KevinMD: The Primary Care Crisis Has Been Legislated

http://www.kevinmd.com/blog/2013/09/primary-care-crisis-legislated.html?utm_source=buffer&utm_campaign=Buffer&utm_content=buffer39a5a&utm_medium=twitter

So, if you're in healthcare and living under a rock, you might not be aware of this, but primary care in the US is in a state of "crisis" right now. Fewer and fewer medical students are choosing primary care and opting for more-lucrative specialties like dermatology, radiology, and anesthesiology. The traditional doctor-patient relationship is doomed, as the ten remaining primary care doctors in the US will be replaced by physician assistants and nurse practitioners.

A solution, at my school among others, has been for doctors to "talk up" and encourage students to go into primary care. It's like sacrificing oneself for the greater good; you are going into a lower-paying but demanding field for the good of the US and your other fellow physicians. If primary care goes, what is next? Psychiatry? Well, that's kind of a spooky field anyway. What about anesthesia, though? Or God forbid, surgery? Nervous laughter.

So it looks like a lot of medical students have taken this call to serve seriously. From the most recent data available, an increasing number of medical students entered primary care this past year for the fourth year in a row. http://www.usatoday.com/story/news/nation/2013/03/15/doctors-medicine-match-residents/1990549/ Despite the hassles involved with primary care, which are very real, a lot of medical students are forfeiting millions of dollars in potential lifetime income to serve on the traditional first line of defense against illness, and prevent encroachment on the field from NPs and PAs. Except... why are NPs and PAs replacing doctors?

PCPs simply do not have enough time to perform their job well. Period. As a 2012 paper notes:

Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. The average US panel size is about 2,300. http://www.annfammed.org/content/10/5/396.full

 So, really, maybe this crisis could be averted if existing primary care doctors just worked 21.7 hours per day. Or maybe we legitimately need healthcare professionals with enough time to actually take a damn physical exam, let alone a history. Maybe patients appreciate being listened to; I suspect that's a reason NPs outscore physicians with regard to patient satisfaction (http://www.clinicaladvisor.com/nurse-practitioners-outscore-physicians-in-patient-satisfaction-survey/article/206090/).

Maybe doctors need time to help heal their patients. This might not always be true; a broken bone is just a broken bone. (A cigar is sometimes just a cigar!) But what about patients suffering from chronic diseases, like lower back pain, depression, hypertension, or diabetes? Maybe part of their treatment therapy could be a healthcare provider's time... regardless of whether it is a NP, PA or MD.

Breaking bad news - relevant link for yesterday

http://www.kevinmd.com/blog/2013/09/delivering-bad-news-vast-divide-doctor-patient.html?utm_content=buffer45f85&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer

There is (a) vast divide between the physician sharing a hard reality and the person receiving it.  As much as the doctor works to imagine what it must be like, he or she is not the one whose life is changing.  The physician moves on to the next patient, while the patient now lives in a new world.

I read this after posting last night; the bulk of the post is about the poster's own autistic son, and how different it is to give versus receive bad news. Neither my spouse or I personally enjoy great health, so I'm hoping I can rely on that to not completely suck at giving patients unpleasant news.

It's kind of funny, I think, that we have an actual class session next semester dedicated to breaking bad news. One other student will meet with a standardized patient (an actor) and pretend to give bad news to him or her, and a group of us will watch a video and critique how the student could have demonstrated more empathy, etc.

I predict it's going to be awkward as hell for that student. But based on my own experiences and those of many people close to me, doctors are often terrible communicators. Your test results are X, Y, Z. Come back in 6 months. On to the next patient. But the patient is still sitting there in the room and the doctor just walked out because he's triple-booked and well it's damn hard to keep to a schedule. No other professional is scheduled the way that doctors are. You don't meet with your attorney for a 6 minute talk, after which he finishes your will. You don't meet with a counselor for 15 minutes and suddenly your anxiety is better. People often need time for healing, and few physicians have it to give.

Ultimately, the problem is not that doctors are terrible communicators (although some are) but the amount of time allotted to break bad news... well, that's time spent not seeing other patients, or performing procedures. You're losing money for your employer if you spend too much time with a grieving patient. You'd hate to get fired, right?

First death (in a manner of speaking)

I had my first experience with patient death last week.

Let me clarify. I'm a medical student, not a care provider, and I am in no way permitted to make any changes, suggestions, prescriptions, or even offer friendly advice to patients. The patient is even, for the moment, alive and well enough. But Crohn's is a nasty illness, and sooner rather than later it is going to claim her.

She was younger than me, which was unusual. Most medical students start out at 22-23 and graduate four years after that. Unless you're in Pediatrics, you shouldn't be seeing too many young patients, period. A large number of people live fairly illness-free lives until the inexorable diseases of hypertension, diabetes and back pain start to kick in during middle age. I am not one of those people, but more importantly neither was my patient for the day.

She had Crohn's Disease, and she had the worst case I've ever seen for her age. Crohn's isn't an autoimmune disease, exactly, but it's very similar to them. Your immune system is in a constant inflammatory war with bacteria, food, and your own bowels. There are a lot of drugs that can delay the progression by decades, to the point where the average life expectancy with Crohn's is only 2-3 years shorter than if you never had it. It's unpleasant, but it's not typically lethal.

My patient was not typical, however. She had three tubes in her draining a collection of feces, blood, pus and God knows what else. Her list of antibiotics filled half a page. If she hadn't had Crohn's, it would still be no wonder she had no appetite. She'd been in the hospital for several weeks, with no end in sight. She was leaking onto her hospital bed and taken over by opportunistic infections that were happy to make a new home in her body. When I talked to her, she was scared and wanted to know when she was going home. Well, what could I say? I wasn't a doctor, and I wasn't even working on the medical service (that is to say, with her main team of doctors.) My job was to evaluate her mental state, empathize, and get out. I had no access to her records at the time that quietly noted hospice care might be necessary soon. Neither did she, of course.

She asked me: what is my long-term plan? When will I get out of here? I had no idea. Her doctors had no idea. Given the severity of her infections, she might be leaving via the basement. Or the heavy-duty antibiotics might clear her infections and she might live several more decades. Nobody could say.

About three patients into my fledgling medical career, and I feel like I really failed already. I have absolutely no doubt her medical care was technically excellent. The doctors I rounded with clearly empathized with her, and the pain consult was trying its best to ease her suffering. But the patient had no idea how serious her illness was. I asked my resident: who will tell her? Well, that's the job of the medical service. We were consultants, and if medical hadn't mentioned hospice care yet, there was no way he or I was going to do that. It wasn't my place, and what if we were wrong? He was not an internal medicine doctor, and I was a medical student, for goodness' sake. We just had to wait.

So, as far as I know, my young patient is still in the hospital still waiting for someone to break the news that this infection isn't like the others so far, and she might not be leaving the hospital. She will continue to receive technically excellent medical care. I hope she recovers, although I don't believe she will. If not, I hope that she is able to spend her remaining time as she wishes, instead of waiting for news from her doctor that might never arrive. We will see.