I feel the need to examine my 2-year foray back into primary care. I failed miserably at it. I did not necessarily fail in my medical decision-making (though looking back I can think of several individual major short-comings that I wish I had managed differently). I did get great compliments from patients and there are several patients I will miss. But I did fail in that I was not able to sustain my job and my satisfaction therein. Even though I literally only worked in clinic 4 days per month on my off-weeks from my full-time hospitalist role, I could no longer bear the thought of continuing. Why? The answer, it seems, is complicated. But I feel the need to examine some of the reasons. I’m not going to go into my little “pet peeves” I dealt with such as always having to fill out paperwork, insurance denying first-line medications, patients showing up late, and so on. Others have dealt with why they think physicians are getting burned out (EMRs are often cited as a large part of the problem). My thoughts deal with more deep-rooted problems with health in America and how this affects primary care.
I will start by saying that I think it takes a very, very special type of person to be a good or great primary care provider. Not only is there the obvious need for good social skills (e.g. making a good interpersonal connection, knowing how to stop a tangential patient, etc.), but they have to be good at time management and familiar with diagnosis and management of hundreds of problems that range from orthopedic to cardiac to psychiatric and so on. They also, ideally, need to have genuine sympathy in dealing with the kind of patients I am going to describe. That some people do this kind of work 4 or 5 days a week every week is extremely impressive to me. I do not have the fortitude or skills to do that.
I feel my biggest personal problem in primary care is the dilemma of the doctor caring more about the health of the patient than the patient himself. It is encountered all the time. I’m thinking of the COPDer on 3L of oxygen who still smokes. I’m thinking of the 45 year old with three coronary artery stents who eats bacon and sausage nearly every day who has no interest in a heart healthy diet and does not think (or perhaps care) that many of his problems can literally be reversed by strict lifestyle changes. It’s clear to the physician that the patient is a ticking time bomb. It’s like you see someone on a raft heading toward a waterfall, but when you tell them what to do, they really don’t seem to care. Motivational interviewing can only do so much. Attempts at education can only go so far. Usually they know that what they’re doing is unhealthy. The problem is that they do not care. They have decided that the costs outweigh the benefits. What is life if they cannot enjoy their meat-based American diet? For me this is a hopeless feeling that I personally struggle with. How am I supposed to help someone when I care more about the situation than they do? We like to think of sick patients as those who yearn for a cure, such as a patient with a heart defect or infectious disease in a 3rd world country. But in rural America chronic diseases are often tied to lifestyle and social ills, and countering such diseases is often not only takes a lot of work and sacrifice on the part of the patient but also requires changes that are countercultural…too much of a leap. Diet and lifestyle in the U.S. is such that it is actually countercultural to live healthily. An individual’s level of care about his or her own health is a spectrum – from suicidal on one end to “health-obsessed”/health-anxiety on the other. When a patient is more toward the former, trying to education them is often futile. Since I am by nature closer to to the latter, it is hard for me to empathize with those on the other end.
Another qualm with primary care was the sheer burden of deep rooted psychological turmoil of high complexity. In rural areas this is exacerbated by very limited availability of psychiatric or psychological services. There is something about poverty which has a strong association with high levels of abuse, trauma, cycles of violence, etc. that really mess people up. I think it’s more than just a “normalization” of bad behavior or “growing numb” to dysfunction. This early exposure to evil (direct and indirect) literally changes one’s neuronal circuitry leading to more socially-deviant behavior, self-destructive practices, severe mental health issues, and (VERY fascinatingly to me) somatic dysfunction like problems with chronic back pain, dysmenorrhea, etc. They often end up on multiple psych meds and many times end up on chronic narcotics. In a lot of cases they get back surgery. They almost universally smoke. Marijuana, alcohol, and other forms of mental “escape” are common coping mechanisms. For me, these are difficult patients to take care of for many reasons. 1) Their problems are in part due to and interwoven with their entire background which cannot be changed. 2) They engage in very unhealthy behavior, making it seem as though they are apathetic about their own health. 3) They never really “get better” but go through various cycles of ups and downs. You invariably go through various SSRIs, SNRIs, atypical antidepressants, and antipsychotics all in various iterations trying to find something that will make the patient less depressed and/or less anxious and/or in less pain and/or more able to sleep. You may or may not find something that works. A lot of times you don’t. Or they really need psychotherapy but this is not available to them or they are not willing to go. This is a “normal” patient in primary care, especially in rural America. Yet it’s clear that nothing here is normal (as it should be). Nothing here is physiologic. Nothing is working properly at it was designed to do. What’s going on here? They were born into excessively high levels of sin and dysfunction. Maybe they were abused, leading to severe permanent neuronal damage. Maybe they inherited some genetic predisposition toward alcohol abuse. They have disordered and unhealthy family relationships. They try to cope with the drama and turmoil as best they can, but have practically none of the biopsychosocial tools to do so. They are not only victims of their own immediate surroundings, but they are also victims of the food system, corporate advertising, and the general consumer culture in which things are made obsolete within a few years. They are victims and victimizers at the same time. I want to help them, but I feel helpless because the only solution is a world without sin and suffering. So I try to pray with them or share the Gospel, but this is hard in the office setting.
Another, although less frequent, issue to be dealt with is the patient with complex psychosomatic symptom(s) who frequently request expensive and unnecessary diagnostic testing and referrals to specialists. Examples of this would be a patient with fatigue who is convinced she has chronic Lyme disease or hypothyroidism (and does not think a normal TSH rules it out). They are usually swayed by what they read on the internet and heavily by pseudoscience and/or personal experiences of family or friends (N of 1 anecdotal evidence). On many occasions I would come across patients so deeply steeped in pseudoscience that getting them to understand something of their own health would actually require them to erase everything they know about the issue and actually go back to high school biology and physiology class. Examples of such insanity include systemic “yeast overgrowth”, benefits alkaline water, vaccinations causing diseases, high levels of heavy metals in the body (with no objective signs), and so on. Internet communities and online articles are making all of these absurd notions much more common than they otherwise would be. They erode confidence in doctors, medicine, science.
I know this comes off very cynical. It is. That is why I’m taking a break from primary care. I wish I could offer solutions to these problems, such as coming up with ways to educate people such that making healthy decisions weren’t so bizarre. I would guess that the answer most would give me is that physicians are by nature reactive (treating whatever disease that presents itself regardless of why it occurred). I think of people like Dr. Tom Catena who alone treats patients (surgical and non-surgical) in the Nuba Mountains of South Sudan. I’m sure if I were to glimpse into his practice a lot of my qualms with clinic would seem pretty trivial.
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