By Katherine Ellington
Doctors providing primary care deliver definitive care to the undifferentiated patient at the point of first contact taking continuing responsibility for providing the patient's care....Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients....the personal primary care physician serves as the entry point for substantially all of the patient's medical and health care needs - not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.
—American Academy of Family Physicians
The attributes and skills described above are cultivated through years of personal growth and professional development beyond textbooks. Primary care physicians need to share their unique white coat experiences to advance first-hand knowledge of the profession. I’m telling the story of my experience with a doctor who opened office hours for me to learn.
When I was a bright-eyed premed, a neighborhood physician allowed me the privilege of bearing witness to his primary care practice. At this stage, my interest was in disease and illness, how doctors treat and cure. Cardiovascular disease, hypertension, diabetes, macular degeneration, dementia, diverticulitis, gout, infections, bronchitis, asthma, lung disease and cancers were among the most frequent case vignettes that I recall from those months that I spent one day a week observing patient care and providing administrative support — a premedical student’s dream. Office hours began in the afternoon and continued late into the evening with overwhelming patient demand peaking during the winter months.
His well-designed small practice space had two small exam rooms, a receptionist and waiting area, bathroom and a space for patient files just outside his consultation office, all on the lower level of his modest family home. In the waiting area, his self-published poetry, artwork hanging on the walls, and collection of magazines offered distinctive storytelling about life in our community. He was open late into the evening because more than 50% of his patients worked full-time but were underemployed and/or underinsured needing evening appointments. There was always was always a crowd, yet most patients endured the wait time, respectfully knowing he’d take the time to listen when it was their turn. When patients called for appointments or checked-in at the desk, I could sense their respect for this doctor and his ways of practice. They’d tell me compelling stories about their past experiences with illnesses or managing chronic conditions where the doctor’s treatment, care and diligence had made a significant difference in their lives.
He was their neighbor and physician. Patients usually lived within walking distance or not more than a few miles of the doctor’s office. He was just blocks away from my grandparents’ home. Couples and intergenerational families predominated the adult patient census. It was not uncommon for him to see many members of the same family, many I knew from the neighborhood, most had been his patients for decades. There was also a stream of new patients, who were always offered appointments near the end of office hours to accommodate more time.
A few times a week, the doctor made house calls to a few select patients with urgent care needs. I remember when he visited my grandmother when she had too much leg pain to get out of bed. He diagnosed her sciatica, gave instructions about bed rest, and wrote a prescription and a note for work. Many years later he’d return to our home to see my grandfather who was in respiratory distress and liver failure. His house call focused on helping our family come to terms with the pressing need for my grandfather’s hospitalization as well as to come to grips with the gravity of his condition. Physician house calls offer field notes of the patient’s environment, lifestyle and dynamics that may be unrevealed during history and physical exam. A vegetable garden growing on the side of the house may confirm a commitment to nutrition. Indoor odors with a hint of bleach may offer notes on cleanliness. On the other hand, the smell of alcohol or tobacco may match symptoms visible in the chart. House calls offer a glimpse of the patient en vivo informing diagnosis, treatment and decision-making.
More than particular manifestations of disease and illness, I was intrigued by the kind of relationships the doctor fostered with each patient. He navigated the stress of delivering bad news whether it was diagnoses of terminal illness, the unknown trajectory of a rare disease or the need for hospitalization. He also shared in happier times with news of recovery and healing. When illness loomed beyond his reach, the doctor helped patients navigate a world of specialists and the hospital experience by managing expectations, explaining procedures and calming their fears while acknowledging the uncertainty. He also held regard for and equipped caregivers with consultations to discuss a range of support issues emphasizing the importance of caregiver self-care. In this setting, I witnessed physician advocacy, one patient at time.
It’s in this practice setting that I began to understand the physician as healer, engaged in the relief of pain and suffering learning that compassionate care involved a commitment to self-care and well-being.
If the field of primary care is to experience growth, future mentors and formal mentoring programs must be within reach for premedical and medical students, residents as well as early-career physicians. Recent reports indicate that 1 in 5 Americans don’t have access to primary care. In rural areas and urban cities there is a crisis looming with significant demand for primary care physicians. The challenge to increase the number of physicians in primary care while holding on to the current workforce substantiates the need for resources enabling a robust and diverse community of physicians engaged in competent, high-quality primary care and mentoring future doctors. Furthermore, as patient-centered medical homes
embrace technology, cost-saving practice management strategies and quality measures to enhance the patient experience in the delivery of health care our challenge continues to cultivate environments enabling compassionate care by well-trained primary care professionals.
I gained a profound sense of the trust and respect necessary in the relationship between doctor and patient. I learned the importance of community credibility for the primary care physician. My interest in medicine and life course continues to be fueled by this early encounter. Role models and mentors can help shape your understanding of the contemporary challenges in medicine and primary care. Such experiences may guide your career choice as well as more closely consider skills you’ll need to prepare. It’s key to use observation, inquiry and reflection so that you can interpret your experiences with role models and mentors making the most of time spent in the doctor’s office.
Katherine Ellington is a medical student at St. George’s University and has studied with the Program in Narrative Medicine at Columbia University. She’s pursuing a career in primary care and community health. Katherine blogs at World House Medicine.