pediatric primary care

This summer has been full of full weekends, and I've really enjoyed having time to spend with friends here and elsewhere. This weekend, I decided to take some more time alone bumming around, because things have been flying. In that vein, I decided to do better with more frequent blogging about daily life. I'm not capable of cultivating the stories yet, so recording will have to do for now.

I'm finishing my pediatrics rotation with two weeks of primary care at St. Mary's Clinic, a nice 45 minute drive from here. Primary care is outpatient, like your family pediatrician, where you go for physicals, colds, and non-urgent symptoms. Ideally, it's continuous, meaning that the same doctor takes care of you from birth to adulthood. Overall it's perceived as less intense than inpatient medicine in the hospital. The illnesses are more common and considered less complex than those requiring hospital or specialist care, though I imagine that with comorbidities there is a lot to consider as well. A lot of primary care focuses on prevention, chronic illnesses, and counseling, all of which the current healthcare system does little to support.

Most (95%) of St. Mary's patients are Medicaid patients, and the psychosocial elements emphasized in school come up often. In front of each chart is a "chronic problem list," to remind healthcare providers of long-standing issues that should be kept in mind during each visit. Among those I've seen listed include asthma, ADHD, depression. One of the things about primary care that appeal to me is this wholistic approach. I do see also that we're very good with recognition, but not so much with management. A lot of the more behavioral and social issues are beyond the scope of a PCP (or PMD, for primary MD...perhaps because of PCP the drug and PCP the infection), and even though the doctors here spend a great deal of time with their patients, addressing these things at every visit isn't always possible or done.

On the purely clinical side, I've enjoyed clinic. I've had the opportunity to consider differentials for chief complaints--shoulder pain, fever, headache. A little more than with the inpatient rotation, where much of the differential has been covered in the ER, here I get to ask the first questions. Remembering septic arthritis from gonorrheal infection, I ask a young teenager with shoulder pain about her sexual history, and had my first affirmative and conversation about sex with an adolescent. Remembering papilledema (swelling of the optic disk in your eye) occurs with increased pressure in the brain, I used an opthalmoscope to examine the eyes of a kid with headache, but still have trouble locating the optic disk (especially the left eye; my left eye is so uncoordinated).

With respect to the patients, outpatient pediatrics is a happy group. I get to marvel at beautiful newborns and infants; despite the familiarity of the idea of babies to most of us, I haven't actually spent much time with them and their concrete selves are a mystery to me--their fast heartbeats, compressible bellies, and funny reflexes. I like seeing the younger ones, because I didn't see any younger than five on my inpatient rotation, and I like the range of ages up to 19. The babies are miraculous, the kids adorable, and the adolescents fun to talk to.

As for the dynamic, sometimes it's chaotic, with stressed parents, multiple kids in a room, and language barriers. There are many limitations in terms of time, resources, communication, and records. Things that have been documented aren't always re-read when patients return, especially things that aren't directly related to current symptoms, and many of the indirect things that comprise a person are lost in past. Three different health providers spent a total of an hour with the family of a wheezing boy with new-onset asthma, whose 15 year old brother took charge of the family's health problems while the mom, having dealt with traumatic stresses in the past few years, seemed unaware and unable to manage this chronic problem. We try to address the long-term with preventative care for the future, but the past is important too. As a silent observer I kept thinking of B's recent emphasis on mental health and PTSD on his psych rotation, and how after understanding what's important, how difficult it is to incorporate it all.

I'm still really interested in primary care. Also in talking to B, who asked me what I want to do, I felt slight inadequacy in not having more specific goals and ways of achieving my broader ideals. But I am surprised by how much sense of things we get from weeks of experience, and looking forward to more to come.