Thursday, July 12, 2012

Common Issues in Primary Care: It's more than just runny noses and strep throat

I've decided to start a series about common issues that a primary care doctor encounters.  As I browse the internet, I frequently see comments that reflect misconceptions about what primary care docs can do and manage.  These frequently run along the lines of, "If there's anything really wrong with me, I'm going to see a specialist anyway!"  Never mind that just about every public health study has shown that countries with more primary care docs and fewer specialists have better outcomes.  There are also numerous studies that show that the more specialists a patient has, the more fractured their care is and the worse their outcome.  See here, here, and here, for example.

I'm going to start this series by outlining a typical day in my life, during which I see an average of 30 patients.  Details have been changed to protect the innocent! Keep in mind- we have a "walk-in" hours from 8AM to 10AM, when people can drop in for quick visits without an appointment.

7:30 AM- Arrive at office, after dropping kids off at daycare.  Review upcoming schedule, making sure people are scheduled in appropriate spots for the right amount of time.  Review labs, phone messages, refill prescriptions, drink first cup of coffee.

8:00- Patients start arriving.

Patient 1: Here for a routine followup of his hypertension and high cholesterol.  Did his labs 2 days ago- I've already reviewed results.   He looks great.  No changes made, see him in 6 months!  Good start to the day...

Patient 2:  Walks in without an appointment.  Been coughing and has had sinus pain for 2 days.  Wants an antibiotic for sinusitis.  Exam is normal- she just has the cold that's going around.  Spend 5 minutes explaining to her why an antibiotic is not needed.  Sample of a sinus irrigation system given to her.

Patient 3:  Here for a followup of her diabetes, high blood pressure and high cholesterol.  Forgot to do her lab work.  Has not been checking her blood sugars at home.  Blood pressure not controlled.  Blood pressure medications changed.  Discussion about the importance of managing disease, checking sugars, doing lab work.  Follow up in 2 weeks to recheck blood pressure and review lab work.

Patient 4:  Walks in without appointment.  States has a UTI.  Urinalysis done in office is negative.  Patient is having severe pain with urination.  Gynecologic exam done- very consistent with herpes. Cultures taken, but I'm 99.9999% sure she has herpes.  Tears ensue.  Education regarding herpes and STDs given.  Medication started.  Discussed with her how to talk about this with her boyfriend.  Make a mental note to call her later to see how she's doing.

Patient 5:  Routine physical with a Pap smear.

Patient 6:  Here for a blood pressure check, looks good.  Follow up in 6 months!

Patient 7:  New patient.  Has not seen a doctor in 15 years.  Only here because his wife forced him to come in.  Feels fine.  Overweight.  Family history of diabetes in both parents.  I do a random finger stick blood sugar- it's 347.  He has diabetes.  Lots of education given.  Medication started.  Given a glucometer and taught how to use it.  Referred to a nutritionist.  Follow up appointment made for next week.

Patient 8:  Itchy rash.  Bad, bad case of poison ivy.  Steroids started.

I'm now about 2 hours into my day.  In between seeing these patients, don't forget that I have to dictate notes on each of them.  I'm keeping a constant eye on my "pile".

Patient 9: Can't hear anything.  Ears are totally blocked with wax.  Wax flushed out- patient can hear.

Patient 10: Reason for visit given as "insomnia."  Patient starts crying while I'm taking her history.  Finally admits that she is being varbally abused by her boyfriend.  Counseling referral set up.  Domestic violence resource information given.

Patient 11:  Knee pain.  Has been hurting for a few months.  Has completed 6 weeks of physical therapy and is no better.  MRI ordered.

I get interrupted by a phone call from another doc.  It's a local endocrinologist.  He's seeing one of my diabetic patients and has noticed that their heart rate is irregular.  Should he send her to the ER?  I tell him to send her over here.  She becomes...

Patient 12:  Exam and ECG reveal that she is in new-onset atrial fibrillation.  Her vital signs are stable but her heart rate is a bit rapid.  Started on a blood thinner and a rate control medication.   Referred to a cardiologist for follow up and potential cardioversion. Follow up with me in 2 days to see how she's doing.

Patient 13:  Here for a follow up of depression and anxiety.  Medication started 6 months ago.  Things are going great, but would like to stay on the medication.  Follow up in 6 months.

Patient 14:  Here to review labs.  Cholesterol is high.  Diet reviewed, suggestions for changes made.  Follow labs planned for 3 months from now.

Patient 16:  Here for follow up of her hypothyroidism, which I diagnosed 3 months ago.  Doing much better on medication.  Energy improved.  No changes made in medication, follow up in 6 months.

Lunch time.  Spent eating at my desk, reviewing results, returning phone calls.

You know, I was going to write out the whole day, but you get the picture.  I don't sit around all day seeing sore throats and colds.  I don't sit around just referring people to specialists.  If it's something I am qualified to take care of on my own, I'll do it.  If it's out of my league, I refer.  However, I love the fact that I'm the one that gets to make the diagnosis.  People walk into my office with a group of symptoms- I get to put them together and make the diagnosis.  That's what's awesome about primary care.  Do we make less money than many (most) other specialties?  Sure.  However, that's not because what we do is less valuable.  It's because the payment system is screwed up and rewards procedures more than thinking.

So, little by little, I'm going to write about common issues I encounter.  This is meant to be educational and perhaps help you to spark a discussion with your own doctor.

Don't worry, I'll still blog about running, my kids, and the ridiculous things I encounter behind the scenes at my office.

2 comments:

  1. Back in 2005 or so Concord, NH had a serious shortage in PCP's. I imagine it was due to high medical malpractice premiums and low insurance payments, along with the uninsured patients they wouldn't turn away but who couldn't or wouldn't pay the medical bills. In 2006 the primary I drove to Boscawen to see went out of business because he wasn't making enough to keep his office going yet he was busy, busy. Last I knew he was working in a jail. I'm willing to be he didn't spend whatever you people spend on your education just to dole out aspirin to the inmate population.
    If everyone goes running to a specialist for everything the PCPs will leave their practices and people will end up in the ER for stupid things like sinus infections and UTIs which crashes the system on multiple levels.
    On the flip side, it's nice to have someone to see when your PCP blows off something you know is serious.
    I believe we are all responsible for being our own health advocates, but we also need to be aware that resources are limited and of the costs involved in seeking specialized care when it's not necessary.

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