I love being a family doctor. That being said, even when I was doggedly studying the sciences in pursuit of a medical school admission, I had a very vague idea of what medicine was. Nevertheless, I had a few principles at that time that I continue to believe in to this day, and that is a blessing. When primary care physicians deviate from these core values, colossal failure and malpractice can be the result:
1.) The best healthcare is delivered over time. Continuity is one of the quietest, yet most powerful, tools we have to treat patients. I may not be able to understand all of my patient’s motivations and beliefs in one or two visits, but I get a much stronger sense of these critical issues by visit 3, 4, or 5. That can lead to the most important types of change in a patient: they might start taking their pills regularly (finally); go to get that cancer screening test they’ve been putting off; or giving up cigarettes. As a physician, I need to know my patients in order to help them live better lives. Continuity allows me that privilege.
2.) The best healthcare is personalized. We do not have that many miracle cures that can simply fix everything. Chronic pain, mental health disorders, and psychosocial stress are examples of conditions that are not well understood, but are seen again and again in primary care. Understanding a patient’s attitude toward these problems, and what they can realistically achieve for their own well being, is a critical first step toward effective care. Without that personal touch, even the most advanced and expensive treatments often fail.
3.) I am at my best when practicing broadly. Caring consecutively for a newborn baby, and then a 90 year-old man, and then a woman in her third trimester of pregnancy is no easy undertaking. But I personally embrace this diversity; not only because it keeps my practice interesting, but also because I work in the most patient-centered of specialties. Whatever the community needs – be it more acute care, pediatric care, or geriatric care – I can do it. And that gives me another level of satisfaction with my practice.
I am absolutely sure that I was naïve when I developed these ideals over two decades ago, but I am equally sure that they are true nevertheless, and they have served as a great foundation for my career.
But what about the larger community of primary care providers? What are their values? In fact, who are they? The core specialties that encompass primary care medicine include Family Medicine, General Pediatrics, and General Internal Medicine. General Obstetrics and Gynecology is also focused on the primary healthcare of women.
It is a sizable group. According to data from the Agency for Healthcare Policy and Research, there were 209,000 practicing primary care physicians in the United States in 2010. And, of course, there are differences of opinion and practice style with such a large group. Most of these differences are benign – but failure to provide conscientious and patient-centered care can be absolutely catastrophic. There are several areas for which primary care physicians are at particular risk of making an error:
1.) Failure to diagnose
An innocent-appearing lump in a patient’s breast. Chest pain that comes on at the strangest times. A cough that just will not quit. Primary care physicians see these issues daily, and, thankfully, the majority of them are not life-threatening. But all of the symptoms listed, as well as hundreds of others, carry red flags that something very serious may be happening. Those cases require prompt attention, appropriate communication with the patient, and many times further testing or referral.
2.) Failure to follow up
When the potentially dangerous diagnosis is identified, it is incumbent on the primary care physician to promptly follow up on the plan of care. An abnormal mammogram? Order an urgent biopsy. A positive cardiac stress test? Urgent cardiology referral. Even when the study reveals a different abnormality than what was being evaluated – a classic example is a thyroid nodule in a patient getting a computed tomograph of the chest – the primary care physician owns that result and has to act on it.
3.) Failure to “own it”
The buck stops with the primary care physician. We have to manage health issues for the whole patient and advise the patient regarding priorities in their care and treatment. One common mistake that I have seen is that the primary care physician washes her/his hands of a medical issue as soon as the specialist referral is done. If that specialist makes an error, the primary care doctor cannot compound the error by ignoring the problem. In fact, thanks to our greater knowledge of the patient as a person, primary care physicians may be in a better place to judge the progression of illness than specialist physicians. As long as we are providing care for the patient, we have the obligation to speak up when something appears wrong.
4.) Failure to inform and advise
Shared decision-making with patients is not only great medicine, but it is vital in medicolegal issues. Physicians should always discuss the plan of care with their patients and then document that conversation in the medical record. My personal habit is to document irregular aspects of an individual patient’s care under the “Significant Events” tab on the electronic health record. That tells me succinctly that Mr. X refuses colorectal cancer screening as well as all vaccines (I will have to work on that Mr. X…).
And this list is not nearly complete. In Medscape.com’s annual report on physician malpractice in 2015, errors in medication administration, failure to follow safety procedures, and failure to achieve informed consent were common reasons for patients to sue Physicians who move away from the principle of patient beneficence. Physicians who do so are at the highest risk for providing poor care, be they motivated by profit, or disabled by burnout and indifference.
Most individuals, and certainly most physicians, do not see primary care as a high-wire act that balances great reward with the constant threat of disaster. But I do, and that is why I find it is such a satisfying career. We are the caregivers who most promote wellness versus treat disease. We help people to not only live longer lives, but healthier lives. And we do so at a substantially reduced cost compared with specialists.
I am proud and extremely grateful for the opportunity to become exactly what I wanted to be. I recognize the challenges of primary care in the modern age and say bring it on! My patients are worth it.
