Shantanu Nundy, M.D.

Shantanu Nundy M.D.

Beyond Apples

Still Figuring Out What Primary Care Is All About

Primary care is more than the sum of its parts

Posted Apr 17, 2011

After three years of clinical practice, I’m still not sure what being a primary care doctor means. This is especially odd because not only am I on the verge of completing my training in internal medicine (yes!), but have also decided to go into primary care and will be a fully fledged general practitioner starting in July. If I looked it up in a textbook, the job of a primary care doctor would probably be described by some combination of the following tasks: diagnosis and treatment of common primary care conditions (e.g., the flu, back pain), administration of preventive health and public health measures (e.g., vaccines, screenings), management of common chronic conditions (e.g., diabetes, high blood pressure), referral to specialists and other allied health professionals, and care coordination. While these tasks make up the majority of my day-to-day activities as a primary care physician, it is what we do in-between the lines that is more uncertain and perhaps more important.

Ms. FB is a 53-year old woman who I first met in clinic over two years ago. Like most of my patients; she is poor, African-American, and has limited insight into her health. In addition; Ms. FB is morbidly obese, has high blood pressure, and despite my best efforts is a smoker. Last Friday I saw Ms. FB as a “return visit” in clinic. Looking through her chart, I was surprised to see that it had been well over a year since I’d last seen her. Typically for a high-risk patient like her I’d aim for at least 3 visits per year. She had missed a follow up appointment with me 9 months earlier but had not been scheduled for any since. I was embarrassed that I had not noticed her absence from clinic earlier, and as I trudged down the hallway to meet her scolded myself for not reaching out to her sooner. Though I’m the main doctor for all of my patients, 99% of my job is passively waiting for patients to show up and then helping them the best I can during their 15-minute office visit.

As soon I walked in the room, I immediately noted that Ms. FB had gained at least 10 lbs since our last visit and kicked myself again. At over 240 lbs and 5′ 2”, her risk of serious complications from her obesity was already unacceptably high. When I asked Ms. FB what kept her away and what finally brought her back, her response was almost too simple to be believable. What kept her away? “I didn’t have an appointment.” What brought her back? “My pharmacy told me my refills had run out.” Shaking off any regret, I got to work doing what a primary care doctor does. I checked her BP (a little high, she ran out of one of her three medications), reviewed her medications and wrote refills for all of them, and started ordering routine labs and her preventive health screening; all the while chatting her up about this and that (in medical terms, obtaining a “review of systems”).

But as we talked, something else about her seemed different. I had already asked her in 2-3 different ways if she was short of breath, having chest pain, or having any other major problems; but finally looked her straight in the eye and asked “But Dear, you getting around ok?” Turned out she wasn’t. She was having a hard time even getting out of the house because of fatigue and didn’t feel like herself anymore. In addition, at times, she admitted, her heart felt like it was racing. Examining her carefully I noticed her heart rate was not only fast but irregular (or in doctor-speak “irregularly irregular”, a sign that she had developed atrial fibrillation). In addition to the blood work, I sent her down for an EKG.

The next day I called her with her results. I stressed how good to was to see her again — an indirect plea to get her to follow up with me more often. Her labs looked good (I breathed a sigh of relief when I saw them) but the EKG hadn’t been done. “Oh, I forgot to get that.” No problem, could she come to in today to get it checked? I felt a little pushy– after all parking at our institution isn’t easy or cheap and getting to the hospital by public transportation can be an ordeal– but added “Could you please do it as a favor for me?”

Two days later I received an email that Ms. FB was being discharged from the hospital. The EKG had shown atrial fibrillation, and she was directly admitted to the hospital where she underwent electrical cardioversion (basically they shocked her heart back into normal rhythm). Could I make room in my schedule to see her in the next two weeks?

After my initial shock, I looked up her room number and rushed over, hoping to catch her before she was discharged home. On the way over I wondered what I would say. On my end I was again embarrassed. If I had kept better tabs on her, then maybe this would have never happened. I was also worried that she would be mad at me or lose trust in my ability as a doctor. At the same time, I wondered what value was there to visiting her in the hospital. I certainly wasn’t going to add anything to her care — atrial fibrillation is outside my field of expertise — and besides in our hospital inpatient and outpatient medicine is separate, so I couldn’t order any tests or medications even if I wanted to.

Before I could answer my own question I heard from across the doorway, “There’s MY doctor! There’s the man who SAVED my life!!” I stumbled awkwardly past her nurse and sat down bedside her. She was gushing. “THIS is the doctor I have been telling you about. The one God sent down for me.” Still dazed, I found myself thrust into a sideways hug.

We talked about her hospitalization. She was feeling much better after the procedure. She was ready to go home, change her diet, start exercising. She was going to lose 20 lbs and make my wife jealous. Pointing to her arm, she proudly showed me her nicotine patch. She had made up her mind and was done with cigarettes for good.

After she settled down, I shared with her my enthusiasm for her enthusiasm. I warned her gently that change was hard. For the next week she’d need to self-administer daily shots that would thin her blood after the procedure (lovenox) and for the next month take a new medication that was tricky to manage (coumadin). I suggested that she focus on taking these medications and quitting smoking, and then when I saw her in two weeks we could move on to talking about her diet and getting her exercising more.

Sensing it was time for me to leave, Ms. FB gave me another hug. We talked casually about our plans for the weekend. and then I waved goodbye. I then found her inpatient doctors to discuss her case and clarify the plan going forward. I contacted my nurse and scheduled Ms. FB into my next clinic opening. And then I replied to the initial email informing them that follow up had been arranged.

For the cardiologist involved with Ms. FB’s care, his job is clear: read the EKG, diagnose atrial fibrillation, and then shock the patient back to normal rhythm. Done. For the admitting team the work is also well defined: admit the patient from the ER, manage them in the hospital, and then discharge them home with follow up. But for me, I’m not sure where my work begins and ends. I find myself ebbing in and out of patient’s lives, sometimes doing medical things (suspecting atrial fibrillation) and sometimes not (pleading with a patient to get an EKG), rarely knowing what exactly I’m supposed to do but just going with my gut and sometimes with my heart. Whatever it is, being someone’s primary care doctor is a joy and a priviledge, and a job that I look forward to trying to figure out how to do for years to come.

- Shantanu Nundy, M.D.

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