Family Medicine Notes

Dave responded to my post below.

I didn't have my facts right.  Dave called his primary care physician first.

I posted a response to the Boston Common weblog   post  (and his response) ... here's what I said:

Dave is sharing some tidbits of his personal life with us, and I shouldn't chastise him for doing so .. I should applaud him. This sort of transparency is educational. Dave is teaching ... and I suppose my goal was/is to teach as well.

Dave - I didn't mean to infer that you were casual about your care. My inference (albeit incorrect!) was that you -- like many -- have been taught -- by a system and culture that values specialty care above primary care -- to seek specialty care before the problem was evaualted by a family physician or general internist.   As point out, I was wrong about how this panned out.  Given your "celebrity" status, and your willingness to share these details of your personal life with us, I used this event as an example of a component of our healthcare system that I believe is dysfunctional.

It turns out that the example was a rotten one, but my sentiment about the dysfunctional system/culture remains the same.

Most patients who reach out to me are seen promptly and are referred to specialists only when necessary. Yes - we see patients on Saturday and Sunday and even at night.  Had you called me, I would have offered to see you in the office.  This is the core of what we do - we are the primary care physicians and we specialize in primary CARE -- not primary referral. We take care of very sick people and very well people. Young, old, pregnant, depressed, sexually active and impotent.

As one who teaches family medicine to medical students, I struggle with the biases against primary care every day. Specialists tell our students that family physicians are "stupid" or that the only role we should have is to "pop the pimples on farmers' butts and refer the rest of the patients to appropriate specialists." No kidding .. this came right out of one of my specialists colleagues' mouths.

My comment speaks to a culture of medicine -- and the role of primary care in how we treat our patients.

Yes .. I have a bit of a chip on my shoulder. (see above re: farmers butts). Primary care physicians are the Rodney Dangerfields of medicine.

We earn respect in an 8 x 10 room with our patients one-by-one-by-one. My post starts with a comment about Dave's encoiunter, but if one reads the whole post, you can see that I discuss much more than that.

Some places - and Harvard is one of them - have developed a culture that remains specialty -focused. I grew up in Boston - where I didn't know what a family physician was until I was 18.   Boston was one of the last of the major cities to host a residency in Family Medicine (There are several in the Boston Metro area now), and there remains NO family medicine education at Harvard. See this note in Harvard Medical School's weekly paper about the dearth of family medicine education at Harvard, and how unhappy the students are about this.  

Finally - since we're all in this to educate ... here's a link explaining why you shouldn't use q-tips in your ears .. and a reminder (I've posted on this one before) that colace (Docusate Sodium) is very good at softening earwax.  I sometimes suggest that people use this once a week to avoid impaction problems alltogether.

Posted by Jacob Reider, MD at 11:14 PM | Permalink

Posted by Jacob Reider, MD at 03:56 PM | Permalink | Comments (1)

Dave needs a good primary care physician.   His post today reveals his ignorance of the importance of primary care.   This is common in people who are wealthy and/or have "very good" insurance that gives them access to specialty care without referral.

I'm not saying that specialty care is bad -- but I can't even count on my fingers how many times each week I provide services to someone who initially called asking for a referral.  This week's struggle was a dad who called and demanded an emergency referral to a dermatologist for the rash that his daughter had for the past 6 weeks.

"Now .. nothing against you, doctor, but I think that this condition has gotten so bad that we need a specialist."

"I'm happy to refer you to a dermatologist if that turns out to be necessary - but since I have not seen the rash - nor have you even called me about it - it's hard for me to tell the dermatologist why I'm referring the child to him."

"Well you saw her in October for her well-child visit and you said she was fine."

"uuh .. yes .. was she not fine then?"

"Yes she was but now this rash is real bad and we want to make sure it goes away."

"We all want the rash to go away.  I'm happy to see her today and if I can't help you, I will be sure to refer her promptly to the dermatologist."

The child has eczema.  I did a quick google search and found some good handouts to reinforce my counseling and diagnosis.  It's unlikely we'll need to send this kid to derm. 

When I was 15 and living in Cambridge, I scratched my cornea with some sawdust as I was cutting something with a circular saw.  Like Dave, my parents decided that the "experts" would be best to evaluate this and drove me down to the Medical Mecca and I received appropriate treatment for this very common problem. 

So what? 

Like Dave - I could have received appropriate treatment for this problem by any competent primary care physician.   This would have been a better use of the limited healthcare resources that exist in this country.   I treat scratched corneas and impacted cerumen all the time.  So do most primary care physicians.   These propblems are not rocket science - nor do they require the services of specialty care.

The Boston area is hyper-specialized.  There are relatively few primary care physicians and an overabundance of specialists - which is a function of the overabundance of wealthy, educated healthcare consumers, and an abundance of training programs.

While I would agree that the folks at the Mass Eye and Ear Infirmary may be some of the best in the world at what they do - we should only use them when we have conditions that the primary care physicians can't handle.  A good primary care physician would have removed the cerumen from Dave's ears, and would have given him the same lecture about not using q-tips as he received from the specialists.

The disjointed care that people get from a horde of specialists is clearly worse care than the care they get from one primary care physician. 

Yet there remains a perception that the care they provide is better.  We can't combat this work our words - we have to re-educate our patients by providing the comprehensive, care that they deserve. 

IN the context of my patients requesting specialty care - I've been seeing more specialists in MY office.   Caring for another physician is always challening, and initially, this was intimidating to me - yet I've become better at navigating this complex relationship.  Like the otolaryngologist or the ophthalmologist or the CT-surgeon, I am a specialist too - in primary care. 

Posted by Jacob Reider, MD at 02:50 PM | Permalink