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OB/GYN Editorial March 2003
The Real Primary Care
Vivian M. Dickerson, MD
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Many years ago, I was among a group of OB/ GYNs called upon by
then ACOG President, Ezra Davidson, MD, to create a primary preventive
care document
that would reassert the role of the obstetrician-gynecologist as a
primary care provider. There were many reasons for this and admittedly,
some of them were financial. However, those of us on the task force
became committed to the concept that we indeed are and have been primary
care providers in the finest sense of the word. The fiduciary component
of primary care speaks more to the gatekeeper/triage concept than it
does to the doctor-patient relationship. This more important aspect
of primary care was highlighted recently in an article in the Journal
of the American Medical Association. In a recurring feature known as "A
Piece of My Mind," Dr
Jerry Kruse writes poignantly and pointedly about the life and death
of his father.1 I was profoundly moved by this one-page
piece and urge all physicians to read it. Why is it pertinent to this
primary care concept? Virtually all of the physicians taking care of
Dr Kruse’s father were specialists from the point of view of their
training, and yet they stepped up and provided continuity and caring.
He describes this best when relating an interaction between his father
and his long time cardiologist who explained to him, that while his
heart was stable, she couldn’t do much for his cancer, but she
would come to see him every day and be available to him. "She
had been his cardiologist. Now, she became his doctor."
Why are OB/GYNs truly primary care? Because we are part, on
a daily basis, of extraordinary dyads. For those of us who are graying, there
have been many patients whom we may have brought into this world, seen throughout
their lives, and in turn, delivered their babies. Others we came to know
later, and have seen them through marriages, births, sorrows, and joys. We
are privy to the most intimate details of their lives, and sharing the joy
of childbirth, marriage, or "cure" is easy and rewarding.
We are the ones, however, who must on occasion break "the bad news"–the
loss of a baby, the inability to conceive, the diagnosis of cancer. We have
learned that the words we use in these situations are not nearly as important
as how we convey the message: that sitting, listening, touching, and grieving
with our patients in these situations is the art of primary care. Being a
primary care obstetrician-gynecologist is an incredible privilege and responsibility.
It is primarily about caring while using all of the medical skills that we
have worked so long to procure and refine.
It is obvious that the primary care role we capably and logically
fill in the lives of women is not about gate-keeping but about a presence,
an attitude. It should also be obvious that anything that interferes with
the long-term doctor-patient relationship, or that falls short of allowing
full access to care is antithetical to this concept. When professional liability
insurance becomes so high that OB/GYNs stop practicing; when the working
poor or other uninsured patients cannot receive care; or when patients are
required to change insurance plans and physician panels every time they change
jobs, this relationship is jeopardized. We didn’t count on the fact
that we would also have to be embroiled in political and health policy debates,
such as tort reform and care for the indigent, but this is the reality. I
would like to think that I will be there for my patients in their time of
need and that I will not only be prepared to do so, but that the exigencies
of the politics and finances of medicine will not create an environment in
which I no longer take care of long-term patients.
Primary care is exactly that: the unencumbered caring of the
mental, emotional, and physical well being of those who we are lucky enough
to call our patients. And if we are consistent in our endeavors, on all fronts,
to protect and nurture this relationship, we too, may be lucky enough to
be not just their OB/GYN, but their "doctor."
Vivian M. Dickerson, MD
Reference
1.Kruse J. A piece of my mind. Convictions. JAMA. 2003;
289(3):273.
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