My style in primary care

I’ve been suffering an identity crisis as a new primary care physician. I’ve had guidance with nearly every decision up until this point but now I’m on my own. I reflect back a distinct interaction with one of my attendings in residency. He is an osteopath, manipulates people’s muscles, and fascia for the bulk of his work. I was precepting a patient with him one afternoon. The patient had terrible sleep habits, drank caffeine in the evening, took naps at 5pm, watched tv in his bed, had untreated anxiety and would contemplate the next day’s plans all night. He didn’t work, didn’t exercise, had nothing to exhaust him during the day. He wanted a medication to make him sleep and instead I counseled him on sleep hygiene, a strategy to fix the problem rather than masking it with meds. My attending, disagreed with me and said I should just give him the med.

I am fundamentally a non-interventionist. At my very core, I feel that doing less for patients is largely best practice. My mom the other day got codeine for a cough, got anaphylaxis and ended up in urgent care. I remember learning an acronym in my macroeconomics class, TANSTAAFL: There ain’t no such thing as a free lunch. The hippocratic oath fails to acknowledge this. The first rule of becoming a physician is “Do no harm.” but fundamentally this is unavoidable. Even a patient coming to an appointment is harmful–it usually costs a fortune to see a physician.

I’ve been having some debates with my partner recently over the role of healthcare and medicine. She is not a non-interventionist but she fundamentally disagrees with allopathic medicine, also known as modern medicine. She uses fluoride free charcoal toothpaste, sees someone who practices reiki, and uses tinctures and essential oils to treat various ailments. She still takes ibuprofen, antihistamines, other miscellaneous normal drugs when she needs them. She’s challenged my core belief of my role and the role of medicine and primary care. I vented to a friend about a naturopath treating a patients diverticulitis with colloidal silver rather than saying this is inappropriate and sending the patient to a modern medicine practitioner. My partner heard our venting and challenged me, accusing that I had some omniscient regard toward allopathic medicine.

I clarified that, while I may be wrong, I have to have some moral and practical guidance to my practice. Allopathic medicine fails in so many regards. Most common ailments we have very little effective therapies. Probably the two most common complaints in primary care, low back pain and the common cold, are treated with symptomatic treatment that is pretty much ineffective. I acknowledge the limitations of allopathic medicine. I also embrace that maybe that’s okay that we cannot treat everything. I don’t pretend to be omnipotent and I think that’s okay. It’s okay for there to be some pain, some discomfort in this world-we should never try to treat all sensations, all experiences.

My goal as a primary care provider is to have my patients forget about their health. My goal for them is to live lives, to exist in the world, to experience it for all it has to offer, to forget there is something needing treatment. The modern healthcare machine is completely in opposition to this, including and potentially especially practitioners of non-evidence based therapies such as acupuncture, chiropractic, reiki, homeopathy, shoulder arthroscopy. This is my primary frustration with these practitioners. It’s not their lack of basis in evidence, although that does irk me. It’s that they hardly ever see a lack of role for their skillset. They are hammers and patients are nails. You see an orthopedic surgeon, you get surgerized. You see a chiropractor, you get your joints cracked. You see a homeopath, you get some tincture. Hardly, if ever, do they say, “there’s nothing I can do for you”, or “you could do nothing for this and your body will probably heal itself”, or “you should see this other person for this.”

As I mentioned, I am by default a non-interventionist. I trust that if we respect our bodies, do what we know they need, exercise them, feed them well, avoid pollutants like alcohol, tobacco, and other recreational drugs, they will largely function and heal on their own. And when they don’t, when they get stuck in positive feedback loops, that is where I can intervene. When I counsel patients on what their options are for treatment I nearly always say “or you could do nothing.” That is ALWAYS an option in my clinic.

Rarely will an orthopedic surgeon, a chiropractor, a homeopath, a reiki person, an acupuncturist tell you that. They profit off the ill-health of populations, they have financial incentive to have a patient return on a regular basis. You will never hear a masseuse tell you, “I think you really don’t need to come back and see me, your muscles are pretty good.” But when you see a physician, for the most part we don’t want to see you back in our clinics. If you can avoid us, largely that means you’re doing well.

My goal for patients I believe will always to have them forget about their health. That doesn’t mean masking sensations. It means providing education on what needs treatment, what is treatable, what is not, and have them enjoy their lives and be with their loved ones and experience this life for all it has to offer. Some people need more to get them to that point and I am happy to be a guiding person on that journey. But I absolutely do not want them taking a dozen vitamins and tinctures and seeing a million doctors and alternative providers who are all convincing them that they need something else to manage their health.

I counsel every patient on limitations of medicine. Many of my patients come in requesting “annual labs”. I counsel them that there are no labs indicated on an annual basis unless you have pathology. I talk people out of getting bloodwork even though it financially benefits my employer. I counsel patients on the harms of prostate cancer screening, that we ended up killing people with prostate cancer treatments for cancers they were never going to know existed, that were never going to cause them problems. Ironically, patients come in requesting all these non-evidence based practices that result in more harm than good, and then an absurd percentage of these same patients decline vaccinations. They’ll get their tetanus, diptheria, pertussis vaccine as if that is what would kill them and then they’ll decline the annual flu vaccine.

I’ve adopted a somewhat paternalistic mentality toward medicine, understanding that, as I am typing this post at 9pm I spend way too much time thinking about medicine and unfortunately sometimes people largely do not know what is best for them. This past week I discontinued a patient’s medications for MS that she’s been on since 2006 because she doesn’t have MS. I negotiate people into getting appropriate vaccines, understanding that they have massive population level benefits, and I’ll talk people out of taking their plethora of vitamins, supplements, medications, and seeing 18 different healthcare providers. I don’t know if I’m right. And I imagine my patient panel will self-select to largely agree with this non-interventionist style of life. I’ll keep living by the mentality TANSTAAFL and “if it’s not broken don’t fix it.”

One thought on “My style in primary care”

  1. I first came across your name in 2015. You were on the AT and I was choosing to stay in Virginia after getting out of the Marine Corps, mostly because of the AT and backpacking. I went to nursing school and currently work in a CVSICU in Michigan. It’s interesting to read your blog now, after so many years. I just want to say I respect to it approach to medicine and think your patients are lucky to have someone who truly cares about them.

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