Why I am happy to be a primary care provider?

Why I am happy to be a primary care provider?

Vijay Gopichandran

I have been invited by my mentor to talk to first year MBBS students about the importance of primary care. Her exact words were, “I want more youngsters to be inspired to do primary care”. I feel extremely honoured that my mentor feels that I am worthy of this responsibility. Here is a sketch of what I am planning to say to the students. I am describing why I am happy that I am a primary care provider.

1.      I believe that there is a 10-90 rule in medicine. I believe that of all illnesses the most common 10% of them affect the maximum proportion of 90% of the people. Whereas the remaining 90% of the illnesses are rare and affect only 10% of the population at any point of time. This inference is based on my years of primary care practice but needs to be validated. There are some common illnesses like cough, cold, fever, headache, malaria, tuberculosis, diabetes, hypertension, injuries etc. which affect most of the people and they visit the primary care clinic frequently. A primary care provider cares for these common minor ailments. Therefore, the primary care provider serves a vast majority of the population. Their reach is far more than that of a specialist.   

2.      As a primary care provider, I am always relevant. I am not dependent on availability of an operation theatre. I do not need sophisticated equipment and gadgets for providing care. I can deliver my services in a small room, a shed, a camp, or anywhere. I am relevant in a rich city, also relevant in a remote tribal hamlet. Even at times of disasters such as a tsunami, it is my services which are essential. I can work anywhere, in any context and I will always be relevant. In such a context even the sophisticated neurosurgeon is called to the field to deliver primary care to the affected population. Even specialists may sometimes have to only provide my type of services if they do not have appropriate resources. In conflict zones, organizations like Medicins Sans Frontieres sends out people like me to deliver primary care services.

3.      I mainly see patients with common ailments at an early stage of disease, which are easily amenable to treatment. Therefore, my work is highly rewarding. For example, I see patients with early diabetes. If I initiate prompt and appropriate treatment and preventive measures, the results are highly rewarding. The sugars get well controlled and I can prevent complications. If I perform a routine screening PAP smear to detect cervical cancer, I can pick early cases of the cancer and will be able to provide a complete cure. I rarely see patients who come with serious illnesses and complications. Even these patients I help by referring to specialists.

4.      I see a lot of socially challenging medical situations. This constantly keeps me thinking and, on my feet, and I like the excitement of looking for simple solutions for complex social problems that my patients have. For example, I have a patient with multi drug resistant tuberculosis. This patient is dependent on alcohol. Patients with MDR TB are required to stay in a hospital for the initial month of treatment. But he runs way from the hospital because inside the hospital he is not permitted to drink alcohol. So, we found a reasonable solution. We smuggled alcohol for him into his hospital. Maybe that is not the best for his liver. Maybe it is not the best for his treatment. But at least it kept him isolated from his family thus preventing spread of the deadly infection, it kept him in the hospital for the period of treatment, and it helped him get on with treatment of the disease, which otherwise would have killed him and infected his entire family. These are the kind of exciting challenges and puzzles I get to solve on a day to day basis.

5.      I am a jack of many trades. I am never bored on any of the clinic days. My typical clinic day will include patients with diabetes, hypertension whose medications I have to adjust, patients with cuts, injuries which I have to suture, diabetic foot ulcers which I have to debride and dress, women with menstrual problems which I have to solve, pregnant women for whom I have to provide antenatal care, children with a wide variety of illnesses, children with malnutrition etc. The variety is limitless and interesting. Unlike a specialist who sees only a limited variety of patients, my choices are unending!

6.      I form strong social bonds with my patients. I know many of my patients by name. I know their families. For example, last week I saw a young woman who came to my clinic with a headache. I remembered that her husband is a hypertensive. As soon as I finished helping her, I enquired about her husband and she immediately broke down and started crying. She said that he has been keeping very ill and has been refusing to see a doctor. I made it a point that she brings him immediately. That extra nudge made her bring him in the same day. His blood pressure was very high, and I learned that he had stopped his medications due to some social problems. I immediately re-initiated treatment and he is doing well now. This kind of social bonding is very useful, and it makes meaningful impact on people and their families.

7.      I get a good and thorough follow up of my patients. If I start a patient on a diabetes medication, I can rest assured that she will report back to me if there is a side effect. She will also report back to me periodically to check if the medicine is working. This is because as a primary care provider my clinic is close to their homes. So, they can easily drop in at leisure. Since I am within their familiar territory, they also feel relaxed and feel at home when they come to see me. Unlike large specialty hospitals, which can often be anxiety inducing, primary care clinics are relatively safe spaces for patients. The good amount of follow up care, helps me see my treatments to completion and it improves the quality of care that I provide. It gives me more satisfaction. In case of many specialist practices, once treatment is over, the patients are sent back to the primary care provider. The specialist rarely has long term follow up of their patients at a personal level.

8.      I am easily affordable. I am not very expensive. My consultation fee is not exorbitant. Most people can afford my care. This makes me less guilty. For example, in my rural clinic, a patient can walk in with 200 rupees and walk out after consulting me, getting sugar test done and purchasing diabetes tablets for a month. The same would cost close to 3000 rupees in a specialist centre. In places like India, where a vast majority of people cannot afford to put medical expenditure on their priority list, such affordable primary care is the way to go forward.

9.      I believe that I have a great impact on the lives of people. They may never see it that way, but I believe I do. I contribute to disease prevention; health promotion and I keep people healthy. I can never count and say how many deaths I averted, how many serious illnesses I prevented, because what got prevented or avoided can never be counted. But I strongly believe that I am doing this, and it gives me tremendous fulfilment.

10.  I have an excellent work-life balance. My work timings are good and reasonable. I seldom get called at night for emergencies. My work is predominantly outpatient based. However, I do make a very meaningful impact.

Therefore, I am very happy to be a primary care provider. People pose the various limitations of practicing primary care and ask me aren’t these deterrents. Here is my response to these questions:

·         I may not be super rich financially – but I am super rich in social capital

·         I may not perform dramatic life saving procedures like the surgeons and critical care people – but I am silently and imperceptible working towards making people healthy so that they need such procedures less and less.

·         I may not work with sophisticated equipment and gadgets – but I do small things at low cost which have high impact like the ORS for acute diarrheal disease

·         I may never be able to do cutting edge research – but I am the one who must implement the research on the field without which it is useless

·         I may be regarded lower down in the hierarchy of elite specialists – fortunately so because the lower I am the closer I am to people, which truly matters

·         I may not have social status and prestige as a “GP”, no halo around my head – but that is great because it helps me stay humble and grounded

·         I may not trot the globe giving invited lectures – but that only means I get to travel with my family and enjoy my vacations peacefully

·         I may not sit on international expert panels to discuss and decide important guidelines – but that means I will do less ‘endless talks’ and more ‘meaningful work’

·         I may never be a teacher or a research supervisor – but I shall always be a role model through the quality of work that I do

·         I may not wear a suit, a tie and sit in an AC room and see patients – but then I would rather work in a dingy place that desperately needs me rather than a swanky one which I desperately need!