Sunday, October 30, 2016

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.

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