Posted by: drrozkaplan | January 7, 2010

On the Soapbox

So where did I leave off in my rantings about health care reform and primary care?  I was on my soap box about why we should at least base our health care system on primary care rather than using specialty care for every problem, because it is more cost-effective and more comprehensive.  As usual, I show my bias because I am a primary care doctor.  But still, doesn’t it make sense?

When I do an initial evaluation of a new patient or an annual physical, I cover the gamut of a patient’s health care needs.  First, I ask about their concerns, so I can address any current symptoms or questions.  I review all ongoing and chronic medical problems.  I get a full list of every medicine, including over the counter remedies, food supplements, herbs and alternative remedies and their doses, and check for safety, efficacy, and drug interactions.  I review medication allergies.

Then we move on to health care maintenance issues. If the patient is female, when was the last gynecological exam, mammogram, and bone density test?  For men, when was the last prostate exam done?  For those over 50, when was the last colonoscopy?  Has the patient had dental care and an eye exam in the last year?  How about vaccines?  Is everything up to date?  Do they need a flu shot or a pneumonia shot?

Lifestyle issues are also discussed.  What is the patient’s diet like?  Are they exercising regularly?  How often and for how long?  What are the activities?  Alcohol intake?  Recreational drugs?  Caffeine?  How much sleep do they get?  What work do they do and what is their work stress like?  Who lives at home with the patient, and what is home life like?  Are there any specific severe stressors?

We do a family history, including parents, siblings, children, and serious illnesses in grandparents, aunts and uncles.

Finally, we review the body systems.  That review covers any symptoms that may not have already been mentioned.  I always ask about mood and anxiety if it has not already come up, since these are two of the most common problems addressed in primary care these days.

By the time a patient and I have finished with a history like this, we know each other pretty well.  I say each other, because I try to have a little bit of give and take.  I try to answer questions and allow the patient to see my personality as we go along. Otherwise the experience would feel pretty cold, and that’s not the experience I want my patients to have.

My physical exam is complete but pretty standard. Then my patient gets recommendations for his or her health, including medications, supplements, vaccinations, tests, lifestyle changes, and, if necessary, referrals to specialists.  Blood tests, EKG’s and vaccines are done in the office.  More complicated tests are generally done at the hospital.  When results are available, I’ll review tests and talk to the patient about any further recommendations.  I’ll likely be checking cholesterol and blood sugar and iron levels and kidney and liver function and maybe thyroid if it’s indicated when I do blood tests.  Blood pressure will have been measured, as well.

So we cover quite a lot in a visit like that.  It has the potential to improve health a lot in that visit- blood pressure, nutrition, exercise, stress, vaccination against infection illnesses, monitoring for osteoporosis, screening for colon, prostate, breast and cervical cancer…pretty good, huh?  And we’ll check in on control of chronic conditions like diabetes, asthma, migraines, and high cholesterol.  Maybe decide that we need to make sure a symptom doesn’t indicate something serious- an example would be doing a stress test because a patient reports some chest discomfort- and ultimately prevent a negative event (a heart attack).

Now, we primary care doctors certainly cannot care for patients without specialists.  We need the cardiologists to perform the stress test and take over care if it turns out that there is significant coronary disease.  The gastroenterologist is going to perform the colonoscopy.  Radiologists do the mammograms and bone density tests.  If my patient has an abnormal mammogram, she’s going to need a surgeon for her biopsy, and if it’s cancer, she’s going to need an oncologist.  Thank G-d for all the well-trained, smart specialists who take the next step in a patient’s care.  But it makes the most sense that it starts with primary care.

When there’s a symptom, or the patient is sick, instead of coming for a physical exam, it also makes sense to start with primary care.  Say you’ve been having low back pain, a very common symptom.  You go to see your primary care doctor, who examines you and finds some tight muscles but no neurological problem.  He knows that most mechanical low back pain resolves in a given time period on its own, and that you’ll feel better with an anti-inflammatory medicine and some back exercises. He educates you about this, and you uneventfully recover over the expected time period, about 6 weeks.  Your care has cost about $200, including your doctor’s visit and medication.

The other possibility is you go see a spine specialist.  Because that specialist is used to seeing ‘bad backs’, he sends you for xrays.  When the xrays show nothing, and your back still hurts, he gets an MRI.  There are some degenerated discs seen on the MRI because you are 50 years old, and most 50 year olds have some degenerated discs (they may not have anything to do with your pain).  He suggests epidural injections into the area of the degenerated discs.  You don’t know any better, so you let him do this.  After several injections, you feel better.  It’s now been about six weeks, the time when you would have been better anyway.  Your care, including xrays, MRI, and epidural injections, has cost over $4000.

Yes, this is an extreme example, but don’t think it doesn’t happen.

Fact:  Studies show that where there are more primary care doctors, costs are lower and outcomes are better.

Fact:  There is a shortage of primary care doctors in the United States, and it’s getting worse.

It’s getting worse, because payment for primary care services isn’t good compared to specialties, especially specialties involving procedures.  And primary care isn’t glamorous.  The lifestyle isn’t great.  We have to take patient calls at night and on weekends.We have to argue with insurers and advocate for patients and fill out forms more than most specialists.  We have to handle whatever comes to us.  Stuff happens whenever it happens.  New doctors coming out of training with mountains of debt don’t find it practical to go into a lower-paying specialty with a lousy lifestyle!  And if we don’t fix this worsening shortage, we’re not going to fix our health care crisis.  We simply need LOTS more primary care doctors.

Okay, off my soapbox.

Last thing.  Am I bitter about the lower pay and worse lifestyle?  Absolutely not.  I can’t imagine doing anything else. There are days I get aggravated, but knowing my patients comprehensively and over the long term is worth the little annoyances of primary care practice. Today a patient came in to thank me for guiding her through some anxiety-provoking tests, and for calling her as soon as possible with the results.  I honestly didn’t feel like I’d done anything out of the ordinary, but her gratitude was immeasurable.  If I can make someone feel better like that, then it’s all worth it.

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Responses

  1. […] the original post: On the Soapbox « Dr. Roz Kaplan's Blog Tagged as: browse, food, health, patient, patients, soapbox, time No Comments Comments (0) […]

  2. Dr. Kaplan,

    What you consider to be nothing out of the ordinary is not so much what you do– but the unusually caring and gracious way in which you do it. Give yourself a little more credit for the the extraordinarily caring manner in which you deal with your patients. “In the sufferer let me only see the human being.” That’s a rare quality in medicine these days– and it makes a difference.


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