I Do Fewer Elective Procedures Now Than When I Started Out. This is Why:

Access is a big problem in primary care. We must be available. We are the first point of contact, the gatekeepers who sort the chaff from the wheat. We are the ones who want to see people early in order to decide how serious their symptoms are. If it takes three weeks to get in to see us, people will come to harm.

Maybe this is more essential in a rural area where there are no walk-in clinics and where many people hesitate going to the emergency room even when they ought to, because of traveling distance and fear of hospitals.

I will double book a swollen elbow because it could either be a medical emergency like a septic joint that needs quick triage or a benign but bothersome olecranon bursitis which takes me only a few minutes to drain and instill some methylprednisolone into. But a large sebaceous cyst that needs a delicate removal so as not to rupture its capsule is something I don’t want to take up the time to do. First, the consistency of equipment available is variable and, second, I could see three other patients in the time it takes to prepare for and perform that procedure. The surgeons at the hospital down the road are better set up to do that quickly than I am and even if there’s a wait to see them, nobody will come to harm.

This choice that I have made is in some ways causing me to lose skills; I am no longer very good at injecting “dry” knees, for example. But on the other hand, for every year that I am in practice, I believe I am becoming a better diagnostician, teacher and therapist. I guess my circumstances and my personal interests are moving me in the same direction: The doctor who will see you now and the doctor who will stick with you over time, not necessarily the doctor who will do it all, even if he could do it in a pinch. I think I am putting my abilities to the best possible use, given where I am practicing.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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