What cultural differences can you name, comparing “acute” and “primary” care?
Patience is a major cultural difference between acute/rescue and primary care. After reading Atul Gawande’s “The Heroism of Incremental Care” (New Yorker, Jan 23 2017) it is obvious that patience is a major component to primary care, which is often not seen in rescue medicine. I enjoyed his statement “most of the time people will get better on their own, without intervention or extensive workup. And, if they don’t get better, then usually more clues to the diagnosis will emerge.” This is a perfect example of many of the patients we see in clinic. By employing incremental care, patient can avoid unnecessary procedures and save healthcare dollars.
But why are rescue specialties attractive? They are attractive in today’s society because of the immediate gratification patients and clinicians expect. Patients want results now, they want treatment now, and they want to feel better now. We all want a special pill to solve problems right away. If you tell a patient their condition will resolve in a couple months by itself or they can pay to get it fixed now, many will probably pay if they can afford it. The culture has shaped patients’ expectations as well as influenced the political aspects of reimbursement. “Construction produces immediate and visible success” and everyone loves a shiny new bridge. But we often forget that maintenance is needed to prevent that shiny new bridge from becoming just like others that are rotting away or on the brink of collapse. It is our job as clinicians to be those maintenance workers and encourage those funding the construction to focus on constant upkeep, known as preventative medicine.
What attracts you to, or repels you from, incrementalism?
I partly choose the field of anesthesia because of the immediate feedback one receives when pushing drugs like propofol or phenylephrine. I enjoy seeing results right away, and being able to react quickly to new data points constantly streaming my way.
In medicine there are people who have personalities designed for incrementalism. These individuals are in the ideal position to discuss factors such as living situation, family dynamics, stress levels, and how intricate parts of their lives impact health. In an ideal situation we would all do this. However, our healthcare system is not set up this way. We have a fragmented healthcare system both practically and economically. Often, even in Gawande’s article, fields of medicine are compared to each other as if we are individual teams fighting to be the ones that have the biggest impact on our patient’s lives. We are competing and making statements to justify why a specific –ologist or family medicine physician is doing better than someone else. This culture sets us up for failure. Gawande elegantly stated, “in his first days rescue medicine was what he needed…. but incremental medicine is what he has needed ever since.” Our focus in medicine should be to treat patients as a team. To incrementally address patients concern and transition to rescue care when absolutely needed. When these transitions occur, they should be done in a collegial, appreciative, and team-based fashion, rather than the often hierarchical attitude that is often seen in medicine. Although I enjoy the immediate results of anesthesia, I also appreciate the work my teammates will put in to prevent surgical procedures and keep patients out of the hospital. But when that time comes that rescue medicine is needed, I will be there to get patients through whatever it is they need, in order to transition them back to my teammates in the outpatient setting who can continue to provide maintenance to prevent their ultimate collapse.
Christopher Aiudi is a student of the Mayo Clinic School of Medicine who writes as part of his family medicine clerkship.