Why this medical student found primary care awesome, and boring

I recently finished another 5-week clinical rotation.  This one was primary care (outpatient internal medicine +/- family medicine).

First a few words about primary care as a field:  I found it to be both awesome and boring.

It was awesome because I was the “doctor.”  I had essentially full responsibility for my each patient.  From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility.  After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested.  I was my patient’s health care provider — a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring.  I could do it.  As a 3rd-year medical student.  The cases I saw were by and large obesity, hypertension, diabetes, and hyperlipidemia.  A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist follow-ups … and far too much of “staying the course.”

Patients with these most common chronic diseases come in for follow-up multiple times a year (or at least they did at the VA), just to go over blood work, get their BP checked, get their referrals, and undergo a focused physical exam.  Those visits really didn’t require much thought.

I like thinking.  Medical students like thinking.  And if this is what most of family medicine/primary care is like … I don’t want to do it for the rest of my life.  Now, I’m not saying that primary care physicians don’t think! My attending was one of the smartest doctors I’ve worked with so far.  I’m just saying that his brain isn’t operating at its full potential when dealing with mundane follow-ups.

So why not save his brain for the difficult things and let someone else, like a PA or NP or even a nutritionist, deal with the simple things?

The most common argument against this “infringement” on scope-of-practice by physician extenders (PE, an umbrella categorization) is that they’re not trained to do the job that MDs and DOs spend 4 years of medical school and 3+ years in residency for.  I agree that their training is different from ours … but that doesn’t mean that PEs can’t do the job that physicians are overqualified for.  Think how much more efficient (both in terms of physician’s time and cost to the system) it would be if patients could have these kinds of simple visits with PEs:  “Your blood test results are on target, keep doing what you’re doing” and “We’re not going to change your medication right now because you haven’t been taking all of them regularly and/or you haven’t been maintaining your diet like we told you to.”

The argument against PEs cites patient safety concerns as a reason not to expand scope of practice for these health care professionals.  But if the PE knows when to refer to a physician, that sounds safe to me.  Having worked with them in the primary care setting, I’ve personally witnessed nurses coming to ask the doctor to take a look because they’re not sure what’s going on.

Of course the devil’s advocate says, “But they don’t know when they don’t know!”  But can’t the same be said of primary care doctors, who routinely refer to a specialist?  If a patient is found to have HIV after a routine screening test, she’ll be referred by her PMD to an Infectious Disease doc for management.  But what if the PMD hadn’t done a screening test?  The patient may not have been diagnosed or had clinical symptoms until she had her first opportunistic infection.  In another scenario, acute HIV presents as a nonspecific flu-like illness … and the actual diagnosis might not be made at that time.  Now, go back and read that paragraph again, replacing “PMD” with “NP.”

That point aside, let’s temporarily concede that, fine, physician extenders don’t know how to spot a zebra.  And they may not be able to handle all the horses.  But they can definitely handle the day-to-day horse grooming.  Which is great, because I don’t want to groom horses after I finish medical school.  I’d much rather see the horse only when I want to go riding.  But that’s just me.

Suchita Shah is a medical student who blogs at University and State.

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