The Future of Primary Care Medicine - NEJM

[Guest guest]

There is a very interesting article in the August 12 edition of the

New England Journal of Medicine entitled " The Future of Primary Care

Medicine " . The gist of the article is that economic realities (poor

pay and long hours) along with poorly designed residency programs are

discouraging medical school graduates from going into primary care.

The piece ends with the prediction that, unless significant changes

are made soon " the practice of primary care medicine seems destined

to become the province of nurses and other nonphysician health care

professionals. "

 

How can we make ourselves ready to step up to the plate? Do we want

to?

 

Adam Margolis

[Guest guest]

, " adamhenrymargolis "

<adamhenrymargolis> wrote:

 

The piece ends with the prediction that, unless significant changes

> are made soon " the practice of primary care medicine seems destined

> to become the province of nurses and other nonphysician health care

> professionals. "

 

this is not necessarily a bad thing, if we are talking about physician

assistants and nurse

practitioners, many of whom I've found to be quite skillful diagnosticians,

often better

than many hotshot MDs.

 

>

> How can we make ourselves ready to step up to the plate? Do we want

> to?

 

Both excellent questions. First, what face do we present to the pitcher? Our

mystical/new

age face or our secular integrative face? Or some combination of both?

 

Where do we need to improve our skills to answer this call? While the answer is

in both

WM and CM, the sad fact is that in order to be true primary care GPs who can

make

necessary referrals to a specialist (not just another GP), society will demand

that we mainly

beef up in the area of WM. In order to be an excellent frontline GP, you need

to know a lot

of WM. Is that folks want to study? Don't anyone delude oneself (not directed

at Adam, I

know where he stands on all this) into thinking we will be accepted in this role

from a

purely TCM perspective (some kind of separate but equal dcotrine of medicine, as

it were)?

So instead of pursuing your qi gong, gardening, classics, chinese language, you

will spend

a lot of time studying WM instead, not only in schoool, but throughout your

career.

 

A colleague said to me the other day that he was advising the school that we

faced a major

liability nightmare unless we devoted substantially more attention to physical

dx both in

class and clinic. What he meant was western style exam and dx. While I value

these

methodologies, it is unclear what liability nightmare we actually face if we

fail to do

western exam. In most states such as Oregon, western exam and diagnosis are

expressly

illegal for acupuncturists, so to perform said exams creates liability, it does

not protect

one from it. In OR, we are supposed to identify the same type of warning signs

that would

cause a pharmacist to make a referral. OR, like most states, expressly avoided

using the

terms primary care and excluded western dx and lab tests, in order to AVOID

liability to

licensees who were not even remotely trained to do these things. Here in CA,

the law is

unclear. The Little Hoover commission will soon rule as to whether we actually

have

primary care rights and responsibilites in CA. Part of their concern is that

while the law

has been interpreted this way for years, testimony on an unrelated issues last

year alerted

the state to the fact that CA px are also not nearly trained well enough to do

western dx.

 

So if we are allowed to practice (and thus required to be) competent at western

dx, this

will necessitate changes to both education and testing to insure this. If it is

determined

that we are not primary care, then the issue is moot for now. To be honest,

while I do not

want to see anything rolled back, the LHC would be disingenuous at best if they

rule that

we could still practice as full primary care px w/o having to undergo the type

of training

and evaluation all other primary care px do. I doubt this scenario.

Personally, I supported

the Oregon approach. I have no interest in the liability associated with being

a primary

care px. I will gladly refer when necessary. I would rather spend my time

studying

herbology, not lab test parameters and x-ray views. While I am strong supporter

of using

lab tests to verify OM, I have interest in doing rectal exams or analyzing blood

myself. I

have often found such tests useful in focusing treatment, but hardly necessary

in the final

analysis. Anyone who thinks one needs WM to practice CM is mistaken. CM can be

practiced effectively in its pure form. We need WM to verify efficacy and

safety for various

social and political purposes, but if one does not think CM herbology can be

practiced

effectively without resport to western lab tests, I think you need to hit the

books (the CM

books, that is).

 

For example, a few weeks back we treated a case of trigger finger. Flexor

digital

tenosynovitis is often associated with rheumatoid arthritis (RA) or diabetes

(DM). I wanted

the patient to get some blood tests to identify these possibilities. But the

results of these

tests would not have affected my treatment of the patient. They would have

provided a

basis for prognosis (injury versus chronic illness) and also provide the pt.

with information

they could use to make an informed decision about care. If a patient knows they

are

diabetic and they had relatives who have gone blind or lost limbs, they make

very likely

want to use western drugs and that is their informed right. We may not like

drugs for high

blood sugar or hypertension, but they do prevent considerable mortatliy and

morbidity

(albeit with side effects, though better than death or dismemberment). unless

we have a

similar degree of confidence in TCM, it would be remiss to direct a patient away

from

proven livesaving therapies w/o letting them investigate and decide for

themselves.

 

The patient was qi and yin/blood xu with blood stasis and dampheat, a

presentation that

could be found in either DM or RA. That is what I would have treated

(unfortunately the

patient want a single visit cure and no herbs). It was important to know if the

patient had

uncontrolled RA or DM for various reasons, but I had no doubt that if either of

these was

the case my formula would have been helpful (not only for the trigger finger,

but also for

the disease processes - since moving blood is equally effective in pain,

autoimmunity and

diabetes complications. Knowing that lowering blood sugar is important would

not really

affect choice here, either. While in theory, knowing the western properties of

an herb may

guide its selection, TCM dovetails so nicely that this is rarely if ever

necessary. For

example, huang qi, ren shen, bai zhu, huang lian, sheng di, jiang huang and dan

shen all

lower blood sugar (and all indicated in this case). Many blood moving herbs I

would

normally choose dislodge antibody-antigen complexes and decreases platelet

stickiness,

reducing clots and normal circulation. My study of WM has largely confirmed

what CM

already knew.

 

While I know this often falls upon deaf ears, my interest in TCM is that it

already IS

scientific and rational. As zhang xi chun said, it has much to offer TCM in its

understanding of the body systems and their interrelationships. Science should

serve all

disciplines and be master to none. But in this service, we will sometimes

discover what we

want to hear and other times not. It is a worthwhile gamble. So I do not favor

reducing

TCM to prevailing normal science (as Kuhn defines the term), but rather

expanding science

to encompass TCM. In clinic, we don't need them as much as they need us. But

for the

overall good of society, we need each other quite a bit. Its just matter of how

and why.

 

So do we want to be the new GPs or do we want to practice herbology in an

integrative

setting. these are two different goals with two different outcomes. I would

rather be

resident herbalist expert at Kaiser than the L.Ac. in the ER who can make the

quick WM dx,

but only remembers the ten herb formulas used for the most common complaints.