The quiet medical heroism of incremental care
From an excellent article by Atul Gawande in the New Yorker (but you really should read the whole thing);
He showed me studies demonstrating that states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke. Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health. In the United Kingdom, where family physicians are paid to practice in deprived areas, a ten-per-cent increase in the primary-care supply was shown to improve people’s health so much that you could add ten years to everyone’s life and still not match the benefit. Another study examined health-care reforms in Spain that focussed on strengthening primary care in various regions—by, for instance, building more clinics, extending their hours, and paying for home visits. After ten years, mortality fell in the areas where the reforms were made, and it fell more in those areas which received the reforms earlier. Likewise, reforms in California that provided all Medicaid recipients with primary-care physicians resulted in lower hospitalization rates. By contrast, private Medicare plans that increased co-payments for primary-care visits—and thereby reduced such visits—saw increased hospitalization rates. Further, the more complex a person’s medical needs are the greater the benefit of primary care.
I finally had to submit. Primary care, it seemed, does a lot of good for people—maybe even more good, in the long run, than I will as a surgeon. But I still wondered how. What, exactly, is the primary-care physician’s skill? I visited Asaf’s clinic to see.
The clinic is in the Boston neighborhood of Jamaica Plain, and it has three full-time physicians, several part-timers, three physician assistants, three social workers, a nurse, a pharmacist, and a nutritionist. Together, they get some fourteen thousand patient visits a year in fifteen clinic rooms, which were going pretty much non-stop on the day I dropped by.
People came in with leg pains, arm pains, belly pains, joint pains, head pains, or just for a checkup. I met an eighty-eight-year-old man who had survived a cardiac arrest in a parking lot. I talked to a physician assistant who, in the previous few hours, had administered vaccinations, cleaned wax out of the ears of an elderly woman with hearing trouble, adjusted the medications of a man whose home blood-pressure readings were far too high, and followed up on a patient with diabetes.
The clinic had a teeming variousness. It didn’t matter if patients had psoriasis or psychosis, the clinic had to have something useful to offer them. At any given moment, someone there might be suturing a laceration, lancing an abscess, aspirating a gouty joint, biopsying a suspicious skin lesion, managing a bipolar-disorder crisis, assessing a geriatric patient who had taken a fall, placing an intrauterine contraceptive device, or stabilizing a patient who’d had an asthma attack. The clinic was licensed to dispense thirty-five medicines on the premises, including steroids and epinephrine, for an anaphylactic allergic reaction; a shot of ceftriaxone, for newly diagnosed gonorrhea; a dose of doxycycline, for acute Lyme disease; or a one-gram dose of azithromycin for chlamydia, so that someone can directly observe that the patient swallows it, reducing the danger that he or she will infect someone else.
“We do the things you really don’t need specialists for,” a physician assistant said. And I saw what a formidably comprehensive range that could be. Asaf—Israeli-born and Minnesota-raised, which means that he’s both more talkative and happier than the average Bostonian—told me about one of his favorite maneuvers. Three or four times a year, a patient comes in with disabling episodes of dizziness because of a condition called benign positional vertigo. It’s caused by loose particles of calcified debris rattling around in the semicircular canal of the inner ear. Sometimes patients are barely able to stand. They are nauseated. They vomit. Just turning their head the wrong way, or rolling over in bed, can bring on a bout of dizziness. It’s like the worst seasickness you can imagine.
“I have just the trick,” he tells them.
First, to be sure he has the correct diagnosis, he does the Dix-Hallpike test. He has the patient sit on the examination table, turns his head forty-five degrees to one side with both hands, and then quickly lays him down flat with his head hanging off the end of the table. If Asaf’s diagnosis is right, the patient’s eyes will shake for ten seconds or so, like dice in a cup.
To fix the problem, he performs what’s known as the Epley maneuver. With the patient still lying with his head turned to one side and hanging off the table, Asaf rotates his head rapidly the other way until his ear is pointed toward the ceiling. He holds the patient’s head still for thirty seconds. He then has him roll onto his side while turning his head downward. Thirty seconds later, he lifts the patient rapidly to a sitting position. If he’s done everything right, the calcified particles are flung through the semicircular canal like marbles out a chute. In most cases, the patient feels better instantly.
“They walk out the door thinking you’re a shaman,” Asaf said, grinning. Everyone loves to be the hero. Asaf and his colleagues can deliver on-the-spot care for hundreds of conditions and guidance for thousands more. They run a medical general store. But, Asaf insisted, that’s not really how primary-care clinicians save lives. After all, for any given situation specialists are likely to have more skill and experience, and more apt to follow the evidence of what works. Generalists have no advantage over specialists in any particular case. Yet, somehow, having a primary-care clinician as your main source of care is better for you.
Asaf tried to explain. “It’s no one thing we do. It’s all of it,” he said. I found this unsatisfying. I pushed everyone I met at the clinic. How could seeing one of them for my—insert problem here—be better than going straight to a specialist? Invariably, the clinicians would circle around to the same conclusion.
“It’s the relationship,” they’d say. I began to understand only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door. Often, they had known the patient for years and would know him for years to come. In a single, isolated moment of care for, say, a man who came in with abdominal pain, Asaf looked like nothing special. But once I took in the fact that patient and doctor really knew each other—that the man had visited three months earlier, for back pain, and six months before that, for a flu—I started to realize the significance of their familiarity.
There’s a lot more at the link.