Despite my lack of updates, PA school has continued to move along. Each day has been another chance to get more experience under my belt and to learn about people and healthcare from the inside. The past two months I have been working in primary care, the frontline of healthcare. Interestingly, even though many PAs are now being utilized in specialty settings, the role was initially created to help compensate for shortages in primary care, especially in urban and rural areas. Well, that is exactly where I have been. In December, I was in Richmond, IN at a county health clinic and in January I spent most of my time at the Methodist family medicine residency clinic in downtown Indy. While I thought I would fall in love with primary care, I have come out of these two months a little shell-shocked and unsure. Primary care is no neurosurgery, but it is no cakewalk either.
Many patients are noncompliant.
I have come to realize there are several reasons for this.
1) Financial hardship. They may have difficulty affording their medication. When people have to choose between keeping their lights on or buying their medicine, the former often wins out. They may not have reliable transportation. If someone doesn’t have a car, relies on the public bus schedule, or depends on a family member, they may have difficulty keeping appointments, picking up their medications from the pharmacy, or going to the grocery store (especially in food deserts, like in certain areas of Indianapolis).
2) A lack of self-discipline. Stopping old habits and making new ones takes will power and consistency, which is usually not easy or fun. Adjusting one’s diet to improve their diabetes, consistently using condoms to prevent STIs, actually doing the at-home physical therapy exercises, putting on sunscreen. The examples are endless and every person can relate to at least one of them.
3) A lack of understanding of the long-term consequences of one’s choices. We live in a society that likes immediate feedback and results. If I have a rash, I put cream on it and it goes away. Most people can get on board with that kind of treatment. However, what about high blood pressure (hypertension) for example? With hypertension people often do not feel short-term effects. Many can walk around for a long time with hypertension and not even know it. So, when their provider communicates the importance of taking their medication, avoiding salty foods, exercising regularly, etc., they are less inclined to follow through because they cannot directly see or feel the effects of these changes. However, chronic hypertension puts people at greater risk for vision loss, stroke, heart attack, heart failure, and chronic kidney disease. Those things are serious. Thus, when patients do not have good basic health education, they have a hard time appreciating the importance or gravity of their medical conditions and their choices, especially the long-term consequences.
Many patients just want a pill.
Unfortunately, many people believe their trip to the clinic is only a success if they walk out with a prescription for something they can pick up at a pharmacy. Sometimes, I would even argue that often times, a pill is not the answer. Sometimes the answer is rest, exercise, eat fresh food, cut back hours at work to reduce stress, stretch, go talk to a counselor to unpack the anxiety and/or pain that you are carrying, drink more water, get more sleep, do something you enjoy, get some fresh air, do some reflective journaling, get out of a toxic relationship… Those things don’t get run through your insurance, they are not picked up at a pharmacy, and they aren’t limited to a certain number of refills. Even though this is what most people need, it is not what they want, so there is tremendous pushback to such “frivolous” suggestions.
Many patients have a skewed sense of pain.
While pain is certainly subjective, our culture in a lot of ways has recalibrated the pain scale. People think that they are entitled to feeling no pain, no discomfort, or no repercussions for their health choices. If you are overweight, it will accelerate the development of osteoarthritis in your knees, and that will hurt. If you foster stress and anxiety in your life, it may manifest as physical discomfort. If you have a weak core, it can contribute to the development of low back pain. Even harder to accept is that sometimes pain is not a result of personal choices, but rather an effect of circumstance. For instance, if someone has been in a severe car accident or if someone was hit by a roadside bomb in the Middle East while serving in the military, unfortunately their pain level may never be at a 0 again. I don’t say that to seem insensitive, but to point out that reality should shape our expectations rather than our expectations shaping our reality, especially when it comes to pain. For more information, just Google “US opioid epidemic.”
Over the past two months I have found primary care to be draining. And while the same things may not be true of all primary care settings, they have certainly been the bulk of my experiences thus far. I would be lying if I didn’t say that it isn’t making me question what area I want to work in after I graduate and whether primary care would be a good fit for me. However, whether I end up in primary care, I certainly hope that the challenge of interacting with patients serves to build up in me compassion rather than cynicism. This next month is urgent care followed by a month of community medicine, so we’ll just have to see where I am at come the end of these next couple of months.