Blog | Tuesday, August 31, 2010

To medical students considering primary care

Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I'd give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? "Being a doctor" covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he's not the target of Oprah's contempt like I am, but that's a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors (PCPs) spend time with humans, normal humans. This is both good and bad, as you see all sides of people, the good, bad, crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don't do it. The single most important thing I have with my patients that most non-PCP's don't have is a relationship. I see people over their lifetime, and that gives me a unique perspective.

2. Do you prefer variety over predictability?

Every room I walk into is different--often vastly different--from the last. I could be walking in on a crisis or a stable recheck. The person could be elated or crying. They could be 90 years, or two days old. They could have something wrong with any system, and it could range from mild to life-threatening. I'd go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney. But some folks do better with routine and a lack of surprise; they don't want their days to be unpredictable.

3. Do you need to be in control?

Primary care is not about control. Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy. Relationships are not always predictable, and much of what PCPs do depends heavily on the patient's "cooperation." I put the word in quotes, because the word implies that the doctor's agenda is more important, an implication that I reject strongly. PCPs are part of "team patient." Our job is to help them, not direct them. We give them our expertise and they make the final choice. Surgeons, on the other hand, don't consult the patient when operating; they don't depend on patient compliance as they cut a person open.

4. Are you a people-pleaser?

The flip side to #3 is that a PCP must always practice good medicine, even if it makes people mad. You have to learn to say "no" to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free. We are not co-dependents. We don't base what we do on the reaction we get from patients. Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health. I deal daily with the consequences of people-pleasing PCPs, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better. Please don't choose primary care if you are a people-pleaser.

5. How important is social status?

PCP's have an interesting paradox in their social status. In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists. In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect. We are actually the ones who run the medical show, using specialists when we think it is needed. We need to know 90% of all specialties, and also know when we are in the 10% we don't know for each of them. I often get "I could never do your job" from my colleagues. So if outward social status matters (like what kind of car you drive or how big a house you own), then don't choose primary care. I am not saying that PCPs don't have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6. Do you like puzzles?

The term "gatekeeper" got applied to primary care via our friends in the HMOs, and that term has haunted our profession since. Good primary care is not simply triaging people and sending them to those who can offer real care. Some PCPs do that, but they are both lazy and unambitious. I do whatever I can to keep people from the specialists and out of the hospital. I need to know when to send them, but I also need to know what to do before I send them. This endears me to my consultants, as I am sending only patients who needtheir expertise. I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient. 80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem. Specialists get sifted problems. I have already thought the situation through and so they get the leftovers. I don't usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect. I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7. How patient are you?

I have to confess that I was not a beacon of patience when I started practice. That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture. We see people over months, years, and decades, and watch the progression or deterioration of conditions. I find this most satisfying. People who were suicidal ten years ago are now cracking jokes and are productive citizens. One of the biggest mistakes a PCP can do is to value intervention over waiting. We are caretakers of the big picture. Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years. But PCPs do their job over the lifetime of the patient. To me, that's a plus, not a minus.

8. Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training. Primary care is about "care" in all of the definitions of the word. We care for people because we care. It does matter to us that people are hurting. There is a degree to which primary care is a calling or ministry, not just a job. There will always be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply punching the clock is both sad and dangerous. You need to be able to listen and see things from people's perspective. You are their doctor, and they are your patients. The possession is emotional, it is one of caring. People judge PCP's on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MD, Musings of a Dinosaur, Jill of All Trades, and DB's Medical Rants for a more complete picture. Sorry to those I left off; there are many other good ones). Any specialist would tell you that a very good PCP is incredibly valuable. I love my job, as do many of my colleagues. I want more PCPs, but I only want you in my field if you'd raise the average. We need good PCPs.

Come join the fun.

This post appeared at Musings of a Distractible Mind. Rob Lamberts, ACP Member, writes the blog and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.