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The curriculum renewal committee of the University Of Washington School Of Medicine[1] offers suggestions for curriculum changes that would enhance the numbers of graduates choosing a primary care specialty. Notably the report did not mention the issues of prestige nor the availability and training in the use of diagnostic tools for a primary care setting.
From a clinical viewpoint primary care is more of a science
not less of one than the other more limited specialties. The training and
clinical tools should match the challenge and they do not. Medical students
need both the tools and the training to do serious diagnostic studies. Contrary
to the image of a doctor making a snap diagnosis wherein the only problem is
the treatment protocol, diagnosis is multifaceted and no simple matter.
Multiple conditions, individual patient constitution, and multiple layers of
symptoms compound the challenge. Many studies suggest a high percentage of
missed and wrong diagnoses, 35.8% in this study.[2] We
use to have the autopsy as a final arbitrator of diagnosis but no more. Autopsy
has gone out of style; it is not profitable enough. Some medical schools have
abandoned the microscope in favor of digital images in training. The
microscope, however, remains one of the most essential diagnostic instruments. Today’s
microscope should provide polarized light, dark field and fluoroscopy. This is
realtime microbiology.
Historically, medical science advanced through the evolution
of diagnostic tools and techniques. First, there was the autopsy, then the
stethoscope, and the microscope, then statistics, the x-ray machine, ultrasound
and more recently bio-molecular science. Today, hospitals excuse the autopsy
with reliance on the CT scan. Largely the CT scan replaces the plain old x-ray.
This is not progress. Today the stethoscope hangs around the neck unused. Offices
send out most lab work, either to a reference lab or to the hospital. It should
be obvious that the primary care doctor needs a small clinic version of all of
the basic diagnostic tools and some that exist only in research labs. Basic
equipment should include ultrasound, microscope, x-ray, and the skills to go
with them. Looking to the future, the primary care physician needs to link current
clinical research with his or her practice, especially in statistics and genomics.
Polymerase Chain Reaction (PCR)[3]
should find common use in the clinic; students should have enough undergraduate
experience in proteinomics to manage it.
Many frustrations to the practice of good medicine come from
outside the profession. These distortions, accepted as the way things are, limit
both the role of the physician and his or her ability to diagnose conditions at
hand. For instance, EPA limits a physician from conducting many laboratory
tests in the doctor’s office, or requires burdensome licensing and exemptions.[4]
While well intended to improve quality and control costs, it does the opposite.
One fear suggests that physicians do laboratory studies because they produce
more revenue. Perhaps some do, but the unintended consequence denies access to
simple inexpensive tests. These tests done in realtime, while the patient is
present, save time, save money and improve outcome. A trip to the hospital, results
in delay and a much more expensive procedure. I cannot imagine a physician
doing a gram stain, a peripheral blood smear, stool, a urine sediment, a sedimentation-rate
or a culture and sensitivity for the money; although, payment for these
services must cover the cost of time and equipment. Some of the tests are time
and space sensitive with unstable chemicals and fragile structures. These further limitations also argue for on site availability in rural clinics.
The same argument can apply to office x-ray. The office machine
requires the same inspections and calibrations as in the hospital. The machine
may be identical. One does not have to use much imagination to see a political
undercurrent persuading legislators that everything must be done in the
hospital. Unfortunately, hospital profit motivates the lobbying.
In 1998 while on the Board of Directors of the South
Peninsula Hospital, I attended a dinner seminar set up by the network of Alaska
hospitals including legislators presumably for educational purposes. It had
only begun when it became evident that this meeting had the primary agenda of promoting
a bill prohibiting office x-ray machines. The program presented undocumented
evidence that office x-ray machines were sub substandard and hazardous while
hospital machines were new and operated by licensed technicians. Presenters
built a case for eliminating office x-ray machines in favor of securing all x-ray
business for hospital radiology units. I was sitting at a table next to Senator
Murkowski. He turned with a questioning look. I simply compared the cost of
flying a patient from a native village to an Anchorage hospital for an x-ray of
the chest in order to assess a clinical pneumonia. The unfavorable cost and the
poor medical treatment of a time sensitive illness delayed by a trip to the
hospital were obvious. The bill did not pass. In today’s environment, a
hospital x-ray becomes a CAT scan. The cost is a hundred fold greater and the
information only marginally better. The accumulated CT radiation expositor falls
into the danger zone.[5]
Students should learn the physics of radiology, quantum physics and participate
in research for the newer less toxic photonics.
In short, the primary care doctor should be educated as a
scientist in the tradition of the great physicians, past and present. He or she
needs the tools of science and of diagnosis and be expert in their use. One
wonders, just what is the character we strive towards in a primary care
physician? Do we want a doc who is indeed a scientist with the humanity of Hippocrates?
Or, do we want a Feldsher with an unused stethoscope hanging indolently around
the neck?
[1] http://www.uwmedicine.org/Education/MD-Program/curriculum-renewal/Working-Groups/Documents/Report-Primary-Care-April-2013.pdf
