Lets face it — the system of primary care medicine in the United States is broken. Even in Boston, the mecca of medicine, patients struggle hard to find an accessible doctor. And when they finally land an appointment, their well-intentioned internist, pediatrician or family physician often seems overworked, rushing from patient to patient, with little time to really listen to details.
As a primary care family physician for 20 years, I hear my colleagues saying, “I went into medicine to put the whole clinical picture together. I really care and want to know my patient — but the system doesn’t give me the time to do it!”
The basic issue is time. People really are beautifully complex, more than the sum of their organs. So patients don’t have isolated problems, but present to their family doctor with two or three (maybe as many as six!) problems that are often interconnected. They’ve stored up all these issues for their one 15- to 20-minute doctor’s appointment, which took a month to get. The patient feels rushed, the doctor feels rushed, and telling details are often missed.
When I was an island doctor in Maine for 10 years, I had more time with my patients. I had less technology at my fingertips and discovered something remarkable. Most diagnoses, even rare ones, can be made by asking open-ended questions and having the focus to listen very carefully to the finest details of the patient’s story. The subtle onset and timing of a wheeze, a fever, abdominal cramping — as symptoms weave and change over time, they leave a trail of diagnostic clues. As most seasoned doctors know, the patient’s story can narrow the diagnosis. Then a precisely chosen test or targeted referral to the best specialist can clinch the diagnosis and point the way toward treatment options.
A dedicated primary care doctor is trained to diagnose and treat up to 90 percent of patient problems without needing a specialist. But in today’s health care environment, with no time to get a detailed history, the trend is to quickly refer patients on to a specialist. This often starts a cascade of specialty consults focused on one organ at a time.
And how does that affect our clinical skills? By referring common health conditions too readily to specialists, both the general doctor and the specialist can diminish their skills. The generalist becomes less expert at caring for common problems, and the specialist, flooded by common issues that could have been addressed by a primary care physician, has less time to devote to the more complicated, rare conditions he/she are specifically trained to diagnose and treat. Ultimately, it costs the patient (and the health care system) more time and money.
From my experience, I believe that urging primary care doctors to spend more time with patients can not only provide better care across the board, but save patients’ time and the health care system money. The primary care doctor is uniquely positioned to put together a patient’s whole health picture by connecting the physical condition with the life stressors that often precipitate disease in the first place. Close follow-up, monitoring for changing symptoms, can make earlier diagnoses possible and help prevent treatment side effects.
At your next appointment, help your doctor see your whole health picture and keep him/her informed of ongoing changes. This can (and should) lead to better treatment and prevention of future disease. The system may be broken, but it’s not beyond repair.
Rick Donahue is a clinical instructor at Harvard Medical School with 20 years of experience delivering complete primary care. His private practice in Back Bay, MA, Personal Health MD is dedicated to providing comprehensive state of the art primary care. This article originally appeared in The Brookline Tab and is reprinted with the author’s permission.
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