adult primary care

A good friend/classmate of mine said to me recently that it's hard to help people. Now in medical school, we realize how elusive is the goal for getting here in the first place, that catch-all "I want to help." It's true, what they say: doctors can do more harm than good, in the flurry of work they can forget to be considerate, and there are indeed many other ways of helping people, so how can that be the sole reason to choose this profession?

Primary care, what I think I want to go into, answers some of this for me in a somewhat ironic way, in that it's proven to me just how hard it is to help. There are two parts to this: the purpose, and the methods. As seems logical, let's start with the purpose, and then the methods get all mixed up in there. If I want to get as simple as it gets, I think of medicine as taking care of a person. Specifically, what does this entail? Concretely, to prevent and treat illness to the best of our knowledge and range of resources. More abstractly, it means knowing a person, from conversation (how to ask questions, how to listen, how to explain and advise) to examination (how to look at their eyes and check their necks, how to situate them in a chair or table, how to maneuver their clothing to hear their hearts). It requires all sorts of memory: science, and personality. You have to know the medicine, but you also have to know who you're treating. Is she a person who likes feeling natural and keeps medications to a minimum? Does he have to construct garage doors for a living and finds muscle aches more problematic than his high cholesterol?

Taking care implies maintaining a certain level of quality of life. My friend brought up the question of whether we help at all, because we treat high blood pressure and high blood sugar, without necessarily healing the people with these problems, without helping them literally feel better, without adding the degree of happiness to their lives that would give them real quality, not just lab values that fall within normal. In primary care, the visits are too fast, the issues too many. It doesn't always seem possible to deal with all the health within the context of someone's life and feelings. So this happens frequently--tests and drugs are thrown at people without them having any sense of what and what for, mood is ignored and if seen, dealt with solely through meds, and privacy and tact has been lost in routine.

But awash in this background, the potential of what we can do is bright. The doctor I work with knows every one of her hundreds of patients by face and by name like the back of her hand, not only every illness they've ever had but everything about their personal lives that they've shared. Illness is vulnerable, and so is the personal, and I'm amazed every day at how much people bare, how much my doctor absorbs and holds. Primary care means that you take care of people through everything, not just when they get sick enough to be in the hospital, and you know about everything they have.

Intellectually, I find it more challenging than it's perceived and admittedly, more than I expected. A lot of "interesting" or serious diseases don't present with symptoms that land patients in the hospital; it's often progressive worsening of these diseases that put them in the hospital, under diagnoses made by the PCP. My doctor makes an extraordinary amount of first diagnoses for her patients, only sending them to specialists after high suspicion of what they have or for further treatment, and also always following up with each of the illnesses that they have, remembering what they go to the GI doctor for one week and why they see the cardiologist the next week. She is the one to screen and frequently finds cancer, and she is the one who already knows through and through, the person to whom she has to give that information.

I also love taking care of chronic problems, like diabetes and asthma. People find this boring after awhile, but in seeing people live with these problems day to day, you get such a better sense of how they live and what it means to have a disease, than when you treat them for an asthma exacerbation in the ER. Having people share, directly and indirectly, how they cope, what drives them and what makes them weak and strong, has the most sustaining power of all the things we experience. There's the pure pleasure of knowing people, not just the substantial stuff like their families and what they do, but are they organized? absent-minded? anxious? laid-back? funny? shy? tough? We naturally live in spaces occupied by people relatively similar to us (when you look at the entire scope of people in the world), and this gives us the chance to not just meet, but know, so much outside of ourselves.

Even with the best of purposes, it can be hard to get through and follow through. My friend compared the bleakness of what we do, alongside the happiness he was able to induce by making his roommate a delicious fruit shake. The sweet made his roommate happy, and that in turn made him happy. Because we're treating things that people sometimes can't feel, especially in primary care and preventative measures, and because we focus on long-term goals at the risk of not seeing people's immediate feelings, often we don't think we're helping or even that our profession is designed to help.

But I've learned from people I respect (both people personally in my life and the health staff in school) that everything is felt, such that small pushes soften thick walls. Connecting to people in any way gives a certain something that's vague and difficult to describe, and it can't be validated with science. I thought about this when realizing that one of my favorite parts of this rotation so far has been the Vietnamese patients. My doctor has a surprising number of Vietnamese patients, such that I see on average one a day. Even for the ones who can speak fairly good English, you can tell that speaking in their own language gives them that something. And with everyone, asking a person what it is that they want, how has it been with this-or-that, being gentle and mindful with the physical exam (and despite previous thoughts that these should be obvious, I'm grateful to Yale for reminding us of this so relentlessly)--I've seen it go noticed, seen it make a difference in one minute of the day. People who are at first a bit standoffish, or skeptical, or gruff, start to open and give way, in their own ways. People notice when they're listened to, when they're respected, when they're given a little extra consideration, and whether you're dealing with disabling pain or you're a healthy person with the standard stressful stressors, it can give that certain something. And what I really like about primary care is the potential to be a continuous source of this something, a place that people feel is always there.

This all sounds very ideal, but I'm not oblivious to the obstacles. I've been more tired on this rotation than any other, including the rotations with longer hours and weekend work. There's more paperwork, more thought to legal issues and insurance, and we're always an hour behind in appointments. Being responsible for routine health maintenance AND chronic diseases AND acute problems that arise is exhausting. And as we've been persistently reminded in this time of supposed reform, most of what I've described above as fulfilling and helpful isn't billable, and doctors have to cater some of their time to what will enable them to stay in business. There are also the patients who make it hard for you to give, those who need more than you can give, and you will fail even those you can help. I've found myself frustrated by language barriers, difficult personalities, the chaos of papers and phone calls, my patience wearing thin in minutes, the openness I claim to want closing in on me.

So to help is hard, and to help in the particular niche of medicine is hard. But having seen that this niche is in fact particular--that it's true that you can help in many ways, but this way is a unique one that I really, really want--makes me transition from deciding whether this is something we want to do to considering whether it's something we can do. I've talked to friends in different paths of helping, and it seems that a common theme is frustration with how difficult it is, amidst systemic and personal barriers, to help. On top of that, I think that a lot of people want to offer this help to those from whom it's been unjustly withheld, so battling deficiencies with a deficient system makes it all the more frustrating. But this has made me think--all the more reason to keep trying, because there is such a gap, such need. If it were easy to help, it would become a routine that forgets to remind us of the need for patience and openness, of how much frustration and fatigue that certain something is worth. And I think, I hope, these things deserve more than our hard work; they deserve us testing our commitment by not letting the illogical and unreasonable and unjust and ugly push us away. I'm not saying that it should be this way--our healthcare system should be a million times more just, and we as individuals can always be more fair; it shouldn't be so difficult to give people basic needs and that something more. But it being hard is not reason to leave but to stay, and makes me think of when Obama said during his inauguration, that "what began in the depths of winter must not end this autumn night." I'm going to try to keep this in mind, as it just became October and already freezing.