Primary Care Medicine in an Urban Population
The clinic had been busy. The day had been filled with a wide array complaints and personalities ranging from the drug seekers with chronic pain to the geriatric patients in need of refills. It was almost time to leave; I had just one patient left to see. An unusually thin chart laid in basket next to the door, in it no information other than a name, Ms. Q. Upon entering I found a middle aged black woman was huddled in the corner holding the side of her chest. Her facial expressions betrayed the fact that she was in a considerable amount of pain as she propped herself up to talk with me. Although I was sympathetic to her pain, it was the end of a long day and my capacity for small talk had worn thin. As per standard protocol I introduced myself and got straight to business asked how I could help her. As I prepared myself to take notes I heard her say “François?” “J’n parle pas d’anglais,” in a soft, labored voice.
As this patient was a new patient, unknown to the clinic, I had to do a complete H&P. I had taken French for many years in high school and a few semesters in college, but did not think that I knew enough French to get through an H&P. As we started to talk about what was ailing her, I discovered that she was one of the most fascinating women I had ever met. With my broken French constantly corrected, we had an engrossing conversation for nearly an hour discussing not only her medical condition, but also her life and circumstances. Our conversation ended only with my attending entering the room. At the end of the visit I had not only obtained a through H&P, I had made a friend. We were able to provide her treatment for her strained muscle (she worked as a janitor and had tried to lift something that was too heavy for her), and also were able to schedule her for blood work, a mammogram, and a pap smear. As she limped out of the office, hunched in pain, she was thankful for what we had done.
This experience typified my experiences in the urban primary care setting. For the majority of the population the primary care setting is their first entry point to the healthcare system, therefore there are many occasions where what lies on the other side of the door is unknown. In primary care, you must be able to handle a variety of situations and this is why I believe that primary care is the most challenging of all specialties. Urban primary care takes this experience a step further because the patient population is so varied. This was my second time with Dr. Helzner in his urban clinic. Of all my rotations working in this clinic has been the most rewarding experience because of the amount of teaching and closeness I felt to the patients. Through the course of the rotation I learned so much about the interplay between the primary care clinic and the community and the vital part the clinic played in this community; about the differences between urban and suburban medicine; and about how to practice medicine in an urban setting.
Primary care more so than any other specialty is fully integrated into the fabric of the community and so reflects its needs. To illustrate this point of the, I would like to compare how two different clinics handle a common issue, namely the issue of drug reps. The first clinic is a suburban clinic that deals with mostly insured, upper middle class patients. During my time at this clinic, there was a lively debate on the ethical issue of letting drug reps host lunches in the office. After considerable arguments on both sides of the issue the conclusion of the debate was the expulsion of all drug reps from the office to minimize bias in prescribing drugs. In this setting minimizing bias and providing each of their patients with the absolute best care was the priority. In contrast to this setting the second clinic was an urban clinic located in an environment where the majority of patients lay uncomfortably close to the poverty line and many are uninsured. Here, drug reps provide breakfast and lunch everyday. But along with the food, the reps also bring with them samples; and keeping the sample closet full is the drug reps main responsibility. In a setting where at least one out of every ten patients depends on samples from their doctors, providing this service becomes a priority. This is concrete example of how primary care clinics reflect the needs of their respective communities and play a vital role in their communities.
One of the main reasons I decided to come back to Dr. Helzner’s clinic was to work in an urban setting. As a student, most of my rotations were in a suburban setting consisting of mostly of a middle class Caucasian population. In this setting, drug addiction, AIDS, teen pregnancy, although present, represented a minority of the cases; cases were student involvement was discouraged. In the urban setting these issues occurred with such frequency that students were expected to tackle even the most challenging cases. During my time at the clinic, with the help of Dr. Schmidt’s and Dr. Helzner’s guidance, I was able learn much about the management of these issues; both in terms of medical management and also psychosocial management.
As an example, one of my patients, a fifteen year old girl was accompanied by her mother for evaluation for nausea and vomiting. On history, the nausea and vomiting was occurring in the morning for the past two weeks. The mother initially refused my request to talk to her daughter alone, but after much coercion, she finally relented. As can be imagined the teen did not want her mother to know about what had happened. Dr. Schmidt’s masterful handling of the situation, where he not only convinced the teen to tell her mother, but also convinced her mother on how to compose herself, was a great lesson in how important a non-judgmental, calm perspective can be in helping resolve these complex issues. Though many of these extremely difficult cases I was able to learn how to better understand, relate and manage these situations. I now am much more confident in my abilities to handle such cases in the future.
Apart from the differences in diagnoses, I found that there were also fundamental differences in attitudes between the two populations. In terms of the suburban population, there seemed to be an intrinsic trust in the physician, where most of the patients trusted the provider’s opinion and advice without much misgiving. On the other hand, in the urban population, there seemed to be an intrinsic mistrust of the medical system. I was questioned multiple times by multiple patients about why? Why was this test necessary? Why was the treatment needed? Why do I need to come back? Etc… These were questions were heard with much less frequency in the suburban clinics. But an important extension to this concept is that it seemed that the initial mistrust the patients had led to low expectations about what you could do for them. So, in most occasions, your failures went unnoticed and your successes were glorified. Patient’s seemed, almost, surprised that you helped them; and they were extremely grateful. I have never felt so appreciated by patients as I have felt in the urban setting. Their initial mistrust was replaced by a tangible feeling of genuine thankfulness from which a solid patient-physician relationship can be built.
In contrast, a majority of the suburban patients radiated the attitude of entitlement. Here, since patients initially had trusted you, their expectations were high, many times unreasonably high. Positive outcomes were met with “Thanks for doing your job” attitude, and negative outcomes are met with, “why didn’t you fix me” attitude. The key point here is that, from a physician’s standpoint, both situations encompass unique challenges. In the suburban setting an emphasis must be made to foster the trust conferred on the physician where as in the urban setting, gaining trust must be emphasized. I do not mean to say that these situations are mutually exclusive to their respective populations, but, undeniably, the frequency of each situation is skewed. The opportunity to be exposed to both situations has been a key learning point for all physicians.
Ms. Q returned to the clinic a week later. This time her chart was filled with her labs and notes from her last visit and upon entering the room I found her smiling widely rushing to greet me at the door. “Merci, Merci, Merci beaucoup,” she exclaimed with a very real sense of elation. Upon conversing with her she had only taken the medicine for two days before she felt much better and now the pain was gone. She was so excited that we had fixed her. She was able to return to her job and resume her responsibility at home in a timely manner and this was of grave importance to her. I conveyed to her that her blood work was ok and that we were waiting for a few other results. In my two encounters with Ms. Q, I had developed a deep fondness for her and felt as though she were my patient. Although we had only given her NSAIDS for her pain, her gratitude far exceeded that of any of my other patients in any rotation. No other patient had given me such a sense of worth, and so I do not think I will forget about Ms. Q for some time.
- Rohit Soans
