Sunday, June 24, 2018

The Moral Vision of Primary Care

The underlying vision of primary care is to do what is needed to promote and restore health. Sometimes this requires referring patients to specialists, but more often it is done directly.

An article in today's New York Times about Dr. Nicole Gastala describes how the young physician, just out of residency and paying off her loans through practice in a community clinic in Marshalltown, Iowa, encountered the opiate epidemic and decided to do something about it. She did the required training to be licensed to prescribe buprenorphine so that she could provide medication assisted treatment to patients with opiate addiction. She got a federal grant that facilitated starting a program and hiring a nurse to join her in staffing it. She continues her own education via telemedicine with a clinic in Connecticut that provides consultation and education to primary care buprenorphine providers. She has strengthened her own capacity for acceptance of patients who relapse. And, as she and her husband prepare to move back to Chicago, she is taking steps to perpetuate the buprenorphine program.

For the past twenty years I've had the privilege of co-facilitating a "patient-doctor" seminar for superb primary care residents throughout the three years of their residency. They've reported how frequent it is to hear versions of "you're so smart and capable - why aren't you going into a medical specialty?" As I thought about their choice of primary care, the Buddhist concept of Bodhisattvas of Compassion came to mind. I've written before about the statue of Guanyin at the Boston Museum of Fine Arts. In Buddhist tradition, Bodhisattvas are enlightened beings who choose to remain among mortals to alleviate suffering.

This vision is available to any and all health professionals, and of course to others in professions like education. But in medicine I see primary care as the purest form of the "Bodhisattva-like commitment," since it puts the fewest filters between the individual physician and the full range of human suffering. The article in today's New York Times does not contain high falutin language, but the simple story of a young physician's post-residency practice gives a down to earth picture of the moral vision underlying primary care.

Addendum: The July 5th issue of the New England Journal of Medicine has an excellent article on "Primary Care and the Opioid-Overdose Crisis: Buprenorphine Myths and Realities." If you've read this far I urge you to follow the link to the NEJM article.

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