A Limit to to Primary Care?

Ever wonder why the pictures of offices are so weird? Me, too.
Somebody put some better free media on wikimedia, please.

As a future specialist, I'm struggling with letting go of primary care. As a pre-med and medical student I got frustrated when my OB/GYN didn't refill my albuterol for mild intermittent asthma. In response, I promised myself that I would not forget basic medicine.

The other day in continuity clinic, I saw a woman with a few medical problems. I wanted to do her age-appropriate USPSTF screening, which is germane to primary care. I had to look up the recommendations because I don't do a lot of screening and immunizations. I care for a single sex population which is largely of reproductive age, and my anticipatory guidance and lifestyle modifications are almost always about pregnancy and sexual behavior.

But I like being a responsible doctor, so I've modified my well woman templates based on age and USPSTF and CDC recommendations. I've built in HEADS screens for adolescents and breast and colon cancer risk scores for older patients. I remember how to read EKGs and do when I order them. I remember how to read chest X-rays and do when I order them. And I know the first few options for medical therapy for the most common problems: community-acquired infections, hypertension, diabetes, obesity, asthma, hypothyroidism, depression, early heart failure, and high cholesterol. I can respond to a heart attack or a stroke.

I'm not pretending I could be a successful family medicine or internal medicine resident. I have to look up the screening recommendations every time. I don't remember or know more than half of the medications they use, I'm sure. I can't ever remember the childhood milestones and immunizations. Don't look to me when someone's in kidney, liver, respiratory, or late heart failure. Find someone else for the endocrinology zebras and for the love of the patient, please have someone else run the code.

But I can look up what the evidence says when I have a well woman exam. So I looked up the tests I was supposed to order. When I went to staff the patient, my generalist attending scrapped most of my plan. "There's a limit to how much primary care we can do," she said.

This made me sad. Most of these women don't have another doctor. If they do, I begin to wonder why that other doctor can't do their pap tests (until things get surgical). I wish women only had to see one doctor unless they had more advanced medical problems. I enjoy continuity of care and building the physician-patient relationship. I find preventative screening a fascinating topic and a very satisfying intervention to execute. I love discussing lifestyle modifications because they knock at the door of virtue.

That said, I'm heading for fellowship and leaving primary care further and further behind. I think that primary care is an excellent sphere for midlevel practitioners, even though I love it.

In the future, there will certainly be a limit to how much primary care I do. If I become an MFM, I will do basically zero primary care and I will rely on specialists to help me manage the medical problems for my high risk patients with heart disease and other problems. (I'll still manage plenty of hypertensive disorders, obesity, diabetes, and thyroid disease myself.) That's a little hard to swallow, but I still dream of extending myself by joining a multidisciplinary practice that can be a hub for a woman's healthcare, so she doesn't have to spread out her time, energy, and medical records.

Coping with Ulcerative Colitis

Credit: Hummuskiller

I am writing this as I am drinking four 450cc barium sulfate containers for an MRE. It's disgusting, and the Crystal Light is not helping.

I didn't realize that I had anything to work out mentally or emotionally with UC. It's mild, it's moderately controlled, and I'm used to big life shifts (getting a chronic disease doesn't hold a candle to becoming a doctor). But in the past few weeks I've had two experiences that showed me how lonely UC has made me, and have helped me.

I was on L&D and was getting ready to do a C-section. I clicked into her chart and saw that she had UC. It always makes me feel a little bit of companionship. The C-section was with one of our pricklier attendings, Dr. M. Of all our attendings, she is the most challenging: she once asked me if I listened to patient's lungs after I'd ruled out PE (hard to explain if you don't get that). As the section proceeded I nicked an arteriole. "Are your cases always bloody?" she asked derisively.

I decided to be silly about it, since the patient was under general anesthesia. "Very," I replied. "It's always awful." To my surprise, Dr. M grinned at me. Had I cracked Dr. M? We continued to banter back and forth as we opened the abdomen. By baby time, we were chatting amicably.

"Bummer that she had to get general," Dr. M observed as I anchored my hysterotomy repair. "It was her platelets, from her methotrexate. Come on," Dr. M went on playfully, "can't you tie better than me? Me with my arthritis?"

"You have arthritis?" I asked softly. Arthritis in a surgeon is a bit of a sensitive subject, because your career is in your hands. When you're mask to mask over an abdomen, few people in the OR can hear you, so I asked quietly.

I guess I
should have
this here for
me? Or Dr. M?

"My gosh, it's gotten so bad in the past few years," she muttered. "The colitis is better, though."

My eyes grew wide. "You have ulcerative colitis?" The word "colitis" doesn't go with the word "arthritis" unless someone is talking about UC, or a very unlucky and uncharacteristic type of Crohn's.

Dr. M. looked up from the field and met my eyes. "Yeah, I have ulcerative colitis," she said.

"Me, too." I said. I completely forgot I was operating, I forgot about anything except for Dr. M. Here we were, operating across from each other and on a patient with our condition.

Dr. M turned her attention (and mine) back to the fascia. "I remember once when I was a resident in the middle of a 72. We worked the whole weekend then. And there was a vag hyst to do, and I felt so bad that I asked the third year to do it. And she made such a stink about it."

I was amazed. A "vag hyst," or vaginal hysterectomy, is a gem among procedures for OB/GYN residents. For a senior resident to give away a vag hyst, she must have felt terrible. (Like, interferon-soaked, uncontrollable diarrhea and tenesmus terrible. Sort of like I feel now that I'm in the middle of the fourth barium dose.) I didn't say anything and we went through the rest of the C-section quietly. There was a companionship that didn't need words. I was flooded with a strange relief.

Someone else knew what is was like to have UC as an OB/GYN resident. Someone knew what it feels like to be rounding and to suddenly need to find a bathroom that people don't mind smelling. Several times as an intern I had over ten patients to see and in the middle of them I suddenly had to go down a flight of stairs and into a guest bathroom, the only one I know of where people won't complain about a BM.

The second experience isn't as much of a story. I have scishow and vlogbrothers on Feedly and clicked on this Hank Green video because it seemed medicine-related. To my surprise, Hank Green has UC. Unsurprisingly he has really smart things to say about it. That's all for now; I can't finish this last barium bottle, but it's time to get the MRE. (Thankfully, there's glucagon in the near future to make me feel better.)