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.”

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.