At the Gregg Stracks Leadership Summit this September, PCP chapter leaders from around the country learned some of the skills needed to mobilize for better primary care training on their campuses. Among those skills, students learned to tell the story of why they were drawn to primary care, also known as The Story of Self. Here, Joe Nelson, of PCP's Baylor chapter, shares his.
By Joe Nelson
"Our health care system is broken." We hear that statement so often that it’s begun to lose its meaning. But for me, Kevin gave it meaning. Kevin is a biomedical engineer and faculty at UT Southwestern. His Ph.D. required that the he complete most of medical school himself, and I know few people who know more about the intricacies of the body than he does. So you can imagine how humbling it must have been for Kevin to come to me, a medical student, for medical advice.
A few years ago, Kevin had an abnormal colonoscopy that revealed some pre-cancerous polyps. In the intervening time before his follow-up colonoscopy, he started his own biotech company. Kevin holds several patents on controlled drug delivery devices, and his technology is far ahead of anything currently on the market. Nevertheless, starting a biotech company is difficult, and finding funding required skills he’d never used. After taking a large pay cut and losing his health insurance, he was never able to follow up with his doctor.
Fast-forward a few years. Kevin is having some weight loss, weakness, and fatigue. That's when he came to me for advice. Talking with Kevin wasn't terrifying just because I felt ill equipped to advise him, but mostly because Kevin is my dad.
In what kind of health care system can a learned, health-literate individual make an educated decision not to seek medical care in such a high-risk situation? Why is a man like my dad relegated to asking medical students for health advice?
In the medical community, we talk about access to care as though it were a separate issue from medical costs. In fact, we usually refuse to discuss cost at all. Instead, we have behemoth yet inadequate government programs like Medicaid, CHIP, and Medicare to help improve access to the care that we've been told is fundamentally expensive. But the elephant in the room is that if medical care were inexpensive, everyone would be able to access it.
A generation of physicians who saw the advances brought to medicine by science in the 1940's and 50's have discounted the physical exam and built a pedestal for the p-value. Sub-specialty care has exploded. And with the creation of expensive tests to replace free physicals, specialists to replace primary care physicians, and the ubiquity of health insurance to blind us to cost, money has poured into medicine like never before.
Physicians today bring home five and a half times the average American’s salary. Hospitals have changed from charity organizations built for the poor into marble-walled, multi-fountained glittering glass edifices. And out of the staggering medical bills footed by the nation, at least $750 billion per year - more than we spent on the entire Iraq war – is unnecessary. If you started saving one million dollars per day on the day Christ was born, you still wouldn't have $750 billion. And the estimated waste in medicine would be even greater if it took into account our abhorrent lack of preventive care.
So what has been the net return on our great investment in our health? Lower life expectancies than our parents and even more dismal forecasts for our children. Obesity is rising like a tidal wave, trailing heart disease, diabetes, liver and kidney failure in its wake. Proponents of the sub-specialty paradigm are sounding the alarm for more cardiologists, endocrinologists, gastroenterologists, and nephrologists than ever before, somehow failing to mention that virtually all of these conditions are preventable.
We're furiously trying to mop up the floor before we stop the leak.
We all know the answer though. Primary care and preventive medicine are the only realistic solution. But the hidden curriculum in medical school too often teaches us that we are exempt from participating in that solution, that other, less talented people should man the primary care field.
From our first day of medical school, we are trained almost exclusively by the physicians most entrenched in the sub-specialty paradigm that caused this crisis. At many schools, a student can go two years without meeting a family physician or general internist. And on the surface this approach makes sense. The heart is taught by a cardiologist; the kidney by a nephrologist; hormones by an endocrinologist. This supposedly deepens our study of each system. Unfortunately, it also undermines our ability to think in terms of the whole organism. As a candid ophthalmologist put it, "The purpose of the heart, liver, kidneys, and brain is to support the eye." When this myopic viewpoint, although amusing when stated outright, is the norm, teaching takes a backseat to outright recruitment.
It is easy to be swayed by the lifestyle and high salaries inherent to sub-specialization, especially in contrast to the outdated models of primary care most med students see: a doctor-who-does-all spending five to ten minutes with each patient only to stay perpetually behind on appointments and paperwork.
Students are never told the true story of primary care: that it can be whatever we make it. Emerging new models, such as the patient-centered medical home, change the way primary care is practiced and reimbursed, increasing quality for patients and job satisfaction for physicians and lowering costs for all.
And payers are beginning to notice. Many are beginning to reward those who practice high quality preventive care and to punish those who don't. The truth that many professors do not admit to us is that the very academic institutions we are taught to revere are being pressed to provide the quality of care rendered by the humble medical home. Even the terms "generalist" and "specialist" are making way for "comprehensivist" and "partialist." The students fortunate enough to learn about this culture change will no longer choose dermatology or anesthesia for the lifestyle or pay. They will choose primary care, and they will be doing the right thing.
Joe Nelson graduated from Brigham Young University with a Bachelor's in Applied Physics. He is a third-year medical student at Baylor College of Medicine. He lives in Houston with his wife and three boys. His dream is to become a family physician and open a free (or almost-free) rural clinic.