Myths of Primary Care

Many people think they don't need to go see a primary care physician (family doctor). They think that specialists handle difficult diseases and so any simpler disease will be no problem for them. These people are wrong.

Dr. Erick Cassell wrote:

"A common error in thinking about primary care is to set it as entry level medicine... and, because of this, rudimentary medicine-for mostly (say) the common cold and imaginary illnesses. This is a false notion... The higher we go on the scale of a specialist training, the less complex the medical problem becomes... One should not confuse highly technical, even comlicated, medical knowledge-special practical knowledge about an unusual disease, treatment (complex chemotherapy, for example), condition, or technology-with the complex, many-sided worldly-wise knowledge we expect of the best physicians... The narrowest subspecialist, the reasoning goes, should be able to provide this range of medical services. This naive idea arises, as do many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of coarse, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations-for example, ordering tests or x-rays when waiting a few days might suffice-thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor."

(taken from How Doctors Think by Jerome Groopman pgs. 97 and 98)

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Preventive Medicine

In the past, I have mentioned that one of the keys to fixing our healthcare system, and more importantly improve people's quality of life, is preventive medicine. I thought it might be good to share what preventive medicine means to me.

As an exercise science major I have studied extensively physical activity's profound impact on our overall health. In fact, increasing physical activity has a greater impact on overall health than any other lifestyle change. All-cause mortality is decreased by increasing physical fitness alone. This is a part of preventive medicine, but it doesn't stop there. Allow me to illustrate using a hypothetical example.

Let's say somebody has numerous gallstones which block the gallbladder and cause immense pain. This pain would lead that person to the doctor's office. The doctor assesses the situation and decides it would be best to surgically remove the gallbladder. This treatment alleviates the pain and the patient goes home happy right? Wrong. This type of medicine neglects the underlying lifestyle which caused the problem in the first place. Let's say that a major reason the gallstones formed was due to obesity. Obesity reduces the amount of bile salts in bile, thereby increasing the cholesterol content. Obesity also decreases gallbladder emptying. Now, the cause of the obesity is the person's high levels of stress, caused by their huge workload, lack of time to exercise, etc. Taking out the gallbladder still leaves the root cause untreated.

Another example is the man who comes into the emergency room with a broken arm. The doctor sets the arm in a cast and the arm heals perfectly. The patient is healed right? Well it turns out that the man has a drinking problem, he broke his arm because he was drunk and fell from his buddy's balcony. He comes into the ER a few months later with another drinking related injury.

Dr. Dan Schmidt shared another great story in one of my previous posts.

Essentially, a specialty doctor quick fixes many people's injuries, but too often the root causes go untreated. I don't really think a universal health care plan will fix this problem. How will free quick fixes give any more incentive for people to make lifestyle choices that will keep them out of the doctor's office to begin with? Preventive medicine helps people make these choices, choices such as controlling their diabetes, their weight, or their nutritional habits.

General practitioners are essential to providing this type of care. GPs see people over long periods of time. They are familiar with a patient's lifestyle and are able to better provide holistic care.

One of the things we need is more incentive for GPs to enter the medical field. Unfortunately, in the U. S., GPs make up only 13% of physicians available to help people. The U. S. is in dire need of this trend to change.

GPs make far less money than specialists and their work environment is far from ideal. Why would I choose primary care when I'll spend twenty years paying off student loans which are pretty much irrelevant to a specialist?

Obama has mentioned that he will help with primary care physicians' student loans. That would be great. Only with more primary care physicians can we really start treating the whole person, practice preventive medicine, and come up with a realistic health care system that is sustainable.

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The Save

Dan J. Schmidt

I started medical school thinking I wanted to be a family doctor--someone who could work in a small town and deal with whatever walked through the door. But in our third year, when we received our first taste of clinical medicine, I found my surgery and ER rotations exciting. I was at our state's major trauma center, and I loved it. Fixing things gives me a thrill--and the power to save a life is even more alluring.

Each "save" felt like a miraculous triumph. Take the nineteen-year-old visiting Australian, stabbed in a random street altercation, his blood pressure dropping as fluid accumulated around his heart. Right there in the ER, he had his chest split open and his right ventricle patched by the very cool chief surgery resident.

But after several weeks of 5 a.m. surgery rounds and every-third-night call, I started to feel a nagging sense of unmet need, both my own and the patients'. To me, it seemed that the specialized care we were giving was excellent but fractured: No one was responsible for the whole person.

It was 8 a.m. during my third week of the rotation. The third-year resident had led us medical students through our rounds, and there'd been time for some drug-rep doughnuts before we headed down to the ER. At the nursing station, we joined those who'd been on call the previous night and were sharing their war stories.

"You shoulda seen what we just got!" said one of the students.

A twenty-something guy had come in with a near-amputation. "He cut off his arm with a Skilsaw!" (the powerful circular saw used by professional carpenters and builders). "He's down in the OR now. Orthopedic surgery thinks they can reattach it."

After the descriptions of the bones, the x-rays, the blood loss, I asked one student, "Which arm?"

She frowned. She didn't know. I looked at the x-rays. It was the right.

I caught the gaze of a third-year surgery resident and asked, "Do you know how hard it is to run a Skilsaw left-handed?" (It's a lot harder than scissors. I knew: I'd spent a year building condos before I'd entered medical school.)

The resident nodded. This injury was no accident.

That evening I heard the orthopedic surgery team talking about how happy they were with their neurovascular and bone-plating work. It looked like the patient's hand would be saved. But they were aware of his psychiatric risks: He was being kept in restraints until they could get a "full psych eval."

The guy was in the post-operative ward; when I'd gone around to check on my patients, I'd seen him. Straight black hair. Intense gaze. Cold affect. Girlfriend sitting at the bedside, then leaving in tears.

The next morning, the psych team came by to evaluate him. They started him on an antidepressant, but thought that he was no risk to himself.

Coming back from lunch that afternoon, I heard stat pages overhead, calling the chief ortho resident to a "thrash" on the post-op ward. Hurrying down the hall, I saw a bed barreling towards me, pushed by three residents. A nurse knelt on top of the patient and his bloody sheets, pressing her hands hard against his arm as they steered the bed into the elevator.

"What happened?" I asked the senior resident.

"He pulled it off! All that work, and he just pulled it off!" he raged.

Before the elevator doors closed, I heard him say, "Damn if we're putting this back on again! He'll get what he wants!"

And off they went, back down to the OR.

I went to his room. There were fine blood spatters everywhere, and a big, dripping arc across the far wall. The Filipina housekeeper quietly mopped the burgundy-stained floor, shaking her head.

A technological success. A medical catastrophe.

We had treated this man's injury, reattached his limb, evaluated his psyche--but not one of us had tried to care for the whole human being. It seemed that our academic and specialized-care system had accomplished a wondrous feat of technological prowess, but didn't foster a focus that could actually heal the patient.

Standing amid the gory mess left by a man I didn't know--a man who seemingly wanted not to be whole--I realized that I wanted to treat the whole person.

So I decided to stick with family medicine and left trauma and surgery behind.

A save still thrills me, although in family medicine they are thankfully rare. I get to keep my eye on the big picture. And I'm rewarded by a constant stream of quieter saves--the type 2 diabetic patient who loses fifty pounds, the alcoholic who's been dry for a couple of years now, the young single mother who's learning to raise her infant well.

These triumphs, bloodless but still lifesaving, keep me going.


About the author:

After seventeen years of practicing full-spectrum family medicine, Dan Schmidt now covers small-town practices on the weekends. Married, and with four grown daughters, he also fixes old cars and remodels houses--yes, sometimes using a Skilsaw. "I find that writing eases my need for reflection." This is the first of Dan's stories to appear outside of his Web site.

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