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In today's Progress Notes, we launch the first in a three-part series about the fall and rise of primary care.

By Anoop Raman, M.D., M.B.A.

Much of the news we hear about primary care is disheartening at best, frightening at worst. Most of us have heard that there is a shortage of primary doctors, and with over seven million new patients enrolled (and counting) through Obamacare health exchanges, that shortage is going to get much worse. On the horizon, while medical schools are increasing their enrollment, there continues to be a dearth of students willing to apply to the field of primary care. And who can blame them when primary care doctors continue to be paid half of what the average dermatologist or cardiologist earns.
However, there is hopeful news.  Last year, I went to the American Academy of Family Physician’s (AAFP) annual conference in Kansas City, tasked with recruiting medical students to apply to Columbia’s Family Medicine residency program.  I spoke with dozens of students who were incredibly passionate about primary care.  At an AAFP conference, that’s not a surprise.  What was a surprise was how nearly all of the students were talking about how interest in primary care is surging at their medical schools.  Indeed, AAFP student membership has soared to an all time high of 26,000. And this year, Columbia’s family medicine residency program, along with most other primary care programs in the country, continued the recent trend in the rising quantity and quality of medical students applying to the program.

Posted by Sonya Collins on Apr 22, 2014 1:38 PM EDT
Based on her own family history, this medical student knows that future physicians need training in health disparities and social determinants of health.

By Tehreem Rehman

When I was growing up, my mother often recounted the story of a dermatologist who figured out that the fungal infection in her hands stemmed from sensitivity to dishwashing liquid. He had asked basic questions about her living circumstances during the first visit, recommended she wear gloves when washing dishes from that point on, and saw improvement in the follow-up appointment. He didn’t charge her for the second appointment as he knew my mom was uninsured at the time and struggling financially. When my mom inquired about the fee, he simply said, “Your getting well is my fee” and gave her sample medications.
Hearing this account made me realize what a significant impact socioeconomic status has on health. As a minor and an American citizen growing up in New York City, I was fortunate to be automatically insured. I took for granted regular visits to the pediatrician. However, when my mom immigrated to the United States, access to basic medical care was a luxury. 

Posted by Sonya Collins on Apr 17, 2014 10:05 AM EDT
Seeing firsthand the ways in which primary care and the health care system in general don't work for many of the neediest patients, this med student urges Minnesota legislators to support innovative models of care that will serve patients better and attract more students.

By Peter Meyers

Mary went to the emergency room 68 times in 2013 despite the fact that she didn’t have 68 emergencies. She was also hospitalized four times for causes that mostly could have been prevented. She suffers from chronic pain, insulin-dependent diabetes, depression, and PTSD. Mary is 34 years old and has health insurance, but the system clearly isn’t working for her.

As a medical student interested in primary care, I’ve met a few people like Mary. Mary is suffering from multiple chronic diseases and several social barriers to obtaining proper health care. The heartbreaking reality is that patients like Mary, and there are frighteningly many, do not fit into the traditional paradigm of clinical care in the US. 
Posted by Sonya Collins on Apr 15, 2014 11:27 AM EDT
In an all-too-common patient story that will frustrate any patient or doc who's been there, regular contributor Stephen Schimpff explains what's wrong with primary care through one patient case.

By Stephen Schimpff, M.D.

A primary care physician needs, of course, to be well educated, well trained and up to date. But that’s not enough. He or she also needs to be a deep listener and critical thinker. And, to be most effective, the physician needs a team with the patient at the center – the patient-centered medical home concept. Listening and thinking require time, and so does quarterbacking all of the other providers and team members needed to care for patients with chronic disease.
Time is the element that’s been lost in primary care practice over the past decade or more. Without time to listen, the full picture of a person and their illness does not emerge. Without time to think, the diagnostic process suffers immensely. The physician is then no longer a healer but rather a well-paid care giver. He or she is quick to send the patient off to a specialist. The opportunity for outstanding preventive care is diminished. And without time to coordinate all of the other providers that are required for someone with a serious chronic illness, the care becomes disjointed, quality suffers and expenses rise.
A patient story will illustrate the problem.

Posted by Sonya Collins on Apr 10, 2014 1:59 PM EDT
In response to a patient case described in a New York Times blog, this family doc explains why listening to all members of a patient's family isn't a violation of privacy and should be the standard of care.

By Jack Westfall, M.D.

In her January 13, 2014, "Hard Cases" blog post for The New York Times, Dr. Abigail Zuger tells the story of a patient, Tom, whose wife calls her to discuss Tom’s alcoholism. Shocked to hear that Tom even has a drinking problem, Zuger tells Tom’s wife, “I’m so sorry. I can’t talk to you about that” citing HIPAA in the blog post. And then the call is over and she never speaks to Tom’s wife again. 

Dr. Zuger could not be more wrong in her approach to this case. She had the opportunity, and I believe, the duty, to stay on the phone with Tom’s wife – let’s call her “Ann” – a bit longer.

Taking care of families is one of the joys of family medicine. To care for the spouse, parents, children, infants, and the elderly is one of the core values of family medicine.  Balance between privacy and relationship-based care is important. However, good care is the first value.  

Posted by Sonya Collins on Apr 8, 2014 11:08 AM EDT
When he told friends and family he wanted to be a family doc, they told him he was crazy. So he proved them wrong and set up a practice that defied all the stereotypes.

By Chad Krisel, M.D.

I went to medical school in order to become a family doctor. My goal was to help people realize their optimum health by treating the root cause of their problems. Knowing that more than 75 percent of total health care costs are incurred treating chronic diseases and their devastating end-points, I aspired to prevent illness in the first place or reverse problems in their early stages. 

Posted by Sonya Collins on Apr 3, 2014 10:18 AM EDT
Even when it seemed he didn't want her help, this health coach never gave up on her patient, and her tenacity made all the difference.

By C. Leigh Goldsmith

Recently “Johnny” came in to see me for the first time in a year. I’m his health coach at Collective Primary Care, an Iora Health practice in Brooklyn, NY. Shortly after our first visit, he had willingly checked himself into the hospital for his clinical depression twice in about a month’s time. After that, I began my relentless and fruitless follow-ups. Despite Johnny’s enthusiasm after our first appointment, month after month his name would appear on the schedule for follow-ups, but he would never show up for the appointment. 

Posted by Sonya Collins on Apr 1, 2014 12:37 PM EDT
Match Day is one of the most important days in a physician's life. It's when soon-to-be docs learn which residency program they “matched” into and whether the Match will lead them to a clinic down the street or a hospital across the country. For the weeks immediately preceding and following Match Day 2014, Progress Notes will run daily posts about your Match experiences. In the final post in our series, a resident explains how he chose between family medicine and internal medicine.

By Hugo Torres, M.D.

My third year of medical school cemented the passion for primary care I developed as a volunteer in a clinic for undocumented immigrants in San Francisco. Relationship building, continuity of care, and seeing the impact a primary care physician can have on a patient's health all ignited my passion more than any angioplasty or neurosurgery ever could. But one question continued to nag me as I filled in the bubbles of my electronic residency application form and formulated my personal statement: family medicine or internal medicine?

Posted by Sonya Collins on Mar 28, 2014 10:32 AM EDT
Match Day is one of the most important days in a physician's life. It's when soon-to-be docs learn which residency program they “matched” into and whether the Match will lead them to a clinic down the street or a hospital across the country. For the weeks immediately preceding and following Match Day 2014, Progress Notes will run daily posts about your Match experiences. In today's post, a med student describes how personal preferences figured into her rank list.

By Alejandra Ellison-Barnes
I was introduced to med-peds when I was just deciding to apply to medical school. I was a college student interning in what was intended to be an elementary school clinic, but which – given the lack of access to care in the area – was functioning as a rural health center. The practitioners saw and treated everyone in the community from infants to the elderly. At that time, I envisioned myself as a future pediatrician, or perhaps a surgeon, but certainly not a combined pediatrician-internist. I didn’t even know there was such a thing.
Posted by Sonya Collins on Mar 27, 2014 9:11 AM EDT
Match Day is one of the most important days in a physician's life. It's when soon-to-be docs learn which residency program they “matched” into and whether the Match will lead them to a clinic down the street or a hospital across the country. For the weeks immediately preceding and following Match Day 2014, Progress Notes will run daily posts about your Match experiences. In today's post, a med student explains why he decided to go with his gut.

By Tom Murphy

“This feels right,” I thought during my third-year outpatient family medicine rotation at what would ultimately be my first choice family medicine residency. The more I interacted with the residents and faculty, the more I knew that this was a place where I belonged.  For a person who has spent so much of his life devoted to science and the last few years of his life devoted to learning evidence-based medicine, this was a scary prospect: making a decision so large as choosing a program for graduate medical education based largely on a gut feeling. 

Posted by Sonya Collins on Mar 26, 2014 9:26 AM EDT
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First-person stories from the front lines of primary care.

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Most Recent Comments

Stephen, thanks for sharing this post! I completely agree. Seeing family members have struggles similar to Monica...
Thanks so much for your reflections, Dr. Westfall! I love the way you put it: "But that is what physicians are called t...
Hugo - Thanks for your piece. As someone who got to be a part of the 2nd cohort of medical students going through the Lon...
It is so very difficult to balance personal interests, professional goals, and personal life all in one decision! T...

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