25 Comments

Interesting. When my kids were growing up I would tell them if they weren't bleeding from a major artery or had a limb bent like a pretzel, they would be fine. Now that I am a grandmother I think my grandchildren, regardless of age, should see a doctor when they hiccup. Hmmmm...... As my mom and dad aged they would take the doctor's word and advice as if it had been written next to the 10 commandments. I then walked them through scenarios. You see the doctor. He says you have______ and should_____. I'd walk them through their symptoms, how they themselves would treat each other, and then the tests. If the test showed you have x,y,z, what will you do about it? There were no wrong answers, but I wanted them to think before jumping into the medical rabbit hole.

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I love you Vinay!

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Where would funding for these types of studies come from, and how do they decide how to allocate the money?

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Touché

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Knowing I had bronchitis and knowing that viral bronchitis isn't very treatable, I waited three weeks. When said bronchitis didn't go away I saw a PA. She said I probably had a secondary infection after three weeks. Antibiotics made it go away.

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I just left 27 years of working in primary care for a large system and joined a direct primary care group. I love the freedom of being able to connect with patients throughout an illness and make new decisions as they may be necessary without feeling as though I'm "giving away care" or losing productivity. The bottom line is, at least what I've divined in the last 30 years since graduation, the patients may be the best decider of all. Some need to be seen for reassurance, sure, but most will know that they've felt like this before and gotten through just fine, and having the option to connect with me if anything changes makes all the difference. Beyond anxiety provoking pain/chest discomfort and shortness of breath, all the other symptoms are tolerated differently by different people, and a one size fits all answer I don't think is achievable.

We need to rework primary care as a capitated system - pay per patient, not per visit, and let the providers interact with patients in whichever way is most efficient and cost effective for all. Sadly, I feel it will have to fully implode before we can see such a seismic change occur. Till then, DPC is where it's at, everyone! The more patients who find us, see the benefits, and tell 2 friends, the faster we will grow and primary care will come full circle back to individual docs or small groups out on their own providing truly patient centered care unfettered by CMS regulations and payor demands.

It's really quite wonderful to return to the art and practice of medicine as we all idealized it to be when we began this journey. Patients are pretty happy with this approach as well :)

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When I was growing up we went to Dr. Spagnuolo. He delivered all 8 children in our family; he took care of our tonsilitis, strep throats, and all other ailments. He was a family doctor. The days of wonderful doctors like him are long gone. They have been replaced by computers and big business; by metrics and protocols. I do not think that is progress.

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Well there you go. "Ask Mom" is the universal answer. 😃.

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Well, and let’s not discount the fact that I often have to take my children to a doctor or do a telehealth appointment to get a school excuse note. Gone are the days of keeping a child home based on Mom’s (or Dad’s or whomever) judgment that they are unwell in many school districts. Unexcused! I am grateful we have excellent health insurance. Those sorts of policies are horribly unfair to those who do not.

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We need to let common sense prevail and trust parents to know when a child needs to be at home. The vast majority of whom want their kids in school and educated. The larger problem as that staying at home with a sick kid causes economic and energy other pressures.

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Coming from a doctor, this is funny! Thank you for being honest.

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A trial like this would be helpful, perhaps incorporating telemedicine, although that would select out a portion of the population. One variable to include is medical literacy. Some people panic at a hangnail because they do not understand how their bodies work. Maybe we need to hand out owner’s manuals. Knowing one’s own health can influence seeing a doctor or not.

I just got over COVID (vaxxed and boosted) and have a persistent cough otherwise fine. This has been a pattern following every URI. Knowing how our bodies work can reduce panic, but I guess it could also result in minimizing something serious. That’s why we need this trial.

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I spent four years of my life after internship fielding phone calls like that on an Indian reservation. Books are written on telephone triage. We provided free care. I ended up seeing 90+% of those patients and giving them Tylenol more often than not. Some needed sutures or delivery. If the flu was rampant it was a “cold pack”. For the most part, a concerned grandmother could have been just fine. If the Institute of Medicine was right, a coin toss would be “evidence based” as well. What a great place for AI.

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As someone working in AI for decades, it will add nothing of value to this conundrum. AI has the same issues as "big data" -- It may be useful for drawing a conclusion about a population, but as von Eye has noted famously "knowing everything about a population tells you nothing about any individual". (I have an hour long lecture on this...lol.) So any AI will say "here is what I think, but go see your LMD if you do not think I am right". And exactly the same people will opt to seek care or not.

We have not yet mastered artificial stupidity -- don't be seduced into thinking that AI will solve any of these misbegotten societal aberrations.

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Hard to hold AI responsible/liable ... there I’ll always be a licensed provider somewhere who is and will not know the patient etc...

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I don't disagree that that such a case has a low probability to have a better physical outcome from such an illness as result of seeing a primary care practitioner ( physician or AP) however I think you have omitted the the other reason many people go to such visits namely for the 'caring'. As the great medical humanist Eric Cassell said 'all illness is personal'. Often without specific treatment such visits with an empathic practitioner can lead to healing, distinct from curing. Enhancing emotional regulation surrounding illness, even benign illness, can be of value, even great value, to some. A well done trial demonstrated that empathic care can facilitate recovery even from self limited disease. ( Placebo effects and the common cold: A randomized controlled trial The Annals of Family Medicine July 2011, 9 (4) 312-322; DOI: https://doi.org/10.1370/afm.125). I am sure such endpoints will be marginalized by many as 'soft' but for so many with medically unexplained symptoms such strategies of caring while not curing disease may relieve suffering ( fear, pain, fatigue, other dimension of quality of life) . Such outcomes from care pathways are generally marginalized or overlooked in studies. These variables need to be examined in Long COVID as well.

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Dr Calabrese, Agree 100% but only so many PCP visits a day and we also need to know when we need a doctor and when we do not. (Individuals with chronic illness, active malignancy and the elderly/frail is a different category and they should have excellent access to their PCPs. I tell those patients that if they are sick they do not have the luxury of waiting it out and I want to talk/see them early). Many healthcare entity “Workflows” are designed with “productivity” in mind not optimal care. Part of our job is to educate and empower the people we care for.

Love you by the way and regularly rec your high altitude overview of the immune system to young colleagues and many many patients! Big fan :)

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My grandmother died at age 84. She saw a doctor less than 10 times her ENTIRE life. I don’t think she ever took an antibiotic. She did have a hysterectomy due to a significant cystocele. Her parents saw a doctor prob even less. They also lived to 80 plus. The people who died in her village died of smoking, drinking too much, accidents and suicide and cancer. Here and there a stroke but not that many and an occasional MI. Both of those groups generally smoked.

“Modern US”: an asymptomatic 21 y/o wants his testosterone checked because he “wants to know his body and follow the trend”. 😵‍💫. If I object too vehemently then I risk being “judgemental” or some other nonsense. Because it’s no longer acceptable for an MD with thirty years of experience to tell a young person that they are “misguided” or refuse.

I see people for fu 24 hours after they have been diagnosed with COVID because they were told to see their PCP?! (Healthy young person). We have no triage, our call center is tragic and mostly : ZERO common sense. That the ER now tells EVERYONE to fu with their PCP which is absurd especially with for a viral illness in an otherwise healthy person during a pandemic/epidemic etc. Usually they need work notes but what the ER cannot generate that? They were well compensated for something that should not have gone to the ER in the first place.

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My grandfather passed away in ‘79 at the age of 88, and other than the last week of his life which he spent in hospital with “multi system organ failure”, he had not seen a doctor since his foot was run over by a tank in WWI. I learned a lot about what was considered life threatening and what wasn’t by listening to him and my grandmother, who birthed all of her children at home in her bed. Including an 11 pounder. Suffice it to say, I’m not one to overreact, either with my own health, or my patient’s. (They also like hearing about my grandparent’s stories, and sharing their own with me.)

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Just read this to my Mom Who was born in 1936 via midwife on the Austrian and Hungarian border.

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Wow! Validation for Christmas! As a mom for 28 years, that question has surfaced many times in my mom-hood, which has led to personal research and data collection on the mom basis. When do I take my kid to the doctor? Well, a virus is a virus and must run the course. What can a doc do for a virus that will make its way through, nothing. Still sick 10-12 days later, to the doc we go. Fever, though, is a beast. If normal meds don’t give a decent relief, then the midnight hours are sleepless and consumed with constant checks. It is a delicate balance and the dance of how much do I meditate my child or let the virus takes its toll. As always, thank you for the articles that inform and continue to be full of witty thoughts.

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As a long time primary care doc who started in a sub-specialty I agree that much of what we do is to just listen and often recommend rest, OTC and follow up by phone if certain parameters are met. But for those who are employed (nearing 50%) dispensing this advice works against their productivity and,ultimately, their income. It’s hard enough to recruit new PCPs for our aging practices especially when the income level is so low. In America we do not put much stock on the cognitive part of medicine. We put so much on procedures and technology which helps the health systems to increase their margins. They put little stock in who actually generates that volume, oftentimes it is their PCPs. I could continue for a long time but I really wanted to say that your analysis and conclusion are spot on. Still love what I do. thanks and look forward to the next year.

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Thank you so much, Vinay, for your endorsement of mothers!

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