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.


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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