Arguably the most important rotation of clinical year, whether you go into primary care or specialize. Not only will your primary care rotation be the most important for your boards test, but also it will be the most influential on your career. This rotation was one where I had a lot of ‘ah ha!’-moments. When random facts from didactic year were finally put into context and ‘clicked’ in a new way.
I admit, primary care turned out to be much more cerebral than I expected it to be. Before I started this rotation, my preconceived notion was that primary care physicians (PCPs) spent most of their day treating the common cold. Of course, that is far from the truth. Many of our patients had multiple chronic conditions and presented with interesting, non-specific complaints that required careful deliberation. More so than any other rotation (including internal med), I felt like a detective solving puzzles.
Another pleasant surprise was how much I enjoyed having ‘continuity of care’. Even in our short 5 week rotations, there were several patients who I saw multiple times. In the emergency department, this was never a good thing. However, in primary care it was generally appropriate and even welcomed. In addition to getting to build a closer relationship with these patients, it was fascinating to follow their diagnoses as I referred them for tests and specialists. Primary care is the one area of medicine where you truly get to follow every aspect of a patient’s care and see the resolution/outcome of their illness.
Something I learned quickly on this rotation is the importance of being a patient advocate. Unfortunately there are times when you will do everything you can to help a patient only to see another provider or insurance company ‘drop the ball’ on them. Too often, the most frustrating part of your day is dealing with medical red tape (not the kind for bandages). You will see compliant patients hit road blocks and generally not know how to advocate for themselves. The best case is that you get a call from a frustrated patient. Worse, you find out 6 months down the road that your type II diabetic has not been taking their insulin because an insurance company wouldn’t cover it. Then there are more acute cases where advocating for patients may save their lives. I saw this more than once on rotation and, yes, it was infuriating. Patients are vulnerable because healthcare is complex. Never forget that the title of PA first and foremost stands for Patient Advocate.
To my surprise, primary care was one of my favorite rotations of clinical year. Much credit is given to my wonderful preceptors. My family med rotation was at one of the satellite clinics of Penn State Health, so several of my preceptors were also instructors during my didactic year. One of them, Dr. Richard, is a man who I in many ways idolize as a healthcare provider. Not only is he intelligent, but also he is perhaps the most patient-centered physician I have ever met.
Throughout our didactic year, Dr. Richard drilled into our heads repeatedly the importance of shared decision making in medicine. The idea being that rather than instructing the patient on what to do (the classic paternalism of medicine), our role as healthcare providers is to provide support to help patients make informed decisions about their own health. This requires listening to our patients and learning about their values and goals. Nobody is better at this than Dr. Richard, and I am fortunate that I was able to precept with him and learn from his example.
- Review screening guidelines. Perhaps the most important thing you can do to prepare for this rotation is to review screening guidelines prior to your first day in clinic. They only take a few hours to memorize and will have huge payoffs throughout your rotation and for your exam.
- Medications are frequently the culprit. The word pharmacy comes from the Greek word pharmakos, which means poison. Never forget that. As wonderful as medications are, they are often the cause of your patient’s complaints. They may cause rashes, nausea, constipation, diarrhea, dizziness, dehydration, Lupus, and even psychosis. The list goes on. So especially with your older patients, don’t forget to ask about recent medication changes. Something as simple as changing pharmacies may lead to a new rash or life-threatening reaction (a different formulary may carry the same drug with different inactive ingredients).
- Shave away layers with Occam’s Razor. Not a literal blade. Occam’s Razor is a philosophic principle stating that the simplest explanation is often the correct one. Some patients are not big complainers. Others may come to you with a laundry-list of problems and expect you to solve every one of them. Your more hyper-vigilant patients may obsess over certain symptoms and lab values or blow their complaints out of proportion based on what they have Googled at home. These not-so-simple patients will make your head spin if you let them. The best approach to these patients is to simplify. Write down their complaints in list form, decide which ones to focus on, and then seek out the simplest explanation for their illness. True, occasionally you will come across those rare ‘zebra’ diagnoses (like African Sleeping Sickness) in your career. But Occam’s razor says that 99.9% of the time this will not be the case.
- What to do with unsolvable complaints. I started this rotation under the impression that every time I walked out of a room I had to have a diagnosis ready for my preceptor. However, sometimes that is simply not possible. There will be times when the complaints are too non-specific or when you just don’t have enough information to make a diagnosis. One patient left me wondering “Did they have a TIA (mini-stroke)? Are they having migraines? Are they diabetic? Do they have cancer? Lyme Disease?” The patient literally had so many non-specific signs/symptoms that I felt the diagnosis could be anything. Rather than come up with a diagnosis in this situation, the goal should be to develop an organized differential. Write down every possible diagnosis that could explain the patient’s symptoms, then rank them from most likely to least likely. Also rank them by most life-threatening to least. Then go from there. Rather than give a specific diagnosis, choose a lab test, study, referral, or treatment that will be the most logical next step for this patient.
- Talk about football. Or baseball. Or dog-grooming, if that’s your thing. You may have short 15 minute appointments, but there is always time to say a few words that aren’t from a medical dictionary. On this rotation more than any other, part of your job will be to build relationships and connect to patients. One of the amazing things about primary care is the extensive continuity of care. Several of my preceptors had built relationships where they cared for 3 or even 4 generations of a single family.