Tuesday, June 21, 2005

Big Doctoring, Little Doctoring


Psst! Is everybody gone yet? I am appreciative of the recent publicity about this blog, but at the same time, I found the extra attention a little uncomfortable. Anyways, back to normal low volume hits.

I recently read a book review on "Big Doctoring in America: Profiles in Primary Care". The author, a physician, interviewed 74 primary care physicians and put 15 of the best profiles together.

Once upon a time, the general practitioner was America's doctor. The GP delivered babies, treated colic, extracted gall bladders and sat by the bedside of the sick elderly. As the 20th century progressed, though, and as scientific medicine advanced and differentiated, specialty medicine was born and the pattern of medical care in the United States changed dramatically. By 1960, the GP was almost extinct.

The last forty years, however, have seen the concept of general practice rebound with a new name - "primary care" - and with new practitioners. The general practitioner has been reborn as the family physician and has been joined by the general internist and the general pediatrician as providers of big doctoring - comprehensive care over time. Additionally, new clinicians - nurse practitioners and physician assistants - play important roles in the "general practice" of the 21st century.

Primary care is a way of medical life, an approach to health care and healing, a skill set and a mind set that is big doctoring. It is about care that is humanist, comprehensive, efficient, and flexible, doctoring that builds on the legacy of the past and the rich tradition of care that has characterized much of the history of medicine and nursing.

"Big doctoring" is a term coined by the author used to describe primary care, meant to convey a sense of the broad scope of problems/issues/organ systems that FPs/GPs/GIMs/GPeds tackle everyday. For me, however, it sounds presumptuous, even patronizing, aimed at boosting the egos of physicians who get too little respect, except perhaps from their own patients.

"Big doctoring" also sounds too similar to "Big Brother", "Big Government" or "Big Pharma". Shades of black monolithic towers, shadowy nameless figures in trenchcoats and institutional red tape up the wazoo.

"Little doctoring" is a more fitting description of what I do.

My exam room is small, my office is tinier still. I see 2-7 patients a day. I listen to the latest chapter in the stories of their lives. I reassure a mother whose child has a cold. I do a physical exam on a healthy young man who hasn't had a physical in 3 years. I freeze a wart. I give a shot. I talk with the slightly overweight woman about the best way to get in shape. I try to convince a diabetic to take his medicine without making him feel guilty. I share a woman's grief at the loss of her mother to pancreatic cancer 3 years ago. I wonder if a patient is late for his appointment or if he will be a no-show. I write a prescription for Cialis to an embarrassed senior. I do a rectal exam. I treat a cough. It's all mostly mundane, not the stuff of heroic 12 hour surgeries or emergency life-saving code blue action.

And yet, sometimes what I do makes a big difference. I recently referred an about-to-retire podiatrist for a colonoscopy because of heme positive stools on a routine rectal exam. 5 polyps. 1 turned out to have cancer. But because all his colon polyps were completely removed, he is cured. Not as dramatic a cure as cutting out a grapefruit-sized tumor, but when it's your own body and health on the line, drama is bad, boring is good.

This is the frontier and we primary care physicians are the scouts. We see, hear, feel and smell many things, and every once in a while, we hear distant hoofbeats and we think: horse or zebra? And often, we never come close enough to even catch a glimpse of what just went by. We're just glad it went away without trampling something we'd rather not have trampled.

Tomorrow is the first day a second year medical student will be visiting me and my solo practice. I remember what it was like for me in medical school, being the 4th or 5th person to ask a patient their symptoms and getting a diagnosis handed to you like a cold steak on a platter. The exception was when I got to visit my preceptor's family practice clinic. There I was sometimes the very first person to hear about a patient's chest pain or headache. It was like exploring uncharted territory.

To paraphrase Forrest Gump, a patient's visit is like a box of chocolates, you never know what you're gonna get. In the next two weeks, I hope to convey to my student the same sense of wonder that "little doctoring" can bring.