff of primetime medical TV shows. It can be tedious and monotonous, and it's no wonder that many primary care doctors become burned out over time. A large part of the burn out is the feeling of repeating yourself over and over without being heard. Much of primary care deals with treating chronic conditions and, more importantly, using preventive medicine to prevent these conditions in the first place. The focus on preventive medicine means that the same topics (e.g. exercise, healthy eating, safe sex, smoking cessation etc.) are covered with almost every patient, yet it can feel like an exercise in futility. It can seem like the patients who are doing well already know and follow the advice you're giving them, and the others have heard it all before and have ignored it. You can't help but ask why they would suddenly listen to you now. 

     A big part of the problem is that primary care battles against silent killers. The diabetic doesn't see the importance of keeping their blood sugars under tight control until they discover the foot ulcer they couldn't feel and suddenly face losing their toe. The patient with high blood pressure doesn't take their medications consistently until they have a hypertensive emergency. The alcoholic doesn't cut back on their drinking until they develop cirrhosis. The patient with high cholesterol doesn't change their diet until they have their first heart attack. The morbidly obese patient doesn't try to exercise until they realize it hurts too much too move. When you try to prevent problems rather than treat known issues, it's easy for patients underestimate their risks or think that they will be the exception. There are some tricks to get your message across, such explaining to the man with high cholesterol that his eating choices and smoking habit not only increase his risk of a heart attack but also decrease his ability to achieve and maintain an erection, yet all too often primary care can feel like an uphill battle, fraught with frustration.

This is not good.

PA-Cat Bob approves of PCPs

     Here's the thing though: primary care might not seem like the most interesting or the most glamorous, but it is arguably the most important specialty in medicine. A primary care provider (PCP) might not be using their fingers to plug lacerated arteries and they might not be compressing a chest just to keep someone's blood pumping, but they are saving lives. They're helping to prevent patients from ever getting to that point of crisis. PCPs are the gatekeepers, responsible for recognizing the difference between when a patient has a common or manageable condition, and when they need to seek a specialist's help. They are the providers who are there for their patients at all stages of life, who get to see their patients in sickness and in health, and who have a truly awesome opportunity to get to see the whole picture of their patients rather than simply how a patient presents in a crisis. And who knows? PCPs might just make that once in a lifetime save after all. The man a PCP works up for iron deficiency anemia might turn out to have esophageal cancer causing an upper GI bleed (and thus the low iron levels). The young guy with pneumonia might have a carcinoid tumor that no one else caught before because they treated the immediate problem and didn't notice the suspicious recurrences of lung issues. The PCP who actually takes time to listen to his female patient and not be biased by the opinion of previous providers might recognize that her malnutrition and frequent bouts of vomiting are actually due to celiac sprue and not an eating disorder.* 
     I don't know whether or not I'll end up in primary care, but I do know that after my rotation I appreciate it, and the potential impact it can have, more than I did before. With this in mind, I have some suggestions now for anyone who will ever be a primary care patient (aka everyone).

• Find a provider you like -I'm not saying you have to be picky and find the best clinician ever, but this is a potentially lifelong relationship you're starting, and there are certain characteristics you should look for. You should find a PCP who listens to you, addresses your concerns, and takes the time to make sure you understand any conditions you might have. Find a provider who is open and honest with you, and is willing to let you seek a second opinion if you're not sure about their advice. If a provider spends less than a minute with you, that's a bad sign. If they spend more time with drug reps than patients, that's a bad sign. If you feel like you're nothing but a nuisance to your PCP, that's a bad sign (unless you are being a nuisance; don't be that guy). You should know what your conditions are, what your medications treat, and why tests are ordered. Now, this last statement certainly requires you, as the patient, to actually pay attention when your PCP explains everything, but if you still have questions, you should feel safe asking them. 
• Get screened -A large part of preventive medicine is screening for certain conditions before they become a problem. While some PCPs may differ slightly in some of their screening techniques (e.g. getting blood work on all patients annually at any age vs. periodic checks after age 40), there are standard guidelines for many conditions which are continually reviewed and revised if necessary. For example, in general, sexually active women should be getting pap smears, women over 40 should be getting mammograms, and adults over 50 should get colonoscopies. The exact timing of these screenings might vary somewhat from person to person based on each individual's risk factors, but your PCP should know the guidelines and how to apply them to each patient. While I know that many people are afraid to be screened for medical conditions because some screening methods are uncomfortable and because sometimes it seems like ignorance is bliss, but the truth is that even if a screening test comes back with an unpleasant result, it's far better to detect conditions early when they're asymptomatic and there's hope of potential prevention or treatment, than later once they've become symptomatic and treatment is much more difficult or merely palliative. 
• Show up on time to your appointments, and call if you're not going to make it -This isn't some huge, life-shattering advice; it's just a courtesy that can be easy to forget. Both in my women's health and primary care rotations I experienced time after time of waiting at an office with all the MAs, nurses, and the PCP because a patient ran late or didn't call to say they wouldn't be coming. If there's limited time for lunch, or if it's at the end of a long day, you can bet most of the people in the office are pleased as punch to have patients who show up right on time (or even a little early), or who call to say when they're running late or can't come.

     There's more that I can (and probably will at some point) say about primary care, but tomorrow starts my week in orthopedic surgery, which means I'm back to a 3:15 AM wake-up call rather than my leisurely 5 AM alarm for my weeks in the surgical offices, so it's time for me to go to bed.

*These are all true examples, by the way. The first two come from a PA and an MD I know, and the third comes from the book How Doctors Think by Dr. Jerome Groopman.