What is Primary about Primary Care?

I am a general internist who has practiced primary care for my entire career. Over the course of that time, fewer graduates from medical school have chosen a primary care field which includes family medicine, pediatrics, and general internal medicine. The evolution of the medical industry has made it challenging to be in primary care fields. Insurers often dictate the kind of medications we can prescribe, the panel of specialists we can use, and the hospitals where patients can be treated. As evidence-based medicine has become the standard of care, we are often asked to take extra time to document that we are providing the treatment we know our patients need and have delivered. When patients are not consistently taking their medications, we get alerts from the pharmacy or from the insurer. When patients decline to have preventative screening tests, we are notified and held accountable. Add to this the fact that the payscale for primary care doctors is at the low end of the range and that medical school debt is at an all-time high, you can understand why it is difficult to attract medical students into these fields. In my community, the wait for a primary care doctor ranges between 2-12 months.

When I began my training in internal medicine, I fully intended to become a specialist. The thing that interrupted that trajectory was the primary care clinic where I followed patients for 3 years and got an inkling of the power of relationships in treating, healing, and educating patients.  Staying in one location for many years has also allowed me to follow young patients as they mature, and older patients as they age and die. Oftentimes, I have cared for two or three generations of families. All of these experiences have been a privilege and have taught me many life lessons as I have helped patients navigate uncertain waters and live their healthiest lives.

Is it important to have a primary care provider? We know that countries where a larger portion of doctors are in primary care means that the population is healthier and that medical costs are lower. That sounds pretty good doesn't it? Do we know exactly why that is true? I don't think so but I surmise that having a trusted relationship with a health professional reduces the likelihood of seeing multiple specialists, having unnecessary testing, and accumulating medications that may not be compatible. Practicing medicine remains an art. The most difficult part of medicine is deciding which complaints to pursue and which to ignore, which conditions we can cure and which we need to live with. Finding the right balance of testing, treatment and benign neglect(which is a treatment unto itself) is a lifelong education for primary care doctors. Specialists focus on a narrower range of medical issues with a greater propensity for testing.   While artificial intelligence can offer up facts and information, asking the right questions in order to get the right answers is the key to correct diagnosis. Can you do that without a medical professional? I can tell you that it is harder than it seems.  

Being healthy has a lot to do with what is happening outside of the doctor's office:  living in a safe neighborhood, having access to green spaces, opportunities to be physically active, the availability of healthy food at reasonable prices, clean air, and clean water.  We are starting to understand just how important it is to address these issues. Unhealthy environments can also be the result of habits we acquire: sitting for hours at screens, regularly ingesting sugar-added drinks, smoking or vaping tobacco or cannabis, using tranquilizers and narcotics, drinking alcohol or mixing alcohol with stimulants, staying up into the wee hours, driving while sleep deprived or impaired, having unprotected intercourse....these are some of the questions that come up in a primary care office. They do not come up at every visit and we do always not get honest answers but laying the foundation of a trusting relationship is the beginning of helping patients to live healthier lives. 

Treating the whole person in the environment they are living is a focus for us in primary care. Let me give you an example: one of my patients was an Operating Room Technician. He has type 2 diabetes. For many years when his only option for treatment was insulin. Well, if he was entering a surgery that could take many hours, he would skip his insulin, being afraid of bottoming out and becoming hypoglycemic. He knew his blood glucose was high and that in the long term that would increase his risk of complications. He had access to medical care and medication but that was not sufficient to optimize his care. I did not berate or abandon him despite the optics that made him seem noncompliant. When newer medications for diabetes became available, and the copays for the medications became more affordable, I was able to treat him more effectively. He is now happily retired and enjoying a less stressful life. The control of his diabetes has significantly improved. He continues to work on getting regular physical activity and making healthy food choices.

Shared decision-making is a buzzword for dealing with medical decisions that are unclear. Patient are advised to consult their doctor and to enter into shared decision-making as far as having screening for breast and prostate cancer. There are plenty of decisions that are unclear to patients that extend far beyond cancer screening. Should I take statin medication? What should I do if I have a strong family history of dementia? Should I undergo genetic testing looking for a disease that may have no treatment? Should I take the vaccine for Covid? Should I stop driving?  Can I continue to live independently? How can I get help for mental health, relationship issues or addiction? The answers to these questions are sometimes more clear than others. Most important is the listening part of the conversation. Understanding the human being at the center of the question helps me to inform the answer. 

On that note, I would urge you to invest the time in establishing and maintaining a relationship with a primary care doctor. We may be at the bottom rung of the medical hierarchy but we are like soil, sometimes underappreciated but vital in helping to nurture, sustain, and grow healthy lives.