Monday, April 19, 2010

Why We Need Wise Primary Care Physicians - A (small) Personal Experience

Last week, while working at my desk at Harvard Medical School, my left foot started to hurt. I stood up. The foot felt like it was on fire.

I took off my shoe and sock. There was an obvious swelling on the back of my foot, somewhat blue, looking like a bruise.

But I hadn't twisted my ankle and nothing had fallen on my foot. I'd been sitting at my computer, writing. I decided to wait. Maybe the pain would just go away on its own.

But instead of getting better, it got worse.

My skills at general medicine are rusty, but I tried to figure out what was happening. Injury seemed the likeliest source of foot pain, but I couldn't remember an injury. Could I have some kind of bleeding problem? I didn't have any other bruises so that didn't seem probable. Some years ago a friend had died of a rare muscle sarcoma that first showed up as a painful swelling. But that's a VERY rare condition, and I couldn't imagine it popping up so quickly.

I put my foot up, finished my work, and hobbled to my car to go home. I put an ice pack on the swelling and sat with my foot up. I was able to work at home the next day, and did more or less the same thing.

Meanwhile, my wife spoke with friends at the college where she teaches. They seemed worried. They imagined various terrible possibilities. Had I seen my doctor?

In medical school my most influential teachers conveyed an approach I applied all through my own years of practice. In an emergency, act now. In non-emergent situations, when it's not clear what's going on, apply what the old timers called "tincture of time" (see here and here) - waiting, combined with tempered optimism and availability.

That's what I did.

In 36 hours, tincture of time did the job.

If I didn't have my own (rudimentary) primary care skills I might have gone to a doctor (assuming I had one, which, happily, I do), or, if worried enough, to an emergency room. I expect that a good primary care physician would have done just what I did.

But an overly rushed physician, or one practicing under the spell of defensive medicine, might have done this:

Or this:

I didn't need a primary care physician last week - I was able to be one to myself. But most of the population hasn't gone to medical school and done a year-long internship in general medicine at UCLA. I'd like to picture the thought process I went through, the common sense measures I applied, and the TLC I was able to give myself, as available to all at the other end of a phone call or in an office visit.

We need wise primary care physicians!

No comments: