American College of Physicians: Internal Medicine — Doctors for Adults ®

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.

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Anonymous JC Johns, MD said...

In your blog you mention several terms that I would like to expand upon. I am a retired sucessful Internist.
DOCTOR: A Doctor is a highly skilled tecnician. The preferable term, PHYSICIAN, is also highly skilled but also compassionate, empathetic and cares for his patients as individuals.

GATEKEEPER: We truly are gatekeepers, but as such I always envisioned this role as being "the HUB of the wheel" for the care of a patient. Treating the patient to the best of my abilities and then referring when necessary, and always requiring the physician to whom I referred to send the patient back to me and not refer him on to another physician. I would make that choice. That allowed me to know everything that was going on with my patient. (This was before the EMR, but was rewarding). This was the best type of CONTROL.

Finally, you missed the greatest advantage of being a Primary Care Physician...that being SATISFACTION/REWARD. When I was in training, one of my mentors stated "If you take care of the patients,they will take care of you." Wise words that served me well during my years of providing care. There were the monetary rewards from patients, but the best rewards came when a patient's grand child came up to me and said "Thank you for saving my Grandma." Many monents like that one made me realize how special it was to be a Primary Care Physician.

January 31, 2011 at 2:30 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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