As a family physician for over 40 years, I loved this piece! Thank you so much for putting into words the reason that this work is so valuable! Best wishes to you!
It’s so important, and so fortunate, to have good mentors. Glad you found one in Dr. Cifu.
One of mine, when I was a junior resident, distilled something for me that in hindsight was inherently obvious, but which has nonetheless served me well for decades:
Q: “Why do we practice medicine?”
A: “To help pts live longer, and/or feel better. That’s it. ”
When I read this it brightens my day and gives me hope that things may be going in the right direction in Brazil.
Here in Washington State I have had three primary care providers myself in the last two years. The first two quit the hospital and left the area.That means three new patient visits to establish, each at about $400 in cost. During those three visits there were never a gown in the room and disrobing was not really an option. The only skin to skin contact made by those three was the third one, when he felt my radial pulse. I don’t really know how those doctors looked because they wore masks the entire time. My last routine PCP visit was less than 15 minutes and he was on the computer the entire time. Despite being on the computer he had not reviewed the previous visit.He did not remember who I was, and did not ask about the two medication he had prescribed on the previous visit. Neither medication was tolerable, neither benefited the problem that we were addressing, but he forgot about them anyway. My wife was there for the third visit, and her comment was; “well that was completely and absolutely worthless.” Such is primary care in my community today.
Wow. I'm sorry about these experiences. As a physician, I hate to see how my profession is going. My suggestion: look for a "DPC" direct primary care, or a Concierge doctor. These are doctors who have chosen to leave the "big system" and go out on their own. Connection and time with patients is the priority.
Well written and yes that's the way it was in my practice (1975-2011) but now the corporate takeover has eliminated long term relationships, patients are seen by minimally supervised non-physician extenders with limited knowledge, the physician of record no longer takes a history or does much examination and attendings come and go like ball players on contracts.
Along with corporate takeover (and likely even more important) are the rules and directives set out by CMS, Medicare, insurance companies - all with the goal of directing physician behavior. What other profession is overseen by a body and process that absolutely directs what the professionals in that field do? Under the guise of "quality measures" and "Medicare guidelines" - with a majority occurring within the framework and set up of the ACA. Medicare "Wellness Visits" direct that "no physical exam is needed". The entire process has been turned into "check box" medicine, where the illusion of "quality" is pandered.
Absolutely! Add egregious false upcoding with 5-level codes with pre checked ROS and PE boxes for visits with zero history and zero examination, multipage notes containing flasification and boilerplate nonsense. I now see this as a patient. I would not have been able to practice in such an environment.
Beautiful essay which reflects a lot of maturity and understanding. You have had good mentors and have learned well. Your thoughts about understanding your biases and being on alert when things do not fit so nicely resonated. You will have a great career and I hope that you have the opportunity to take care of the same population for decades for the reasons that you stated
Beautiful essay Paula. Sadly whenever I read Adam, and now you, they seem like letters from another person universe. I haven't seen primary care that looks like what you describe in 20 years.
Instead providers are shuffled from office to office as organizations are sold, merged, split. There's no continuity of care for patients. Constant staff changes are the norm. Doctors are reduced to "liability sponges for computer driven diagnoses" (as someone wrote so succinctly in the comments recently).
Paula is one of our residents — a remarkably talented physician, as reflected in her thoughtful words here. May this be the beginning of a lasting collaboration and friendship between our cultures and universities, united by a shared commitment to clinical excellence.
Dr Damasco - your essay is inspiring! God Bless you and I thank God there are still in this world physicians like you. And I hope that others reading your essay recognize that the medical arts are alive and well in places other than ‘the West’…
When I tried to post a comment sub stack forces me to find a code in my email when I go to find the code in my email I have to return go to the bottom of the article click in the comment box and try to post a comment during which time the code expires.
Wonderful pic!!!
As a family physician for over 40 years, I loved this piece! Thank you so much for putting into words the reason that this work is so valuable! Best wishes to you!
As a Canadian general practitioner I loved this view of medical practice. Thank you for sharing it.
It’s so important, and so fortunate, to have good mentors. Glad you found one in Dr. Cifu.
One of mine, when I was a junior resident, distilled something for me that in hindsight was inherently obvious, but which has nonetheless served me well for decades:
Q: “Why do we practice medicine?”
A: “To help pts live longer, and/or feel better. That’s it. ”
When I read this it brightens my day and gives me hope that things may be going in the right direction in Brazil.
Here in Washington State I have had three primary care providers myself in the last two years. The first two quit the hospital and left the area.That means three new patient visits to establish, each at about $400 in cost. During those three visits there were never a gown in the room and disrobing was not really an option. The only skin to skin contact made by those three was the third one, when he felt my radial pulse. I don’t really know how those doctors looked because they wore masks the entire time. My last routine PCP visit was less than 15 minutes and he was on the computer the entire time. Despite being on the computer he had not reviewed the previous visit.He did not remember who I was, and did not ask about the two medication he had prescribed on the previous visit. Neither medication was tolerable, neither benefited the problem that we were addressing, but he forgot about them anyway. My wife was there for the third visit, and her comment was; “well that was completely and absolutely worthless.” Such is primary care in my community today.
Wow. I'm sorry about these experiences. As a physician, I hate to see how my profession is going. My suggestion: look for a "DPC" direct primary care, or a Concierge doctor. These are doctors who have chosen to leave the "big system" and go out on their own. Connection and time with patients is the priority.
That is the true reality of medicine today. This article is the ideal that is fading into history.
Well written and yes that's the way it was in my practice (1975-2011) but now the corporate takeover has eliminated long term relationships, patients are seen by minimally supervised non-physician extenders with limited knowledge, the physician of record no longer takes a history or does much examination and attendings come and go like ball players on contracts.
Along with corporate takeover (and likely even more important) are the rules and directives set out by CMS, Medicare, insurance companies - all with the goal of directing physician behavior. What other profession is overseen by a body and process that absolutely directs what the professionals in that field do? Under the guise of "quality measures" and "Medicare guidelines" - with a majority occurring within the framework and set up of the ACA. Medicare "Wellness Visits" direct that "no physical exam is needed". The entire process has been turned into "check box" medicine, where the illusion of "quality" is pandered.
Absolutely! Add egregious false upcoding with 5-level codes with pre checked ROS and PE boxes for visits with zero history and zero examination, multipage notes containing flasification and boilerplate nonsense. I now see this as a patient. I would not have been able to practice in such an environment.
Beautiful essay which reflects a lot of maturity and understanding. You have had good mentors and have learned well. Your thoughts about understanding your biases and being on alert when things do not fit so nicely resonated. You will have a great career and I hope that you have the opportunity to take care of the same population for decades for the reasons that you stated
Beautiful essay Paula. Sadly whenever I read Adam, and now you, they seem like letters from another person universe. I haven't seen primary care that looks like what you describe in 20 years.
Instead providers are shuffled from office to office as organizations are sold, merged, split. There's no continuity of care for patients. Constant staff changes are the norm. Doctors are reduced to "liability sponges for computer driven diagnoses" (as someone wrote so succinctly in the comments recently).
Long may you be able to avoid these forces!
Paula is one of our residents — a remarkably talented physician, as reflected in her thoughtful words here. May this be the beginning of a lasting collaboration and friendship between our cultures and universities, united by a shared commitment to clinical excellence.
Dr Damasco - your essay is inspiring! God Bless you and I thank God there are still in this world physicians like you. And I hope that others reading your essay recognize that the medical arts are alive and well in places other than ‘the West’…
“Finally, at the end of the day, primary care physicians just want to do the right thing, at the right time, in a way that feels right.
There’s only one way for this to happen: study, discipline, suffering, and principles.”
Excellent. 👍
When I tried to post a comment sub stack forces me to find a code in my email when I go to find the code in my email I have to return go to the bottom of the article click in the comment box and try to post a comment during which time the code expires.
I’ve been frustrated by this too. Hit the not totally obvious “use password” button at log on. Much more efficient.