A Country Doctor Writes:

Primary care is a messy business. Nobody has just one simple problem and no patient has all the typical symptoms for their diagnosis. Most don’t even tell us everything that’s going on. And most don’t follow their treatment plan completely. But this may be O.K., since we often change our minds about what is right or wrong in the practice of medicine.

Knowing what constitutes success in frontline medicine is not easy. Let me illustrate:

A middle aged smoker comes in for a follow up on his blood pressure treatment and mentions that he would like to try Chantix (varenicline) to help him quit. My nurse has already secured our practice credit for documenting his smoking status. I can use certain billing codes to document my counseling on the subject, and I can get credit for printing out the drug information, even though the pharmacy also provides a printout. This is a successful visit, it might seem.

But I also ask, “Ron, what makes you want to quit at this particular point in time?”

“Well, I’ve had this funny cough, like a dry hack, for the last two weeks whenever I take a deep breath”, he answers.

Ron turns out to have a very small, resectable lung cancer. My question about the reason for his request probably saved his life, and catapulted us from shallow administrative success to probable or at least possible clinical victory, without making any further difference in my own quality metrics.

Another patient, Ellen Wurtz, a diabetic in her late fifties, makes me look like I am treading water. Her blood sugar, blood pressure, weight and cholesterol are all above target, and she never brings in her blood sugar logs. She has nonspecific side effects from every new medication I prescribe for her. But she keeps all her appointments. We talk about how she can best help raise her granddaughter, now that Ellen’s daughter is in rehab, and we talk about how she can support her husband’s self esteem after he lost his job at age 61. Am I wasting her time and mine, or am I part of the safety net that helps her keep her family going through difficult times that threaten to shatter their lives?

Joe Parva, a 65 year old with high cholesterol and two previous heart attacks, never reached his LDL target of 70 or less, and both his triglycerides and HDL were out-of-range. I just kept him on his Lipitor. I didn’t prescribe Zetia (ezitimibe) to push his LDL to target, and I never gave him niacin for his HDL or a fibrate for his triglycerides. We talked about it several times, and when I told Joe that Zetia and niacin had never been shown to lower heart attack risk, he chose not to try them. After hearing that there were no studies comparing heart attack risk on 80 mg of Lipitor alone versus Lipitor plus a fibrate, and after hearing that the combination increases the risk of side effects, he elected not to be a guinea pig. If we had done quality metrics around lipid treatment during the last half dozen years, Joe would have made me look pretty bad, but after the introduction of last year’s new guidelines, Joe’s care has been top-notch all along.

When my own children were infants, we laid them on their bellies to sleep because science had shown that infants sleeping on their back had an increased risk of Sudden Infant Death Syndrome (SIDS). My grandchildren were placed on their backs instead, because by then science had shown that infants sleeping on their bellies had an increased risk of SIDS.

Every primary care provider’s day is filled with moments of opportunity to do the right thing or not; we are almost always walking that fine line between failure and success. Sometimes the balancing act is about noticing clinical signs, sometimes it is about setting the right priorities, sometimes it is about weighing guidelines versus actual evidence and applying it all to individual patients. Much of the time we won’t know if we did the right or the wrong thing until much later, and in many cases we’ll never know. All we can do is be diligent, do our best and be willing to learn and re-learn.

Just like tightrope walkers, we can’t focus our attention on the hard surface beneath us should we falter and fall, but on what’s straight ahead, or we will lose our courage and our concentration.

A career on the frontlines of medicine requires that you are comfortable with uncertainty, because primary care is very often messy and quite seldom completely straightforward.

In the words of Elbert Hubbard:

“The line between failure and success is so fine. . . that we are often on the line and do not know it.”