When I came to medical school, I was certain I wanted to do primary care. Despite the forces that steer many of us off the path – how many times have we heard, “but you’re too smart to do primary care!”? – after three years of medical school, I was still committed to primary care.
But I struggled with which type of program would be best for me. I applied to both family medicine and internal medicine programs in primary care. After my third year, I loved the patient-centered approach to family medicine—the now clichéd mantra within primary care circles of seeing the patient as “a whole.” But I also loved the rigor of internal medicine, the process of forming deep differentials, and the robust understanding of pathophysiology that often made itself evident during morning rounds and afternoon conferences.
It was only after sub-internships in both specialties that it became abundantly evident that family medicine was the best choice for me. My tilt towards family medicine happened on three levels: philosophical, practical and personal.
Philosophically, I believe that family medicine is the best platform for delivering primary care. People live in families and communities, and rarely do illnesses affect only one person. Patients often come to the doctor with family members, and thus building trust by treating the entire family, offering anticipatory guidance to family members when they come as patients as well as caregivers, and better understanding the dynamics at home through multiple visits are powerful assets when delivering primary care as a family physician. When that primary care for the family is fragmented through multiple physician practices, the benefits of hi-touch primary care can be lost.
Practically, I found that most family medicine residents spend nearly 50 percent of patient-care time in the outpatient setting. Meanwhile, most internal medicine primary care residents typically spend 20 to 25 percent of their time in outpatient care. It’s more important for me to become well-versed in the bread and butter outpatient procedures I hope to perform as a physician—incision and drainage procedures, freezing warts, osteopathic manipulations for back pain, mole biopsies—than in thoracenteses or floating swan catheters, procedures that I think are incredibly cool but that I would likely never perform post-residency.
Moreover, if I am honest with myself, as much as I love primary care, it can get boring and tedious at times like any other field of medicine. Treating diabetes, correcting hypertension, recommending lifestyle changes, and screening for depression are undoubtedly some of the most important things a primary care physician can do. Yet my role models in primary care have fought the tedium that can set in by maintaining their breadth of practice—treating adults with chronic conditions of course, but also performing prenatal care and sprinkling their day with the joys of well-baby check ups. As a primary care doctor, it seems as though the vitality of one’s practice is often proportional to the breadth of one’s practice.
Personally, I will likely not be a full-time primary care physician practicing medicine in the U.S. all my life. I foresee my career taking me abroad again one day. In settings of poverty, the broad tool set that family medicine provides – the ability to take care of children, pregnant women and sick adults confidently – is invaluable. Working with family physicians in rural India, it was exhilarating (and exhausting) to see them move seamlessly from the pediatric ward, OB ward, and adult medicine wards with ease each morning, and then see patients of all ages in clinic in the afternoon.
Finally, as we all know, the health care system in this country is broken, especially, when it comes to the coordination of care. Personally, I believe the broad clinical training one receives in family medicine, as well as the strong new emphasis many family medicine residencies are placing on team-based care, uniquely positions family doctors to help lead the revolution that is stealthily underway in primary care.
Anoop Raman is a medical student who blogs at Primary Care Progress.