When done well, primary care is hard work. Family Physicians, Internist, Pediatricians, PA’s, NP’s, PMHNP, OB/GYN, Midwives – we’re all in the same boat. It’s messy business. Human behavior and life often defy predictability and protocols. You learn to accept that. You must be willing to get dirty. And it takes a toll. There have been times I’ve felt spiritually dehydrated. Like everything had been sucked out of me. Yet, it’s been an honor to belong to this noble calling.
Everybody wants to tell us how we should do our job. Few could do it. Many physicians cannot accept the broad scope of practice and ambiguity that comes with incomplete knowledge and unlimited variables that define primary care. These providers do not get into the boat at all, preferring to shout advice from the shore. It’s easy to become obsessed with lab values, data, another CT scan, and the rituals of the profession and stethoscope. Now, the computer is safely inserted between provider and the patient so that hardly a glance is necessary before the provder can be off to the next person. Always staying a safe distance from the human condition begging to be held and understood.
For this type of doctor, there is no appreciation of the context within which the problem lies. The loss of a patient or acknowledging limitations is a narcissistic blow. It represents a professional failure. And it makes a sham of what medicine is supposed to be. Futile treatments – more surgery, drug trials, rescue chemotherapies – are symptoms of the physician’s inability to accept an ending. Another referral or more tests are easier than a tough conversation. The doctor pretends, protecting the illusion of power and knowledge. But the illusion is untenable. The outcome is inescapable because the house never loses.
American medicine is overspecialized. Compartmentalizing patient care creates plausible deniability. By that I mean, no one is in charge. Responsibility is limited to this organ system. It is primary care who owns the big picture. Putting the acute issue into perspective. We find our deepest relevance in guiding patients through the difficult valleys of their life’s journey with truth and dignity. To sometimes cure. But always to comfort. To walk alongside
Most people who work in the medical system see it through the window of their job. Patients see it through their experience. Neither know how the system works. The simple explanation is that it is not a system. In no way, shape, or form is it a system. It is a congeries of interest groups that has carved up and distorted how health care is paid for and delivered into balkanized protected feudal states enlarged and serviced by armies of lawyers, lobbyists, and posturing politicians.
When health care is measured by a “medical-loss ratio”, and the percentage of spending on health care is considered a “loss”, then we are really lost. Primary care’s job is to provide an interface between this morass and the patient. We become the system for our patients.
It is up to primary care to speak for the patient. Population health matters. But our first obligation is an individual one. We sit through mandatory training of cultural competency, HIPPA, and OSHA. We are lectured about social determinates, equality, and justice in medicine. We compel our patients to complete endless surveys of ethnicity, race, disability, language, and self-identity preferences. Because the elite planners, who could never do our job, believe gathering of this data few patients care about, somehow reflects virtue. It’s up to primary care to understand what is important to the patient in front of them.
We all have patients we know better than others, and a few that get to us in some personal way. Sometimes a good way, often bad. Most of the time we don’t take the time to figure out why. We should. The why could ramify in deepening and widening circles. It’s worth taking the time to seek the meaning found under the circles. That insight will direct our path.
Is it a difficult diagnosis or a difficult patient? Are we spending too much time with one patient who isn’t ready to change, missing an opportunity to tend nine patients who want help? Have we learned to walk past the expression to find where the pain lives? Does the patient need help discovering the words to describe what they feel? How do we close the space between what the patient wants and what they need?
So many of our patients don’t have anything resembling the all-American family. The families of our patients are more typically fraught, complex, dysfunctional, and compromised. There are both public and private narratives for family affairs that spill through our front doors. The narratives morph from a cocoon of family secrets into semi-public awkward, embarrassing, financially devastating, humiliating destructive, demanding, and lifelong family sagas. Complex stories. Ruined relationships. Alcohol and substance abuse. Rarely are two narratives the same. Even from the same family.
But these forces, far removed from the exam room, exert powerful influence on how symptoms present, prognosis, and course of treatment. When crisis or end of life decisions present in one of these families, the provider may be swept away by the tornado of acrimony palpable the moment they enter the room to engage. De-escalating that tension to come to pragmatic decisions require mental martial arts. It means accurately reading emotional language, decoding it in the moment, and having the tools to bring the tension down.
We need to know not just where, but when to dig. If we can stay on the surface all the time, dealing with the facts of the cases, it’s a safe place. It doesn’t require much. And we do not know very much. The treatment plan is a caricature, copy and paste. A game of what is the right dose of which medication.
Sometimes the superficial approach is not just easier but what is preferable to the patient. Treat the symptoms. Give a diagnosis. Any diagnosis. A diagnosis justifies the symptoms and disability. Even if its only an illusion. Because the truth is too frightening or painful.
As a provider, do you accept that? What is the ethical way to proceed? What is in the patient’s best interest? And what of their choice?
Family medicine. It’s the life we’ve chosen.
Tim Powell MD