Archive for the 'Primary Care is…' Category

One Shot Medicine: The Stilted Pseudo-comprehensiveness of American Primary Care

As a Family Practitioner, I trained and I always practiced with the philosophy that my work is best done over time, in an ongoing relationship with each patient. The longer I know someone, the more they trust me and the closer they let me into their personal lives and the workings of their minds. In many cases I treat several generations of the same family. Even with a brand new patient, I often find out I know and have treated several of their relatives, and such new patients often act as if they already know me.

All that is very different from the stilted pseudo-comprehensiveness of medicine in America today.

First, those in power think that we can cover each patient’s presenting concern AND all appropriate health screenings, immunizations and other public health issues, along with the latest protected-minority-and-political-correctedness inquiries, in our typical fifteen minute visits.

“They”, whoever they are that decide coding standards, Patient Centered Medical Home standards, Meaningful Use standards, EMR workflows and the general purposes of life in medicine, have, in their inscrutable wisdom, decided that all of these items are best addressed by administering standardized, “validated” questionnaires every time we see each patient, just like even a patient with a dozen prescription medications is supposed to get a complete medication reconciliation every time they walk through the door, even for a hangnail. At twenty seconds per medication, that would take up four of our precious fifteen minutes, just for starters.

“But not all of this has to be done by the physician”, goes the refrain. “Team members, practicing at the top of their license, can do this”.

Right, have a medical assistant who never took a day of pharmacology reconcile medication lists, and trust that they know that Compazine is prochlorperazine, Trilafon is perphenazine, Phenergan is promethazine, and Thorazine is chlorpromazine. And, that metoprolol tartrate is a 12 hour drug, while metoprolol succinate is taken once every 24 hours and that bupropion comes in short, intermediate and long acting varieties.

And, right, keep telling me that a two or nine item questionnaire administered in rapid-fire fashion during check-in will outperform a trusted physician leaning forward, asking a long term patient “how are you feeling?”

And, right, tell me how much a woman with pneumonia appreciates being cornered for her overdue Pap smear when she’d rather just get an antibiotic and some cough medicine and crawl back under the covers for a few days.

And, right, tell me the local pastor is going to be forthcoming with a medical assistant he also sees in the second pew from the back of his church every Sunday as she probes his alcohol habits while pumping up the blood pressure cuff.

And, right, that new patient with anxiety and heart palpitations is going to feel much more reassured after her EKG and careful history and physical and a thorough discussion about whether or not she would want to be resuscitated if her heart were to stop suddenly.

Doctors have been doctoring for thousands of years and we have learned a few things along the way. Medical progress usually comes to practicing physicians via scientific research and from the major teaching institutions.

Since when do we really think it will come to us from bureaucrats, statisticians and other nonmedical sources?

Primary Care is Personal and Passionate

It’s been thirty years since Dr. Pete shook my hand on graduation day and slapped my back, his gravelly voice mumbling a wisecrack that couldn’t quite hide his emotions. I was the first foreign medical school graduate in our small residency program and he had trusted me, just as I had trusted him, through three years of hard work and many challenges.

Our residency program was only a few years old, and my specialty was only twelve when I started. Family Practice had begun with the realization in the 1950’s that fewer and fewer medical school graduates chose to enter general practice after their internship year, but instead went on to specialize. With the knowledge explosion of the twentieth century, the need for well-trained generalists gained acceptance and the void left by retiring GPs was filled by the graduates of three-year Family Practice residencies focusing on 1) first-contact care; 2) continuous care; 3) comprehensive care; 4) personal care (caritas); 5) family care; and, 6) competency in scientific general medicine.

Medicine has changed a lot, and America is not the same as when I first came here. Primary care is more complex, with more demands from forces outside the physician-patient-family constellation we thought and talked so much about thirty years ago.

In the early 1980’s CT scanning had just been introduced, but there were no MRIs in our state yet. We didn’t have EMRs, there were no Prior Authorizations, no direct-to-consumer drug advertising; we didn’t even have the Internet.

What we did have when I started out was a generation of young doctors with a shared passion for clinical, albeit low-tech medicine, and for taking care of patients and families in their small communities.

My generation had sit-ins over minor injustices in High School. We wore bell bottoms and sang songs about love, peace and justice. We wanted to make the world a better place. Those of us who wanted to become doctors watched Marcus Welby, M.D. – I did, as an exchange student, on a large console TV in my Massachusetts host family’s suburban living room. My determination from a year of illness in early childhood to become a doctor gelled right then, in 1971, into a vision of what I have been fortunate to actually be doing for the last thirty years.

I have better tools now than Marcus Welby had, and the technical standard of care has made huge leaps since my residency days. But something has gone missing. The idealism and passion of physicians has become worn and frayed as a result of the paradigm shift toward the manufacturing view of healthcare. Healthcare is now becoming impersonal. It is organized, delivered and measured like industrial output in automobile plants. It is mass produced and valued by its consistency and conformity, even though no two patients are exactly alike.

Most of our patients still come to us looking for personalized care, but they feel the pinch of our newly imposed agendas in their fifteen minutes with us. We are more and more put in the role of public health officials, collecting data for Government and insurance companies and promoting their population-based agendas.

But when we really engage with our patients we can see the power of the traditional doctor-patient relationship that many others in healthcare have tried to negate.

The passion and commitment of doctors have been de-valued as we are instead building entire systems to do what Marcus Welby and his nurse did, day in and day out, when they practiced their professions and held themselves to their standards and ideals.

But no “system” can replace human effort and commitment. Doctors, nurses and everybody else in healthcare need to be at the center, side by side and face to face with their patients and the “system” needs to capture, rekindle and support their passion, not suppress and replace it.

Family physicians were trained to be capable in areas where our ability to keep up is now challenged, just like the General Practitioners’ sixty years ago. Fewer and fewer primary care doctors now set fractures, deliver babies or perform even minor surgeries and procedures.

Increasingly, we are instead taking on the role that the journal Canadian Family Physician calls “broker of choices”. With the Internet and all the media exposure about medical issues, we are no longer patients’ primary source of medical information, but we are the ones that are best suited to help them sort out information and compare alternatives.

This actually builds on our specialty’s founding principles. We are still the glue that holds the parts together, even when other specialties are involved. We provide the first contact, the continuity, the personal focus and the family view of the patient and their support system; it requires our solid competency in general scientific medicine; and it is comprehensive in the ancient meaning of the word as it derives from comprehendere – ‘to grasp mentally’; we help our patients with the big picture while we attend to their everyday medical needs.

Primary Care is not General Motors

When Uncle Will needed a hip replacement, he chose an orthopedic surgeon, Jason Brockman, and Mountain Memorial Hospital because of their excellent reputations for low complication rates and satisfied patients. The process reminded him of when he bought his first brand new truck.

Norm and Clara Anderson chose Dr. Wheeler as their family doctor once they had made the decision to relocate to Maine and raise their family away from the big city. The process of choosing a doctor reminded them of working out where to live. That was twenty years ago, and Dr. Wheeler has seen them and their two daughters through childhood illnesses, one heart attack, two cancer scares, Clara’s bouts of depression and irritable bowel syndrome, and their youngest girl’s struggles with migraines. A graduate school student near Boston now, Holly still checks in with Dr. Wheeler when she visits her parents. The Andersons sometimes reflect that Dr. Wheeler is like a pastor and a friend, and not just their family doctor.

Dr. Brockman is part of a big group of orthopedic surgeons now, and Mountain Memorial has merged with Countywide Health Systems. Uncle Will’s children know that Dr. Brockman still does top-notch work, because his outcomes are posted on the Internet.

Dr. Wheeler also works for Countywide Health Systems these days. He sometimes jokes that he is a healthcare factory worker now, and the Andersons get to rate him every year in Countywide’s patient satisfaction survey. Asked if they thought Dr. Wheeler delivered high quality care, they answered unequivocally yes.

Dr. Wheeler gets graded on how many of his patients reach targets like immunization rates, blood pressure levels and average blood sugars. He also gets graded on how many of his diabetic patients are prescribed ACE inhibitors, and how many men with heart disease, like Norm, are taking aspirin and beta blockers.

The Andersons understand the importance of these quality metrics but they are confused about why Dr. Wheeler’s diagnostic skills aren’t on his report card. He was the one who diagnosed Clara’s IBS after two of her previous doctors failed to do so. He also found Clara’s pheochromocytoma, the very rare tumor that presented as a slight vibration Norm could feel when he put his arm around Clara’s waist in bed at night. He also seemed to know the diagnosis the instant Norm arrived at the clinic with his heart attack, even though his only symptom was nausea and even though Norm had passed a stress test for work the month before.

Clara thinks Dr. Wheeler has worked miracles with Holly, her youngest daughter. She was a shy and insecure girl with crippling bouts of vomiting. Dr. Wheeler diagnosed the spells as migraines, tried and succeeded in preventing them with medications and he gave Holly a sense of control over them by helping her identify her triggers. He seemed to spark a scientific talent in Holly that is now becoming her career and life passion.

On TV the other night, Norm and Clara saw the Chief Executive of Countywide Health Systems talking about the future of healthcare. He pointed to statistics from their surgery department that outperformed every other health system in the region. Then he spoke of primary care. He showed the rates of compliance with dozens of guidelines, and he pointed out that the new systems Countywide had begun to put in place throughout all of its primary care offices were going to bring quality in primary care to new and even higher levels.

The executive went on to say that healthcare cannot rely on mom-and-pop individual doctors offices or exceptional efforts by superclinicians to deliver the quality healthcare America needs now and into the future. Just like in aviation and manufacturing, process design and quality measurements are the key elements that will raise quality standards and eliminate human error as well as unnecessary variability in healthcare.

Next up on the evening news was an in-depth story on the corporate culture within General Motors that allowed faulty ignition switches to be installed in millions of cars over so many years.

The next story was about the Veterans Administration scandal over forged waiting lists that had tried to cover up the long waits for access to healthcare in the VA system.

Right before the weather was a piece about how long it has taken this country to recover from the collapse of the banking industry and the fines paid by some of the top banks in recent years.

“I wonder how all this corporate medicine and process design talk will affect Dr. Wheeler. They may not think they need superclinicians, but I’m grateful we’ve had one for the last twenty years”, Clara said and turned to her husband.

Primary Care is Messy

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.”

Primary Care isn’t Brain Surgery

A brief exchange I had with a neurosurgeon in the comment section on KevinMD the other day left me pondering the diversity of skills needed in different types of medical specialties, and also how differently technology has impacted various specialties during my years in medicine.

Neurosurgeon F. X. Wall disagreed with the post author, Dr. James Aw, about the value of old-fashioned physical exam skills, because in neurosurgery the anatomical accuracy of interventions has approached 100% as a result of new technology.

I can see that in neurosurgery and many other surgical specialties the advances in imaging have made clinical exam skills too inaccurate to guide treatment in this day and age, just like few cardiologists would forego an echocardiogram in evaluating a heart murmur.

My reply to the neurosurgeon was:

“Good points, but possibly more relevant in specialty care. When a patient in primary care has nonspecific symptoms, like shortness of breath, we need doctors with enough clinical exam skills to notice pallor, prolonged expiratory phase, JVD, irregularly irregular pulse, tachycardia and all the other clues that help us decide what tests to order first.”

The more I thought about it, the more fundamental this seems to me: In primary care, we don’t have many technologies that make clinical exam skills entirely obsolete. When I see a patient in my office 20 miles from the nearest X-ray machine, when a simple lab test won’t be resulted for 6-24 hours, when there is almost no way I could get a same-day echocardiogram or MRI, clinical exam skills are essential.

Time and distance aside, primary care doctors also need enough clinical skills to either make the diagnosis without technology or at least to know which diagnostic possibilities to pursue before others; if we did every possible test in every case, we would obviously waste a lot of resources. Just like in my example of shortness of breath above, almost every presenting complaint in primary care has many diagnostic possibilities, ranging from trivial or self-limited to serious or even life-threatening.

The broad range of differential diagnoses to consider when we evaluate both common and unusual symptoms people see primary care providers for is something to consider when we look at what type of clinician we assign to front-line duty. In many practices, this task falls on the least experienced providers. This is also the case in some freestanding urgent care centers. Having more seasoned doctors available as back-up isn’t necessarily a good system if the clinician on the front line hasn’t seen enough to know what he or she doesn’t know.

There have been many attempts to use technology as a substitute for clinical experience in front-line medicine. In my opinion none have really emerged that can compare with the technological revolution we have seen in imaging, microsurgery or laboratory diagnosis.

Systems that require the clinician or the patient to enter data in order to produce differential diagnoses, for example, are clumsy and either simplistic or bogged down with detail, and assume that everybody shares language and values they in fact don’t. In real practice, the patient who says “it only hurts a little”, but whose pained or panicked facial expression makes the hairs stand up on the back of a seasoned doctor’s neck is not likely to be better diagnosed by today’s available technology.

Even in more technology dependent specialties, there are good reasons to cultivate low tech proficiency. What does a doctor do during a hurricane or an ice storm, during a war or on a foreign assignment when there is no technology available? Why would we not listen to hearts, lungs and peripheral blood vessels and then compare our impressions with the results of the imaging?

And, without excellent clinical exam skills, how do we evaluate unexpected or conflicting technology-derived results?

Ultimately, we need both hands-on and technical assessments in health care. But on the front lines, we are perhaps more dependent on our clinical assessment skills. I never get praised for ordering lots of tests, only for ordering the right one.

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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