“I Don’t Want To Lose My Skills”

Will You Lose Your “Skills” If You Don’t Start Practicing Primary Care Right Out of Residency?

 

This is the argument I hear from family medicine residents that I try to recruit into an urgent care career. Their main concern is that they will lose their primary care skills. Interestingly, they don’t mention that they are slightly intimidated by the faster pace and urgency of an urgent care. They are afraid that they will forget how to work up and manage diabetes, obesity and HTN.

I graduated residency in 2009 and started moonlighting in my 2nd year and all the way through my 4th year chief resident position. I loved urgent care because of all the independent learning. I enjoyed it because there was so much pathology, so much medicine and so much that I had to look up. Thank you UpToDate and Epocrates.

The average primary care doctor in the US manages depression, obesity, DM2, chronic pain, HTN and a few more acute issues. Primary care unfortunately has become a juggling act for docs to spend as little time in the room as possible, refresh as many medicare diagnosis as possible and chart as quickly before moving on to the next patient. The ‘medicine’ that’s practiced by primary care doctors is mostly adjusting medications; as a matter of fact I will go as far as to say that medications are the biggest crutch for primary care doctors.

I still do primary care in the daytime and for those that do, we all know that there are patients that only need some reassurance, perhaps a lab review or an exam to rule something out/in. However, since the medication game is so big I firmly believe that it should be handed off to pharmacists who need to step up their clinical skills game. If we can train PA’s in a few short years to be an integral part of patient care then we certainly can tack on a few clinical years for pharmacists to manage these medications that they are so knowledgeable of. I want to see a group of pharmacists taking the reign and building such a residency program. Many pre-docs go through med school and realize that medicine is NOT their calling, some will pursue other options and others will unfortunately get stuck. The same is true in pharmacy school. Some students will recognize that their talent or passion is in the clinical side and not retail pharmacy. There are residencies for inpatient medication management so why not for clinical medication management outpatient.

Primary Care Has Failed Patients

The real medicine doesn’t happen in the primary care offices. Primary care has failed our patients (I didn’t say doctors, it’s a much deeper discussion – maybe another time) in showing tough love, in enforcing prevention, in  keeping them off of medications and more importantly we have failed to empower our patients. Medicine has become paternalistic… “This is what you need to make you better, let’s try this medicine and if it doesn’t help we have other options.”

Antibiotics are given out of fear of a law suit, pain medications dispensed because we hate to see our patients suffer, and work notes given because we don’t want to come across as heartless. We refrain from calling our patients out on their 20″ neck diameter, their 48″ wastes and their 300+ lbs weights. Sure, we may broach the subject or maybe mumble a few slurred words about how just maybe their warfarin is losing it’s efficacy due to their ever-increasing surface area. Maybe we have become those fake Newport Beach friends that sit around the table once a week and tell each other everything the other person wants to hear in order to keep everything calm on the surface while we are all drowning in our ways on the inside.

Oh yea, here is where I get to plug in urgent care… the antidote to enabling primary care doctors, the antivenin to the grumpy burnt out physician who rarely touches their patient in the exam room. I feel the power of the urgent care doctor lies exactly in that they don’t develop this buddy-buddy relationship with the patients. Sure, some of my primary care colleagues like to brag about how their patients bring them gifts and send them thank you cards. They are proud that they are making a difference in their patient’s lives because they are bit-by-bit influencing them towards something better. I don’t see bit-by-bit as any form of success. Brushing only one tooth won’t keep me out of my dentist’s chair.

If you are visiting this website and reading what I’m writing about spending less, investing conservatively, cutting back when you no longer need as much money to live your life, developing a life outside of medicine and maintaining your physical and mental health  but you end up saving just $100 more a month or retire at age 58, which is also the time by when you paid off your student loans, then there was no success. So what if your patient lost 15 lbs in 2 months… they probably have lost and gained more weight in their adult life than they actually weigh. If they keep it off then I’ll be impressed. And guess what, they will keep it off when they decide to do so.

The Skills You Develop As An Urgent Care Doc

As an urgent care doctor you develop the skill to win the patient’s trust in a short period of time. As a good urgent care doctor you won’t rush the patient because you’ll know that the H&P in more than 90% of the time will give you the right diagnosis. Furthermore, you will listen to your patient because many times they already know what they have and you’ve learned when to listen to them in that regard.

You will use your hands and fingers, your stethoscope and the tongue depressor, the ear curette, the manual sphygmomanometer, the Dix-Hallpike test, your percussion techniques and unfortunately even your nose to make your diagnosis. You will learn to rely on imaging and lab work less and less as you hone your skills. You will learn to tell the difference between acute venus stasis dermatitis and cellulitis. You will recognize podagra just by the way the patient walked by your office.

You will learn the skill of managing many injuries without an ortho consult coming down and seeing the patient. You will repair lacerations that ENT or plastics would take on in a larger hospital. You will remove things from places that I won’t get into here and you will learn all sorts of new tricks for removing splinters and glass from skin.

Sure, along the way you’ll adjust a few blood pressure meds. You will switch an ACE-I to an ARB because of a cough or angioedema. You will stop metformin because of low creatinine clearance. You will catch myalgias before they progress on patients started on a statin. You will even know how to adjust someone’s insulin, how to start them and when to add in a short acting insulin and when to stop their oral diabetes medications.

In Summary

I don’t think these residents should fear losing their skill if they begin an urgent care career. I feel that they most certainly will lose their skills and likely develop some new bad ones by entering primary care so early on in their career. Well, I’m sure I’m exaggerating here a bit. There are fantastic primary care doctors out there as well. There are pediatricians that could go toe-to-toe with Mother Teresa. There are Ob/Gyn docs that handle their patient’s primary care needs with impeccable expertise and finesse. But I think the road to becoming a great doctor is complex and you as a resident need to really understand what kind of person you are and develop your own learning blueprint out of residency.

 

If you are doing both primary care and urgent care, how do you think your skills differ in each field?

If you could start over would you have started out in primary care or urgent care?

Share your thoughts...