Quick and Easy: How to Save Primary Care

American Primary Care is a dinosaur, threatened by extinction. It is too large and too slow moving for today’s fast paced society. The Fed made us that way.

When this country needed to vaccinate more than a hundred million people, nobody imagined Primary Care offices could be of any help. Instead, pharmacies became the outlet, along with temporary sites in sports arenas and community centers.

Why were clinics like mine excluded?

It all happened because of all the requirements of comprehensiveness we slave under. Even if a patient only comes in once a year for something simple, we have to screen them for everything from food insecurity to depression to domestic abuse. We also have to address any elevated random blood pressure or gaps in preventative care, like annual flu shots or smoking cessation counseling.

This cumbersome requirement stems from the misguided notion that people who choose not to partake in preventative medicine should be ambushed (see my 2018 post Upselling in Medicine: Would You Like a Pap Smear With That ankle Brace, Ma’am?) if they happen to seek us out for a medical concern they themselves see as a priority.

We do offer those screenings when people come in for a physical or a Medicare Annual Wellness Visit, but why are we held responsible for doing them with people who elect not to come in for health maintenance visits?

In today’s reality, a quick visit for a wart or a urinary tract infection creates a lack-of-comprehensiveness quality liability. What if the patient doesn’t return for another year and we missed our opportunity to address everything our payers require of us?

The irony here is that the buzzword for Primary Care these days is Patient Centered. But it is anything but that when our required agenda pushes our patients’ own concerns aside.

The quick and easy patient driven services we could so easily perform are instead being delivered at freestanding urgent care centers, in pharmacies and big box stores, even through telemedicine companies. This fragments care and removes from our workday the less complicated, lighter visits that could give us a welcome variety in our otherwise chronic care focused workday.

Family doctors were trained to offer a broad variety of health care services according to our patients’ needs. We are instead now more and more working as geriatricians and public health policy enforcers.

Comprehensiveness is Killing Primary Care

All These Gut Feelings: A 10-Year Old With Belly Pain

Today I saw my young adult patient with a distant history of Crohn’s disease and new, chronic abdominal pain. Amitriptyline, 10 mg twice a day, has worked like a charm with no pain remaining, confirming my diagnosis of visceral hyperalgesia.

A few hours later I saw a 10-year old girl who has been to the emergency room several times with belly pain. Her family moved to this area a few months ago and we still don’t have the pediatric gastroenterology records her parents had signed a release for.

This girl has depression, anxiety and maybe more, and quickly established with a mental health provider in the area. She is on several medications. Today’s visit was an emergency room followup with labwork and a CT scan showing nothing abnormal.

Heather will double up with poorly localized belly pain most mornings, many evenings and not infrequently during her school day. The pains start and stop fairly suddenly and can last a couple of hours, sometimes more. Her bowels used to be on the constipated side for most of her life, but someone started her on Miralax and this has helped.

As I talked with Heather and her mother I learned she is often nauseous and pale looking during her attacks. And she sometimes has a very slight headache.

Her mother is on topiramate for migraines. That clinched it for me. I think little Heather has what people call abdominal migraines. I didn’t feel comfortable starting her on topiramate because she’s on the thin side, but as her mother had told me her hay fever wasn’t controlled by cetirizine, cyproheptadine seemed like a good place to start. This lesser known antihistamine is the second choice according to most experts. And for some reason, propranolol is the first choice for abdominal migraines, not topiramate. My thinking was that a nonselective beta blocker might worsen Heather’s depression.

We shall see. Is my gut feeling going to help modify hers? Just like it did for Wanda, who got her diagnosis ten years after I first met her.

The Correct Diagnosis – Ten Years Later


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”.

BOOKS BY HANS DUVEFELT, MD

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