The right choice
Finding the right primary care physician for you is not always easy and it shouldn’t be taken lightly. It is one of the most important relationships you will ever have. This is the person who will monitor and direct all your care. You need to be sure. There are many factors to consider.
The choice of primary care provider is not easy, but necessary to manage overall health care
Primary care covers a wide spectrum of ages. Pediatricians treat children from birth to the teens. Geriatricians treat the elderly with multiple complex conditions.
Not only is it difficult to find a PCP that is accepting new patients, what to look for in a doctor can be equally daunting. Personal preferences prevail. Gender and age can be a factor. People might have a higher comfort with a doctor of the same sex. Some might prefer a younger doctor more likely to be up-to-date with newer treatments while others may relish the attention of a more experienced doctor.
Hospital affiliation, location and access are also important. Even race or ethnicity often plays a role. People are sometimes more comfortable with someone who looks like them.
Unfortunately, a perception exists that doctors trained in another country just don’t measure up in terms of quality. Yet, foreign-trained medical doctors are subjected to the same rigorous standards as American-trained doctors. They undergo residency training in American hospitals and take the same national three-part licensing exams and specialty tests.
And they’re helping to fill the void of PCPs created in part by the increased demand.
A study published in 2010 in Health Affairs concluded that the medical school attended — international or U.S. — did not affect mortality rates for patients hospitalized for congestive heart failure or heart attack. Rather, board certification and the number of years since graduation had the most impact.
Board certification is a measure of quality that certifies a physician’s expertise in a medical specialty.
Further complicating a choice in PCP is that there’s more than one type.
An internist is a doctor of adult medicine, while a pediatrician tends to the needs of children. Geriatricians confine their care to the elderly. Family practitioners, on the other hand, provide comprehensive medical and surgical care for the individual and family regardless of age.
In some organizations the gynecologist is considered the PCP for females. Non-physician providers, such as nurse practitioners and physician assistants, round out the PCP players.
For the most part, medical care and the choice of PCP revolve around age, starting with pediatrics and ending with geriatrics.
The good news is that people are living longer. According to a recent report from the Massachusetts Department of Public Health, those born in the Commonwealth in 2008 are expected to live an average of 80 years. But the longevity comes with a price.
Daniel J. Oates, M.D, M.Sc.
Boston Medical Center
The typical age is at least 65, but there is no set age at which a person “graduates” from an internist or family practitioner to a geriatrician. More telling is the health status of the person. “I often treat people with geriatric syndromes,” Oates explained. “These are people with multiple problems that require coordination of care.”
The list of problems he sees is long — falls, arthritis, pain, cardiovascular disease, poor vision. Special attention is made to functional independence and activities of daily living — concerns not typical in the younger population.
People with memory problems are increasing in number and those with depression require coordinated efforts, not only with other providers but with the family as well.
Getting medications right takes a bit of work. Those with complex and multiple medical problems take multiple drugs. It’s easy enough to juggle one or two medications, but, according to the Centers for Disease Control and Prevention, the average 75-year-old takes five prescription drugs. One of the most common reasons an elderly person lands in an emergency room are side effects of medication mishaps.
Oates does not view working with the elderly as a challenge. “I see it as an opportunity,” he explained. “It allows me to have a major impact on a person’s quality of life. The focus is more on quality instead of quantity.”
One challenge he and other geriatricians deal with regularly is the lack of research on the elderly. Clinical trials typically do not include elderly subjects. “It makes it difficult to know how older people will respond [to treatment],” he said. “We have to look more at personal experience.”
But Oates is not complaining. And he has his work cut out for him. The American Geriatric Society (AGS) has determined that the current number of 7,100 geriatricians is not enough to go around. That’s only one geriatrician to every 2,620 Americans 75 or older.
Due to the expected increase in the number of older Americans, the AGS estimates one geriatrician for every 3,798 elderly in 2030.
On the other end of the age spectrum are pediatricians with a different set of problems. Their care begins shortly after birth and lasts for at least 18 years.
They take care of sniffles and colds, provide immunizations, keep track of developmental milestones, monitor nutrition and escort teens into puberty.
Renee D. Boynton-Jarrett, M.D.
Boston Medical Center
Pediatricians are unique in that when they treat a child, the entire family comes in the deal. “It’s about creating a therapeutic alliance,” explained Dr. Renee Boynton-Jarrett, a pediatrician at Boston Medical Center. “There’s a bond with the family.”
Pediatrics spreads a much broader swath than just runny noses and shots. Times have changed, requiring a more trauma-informed model of health care practice.
Questions are posed regarding child abuse, bullying, depression and trauma. Is there evidence of an eating problem? Is the child anxious or stressed? What is his or her academic achievement?
“All these factors are intricately interwoven,” she said.
Her reach extends beyond the doctor’s office. A thorough analysis of a child’s environment can involve the school system and interaction with principles, guidance counselors and teachers. Boynston-Jarrett explained that in order to optimize a child’s health and well being, it is essential to consider and coordinate all the environmental risk and protective factors that may come into play and have an impact.
“It’s important to never disregard a parent’s concern,” she said. “I have a snapshot view of the child. The parents live with the child. They speak with authority.”
The types of concerns change as the child grows. While breastfeeding may be an issue with infants, exercise and healthy eating take its place for older kids, and drug addiction and smoking become issues for adolescents.
Obesity is a growing concern among children of all ages. “Obesity before the age of 10 can result in obesity in adults,” she said, “and lead to high blood pressure and diabetes even in the young.”
Boynton-Jarrett is clear on her role as a PCP. “I intervene early,” she explained. “Adversities early in life may have an enduring impact on health and development.”