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Is primary care relevant?
You probably still remember your pediatrician. Your relationship with her may have influenced your decision to become a physician. She was your parents’ go-to source for pretty much anything to do with your health. You had a primary care physician in large part because your parents felt that children were particularly vulnerable to disease and wanted to avoid any missteps on your road to maturity. On the other hand, while you were growing up your parents probably were much less concerned about their own health. Their peers and friends seemed healthy enough; why would they need annual checkups? Your folks made sure they had life insurance because accidental death and injury felt like more pressing concerns. If they had a primary physician, they may have visited him infrequently. They may have been more likely to visit their dentist, in part because the office put a strong emphasis on the value of preventive care.
A recent survey from Harvard Medical School, Boston, determined that, in 2015, 75% of adult Americans had an established source of primary care. (“Fewer Americans are getting primary care,” Jake Miller, the Harvard Gazette, Dec. 16, 2019). This number sounds pretty good and not unexpected until you learn that in 2002 that number was 77%. While 2% seems like a drop in the bucket, remember we live in a very populous bucket, and that 2% translates to millions fewer Americans who are not receiving primary care than did more than a decade ago.
While the researchers don’t have data to explain the decline in primary care, they suggest raising the pay of primary care physicians, incentivizing rural practice, and making health insurance more available and affordable as solutions. Of course these recommendations are not surprising. We’ve heard them before. More supply might translate into more usage. But could some of the decline in primary care be because it no longer feels relevant to a population that has become accustomed to instant gratification? One click and the thing you didn’t feel like waiting for in line today is on your doorstep tomorrow, or even sooner.
If we want to create meaningful change, we need to learn a thing or two about marketing from the competition and from the successful businesses who are shaping consumer behavior. It’s not surprising that, when people feel healthy (whether they are or not), they will devalue primary care. But if they sprain an ankle or have a cough that is keeping them up at night, they would like some medical attention ... now. And that will drive them away from primary care toward sources of fragmented care – the doc-in-the-box, the walk-in clinic, or even more unfortunately to the local emergency department.
If we want more people to establish relationships with primary care providers, we need to welcome them in the door ... when they feel a need. Once in the door we can establish rapport and show them there is a value to primary care while they are feeling grateful for the prompt attention we gave them. But too many primary care practices are shunting potential patients into fragmented care by appearing unwelcome to minor emergencies and by creating customer-unfriendly communication networks. Most people I know would be happy to go back to the old days of “take two aspirin and call me in the morning” primary care. At least you had talked to a doctor in real time, and you knew that he or she would see you the next day if you still had a problem.
You may think I’ve suddenly gone utopian. But there are ways to run a practice that welcomes patients with minor complaints on short notice. It requires some flexibility, some willingness to work longer on some days, and being more efficient.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
You probably still remember your pediatrician. Your relationship with her may have influenced your decision to become a physician. She was your parents’ go-to source for pretty much anything to do with your health. You had a primary care physician in large part because your parents felt that children were particularly vulnerable to disease and wanted to avoid any missteps on your road to maturity. On the other hand, while you were growing up your parents probably were much less concerned about their own health. Their peers and friends seemed healthy enough; why would they need annual checkups? Your folks made sure they had life insurance because accidental death and injury felt like more pressing concerns. If they had a primary physician, they may have visited him infrequently. They may have been more likely to visit their dentist, in part because the office put a strong emphasis on the value of preventive care.
A recent survey from Harvard Medical School, Boston, determined that, in 2015, 75% of adult Americans had an established source of primary care. (“Fewer Americans are getting primary care,” Jake Miller, the Harvard Gazette, Dec. 16, 2019). This number sounds pretty good and not unexpected until you learn that in 2002 that number was 77%. While 2% seems like a drop in the bucket, remember we live in a very populous bucket, and that 2% translates to millions fewer Americans who are not receiving primary care than did more than a decade ago.
While the researchers don’t have data to explain the decline in primary care, they suggest raising the pay of primary care physicians, incentivizing rural practice, and making health insurance more available and affordable as solutions. Of course these recommendations are not surprising. We’ve heard them before. More supply might translate into more usage. But could some of the decline in primary care be because it no longer feels relevant to a population that has become accustomed to instant gratification? One click and the thing you didn’t feel like waiting for in line today is on your doorstep tomorrow, or even sooner.
If we want to create meaningful change, we need to learn a thing or two about marketing from the competition and from the successful businesses who are shaping consumer behavior. It’s not surprising that, when people feel healthy (whether they are or not), they will devalue primary care. But if they sprain an ankle or have a cough that is keeping them up at night, they would like some medical attention ... now. And that will drive them away from primary care toward sources of fragmented care – the doc-in-the-box, the walk-in clinic, or even more unfortunately to the local emergency department.
If we want more people to establish relationships with primary care providers, we need to welcome them in the door ... when they feel a need. Once in the door we can establish rapport and show them there is a value to primary care while they are feeling grateful for the prompt attention we gave them. But too many primary care practices are shunting potential patients into fragmented care by appearing unwelcome to minor emergencies and by creating customer-unfriendly communication networks. Most people I know would be happy to go back to the old days of “take two aspirin and call me in the morning” primary care. At least you had talked to a doctor in real time, and you knew that he or she would see you the next day if you still had a problem.
You may think I’ve suddenly gone utopian. But there are ways to run a practice that welcomes patients with minor complaints on short notice. It requires some flexibility, some willingness to work longer on some days, and being more efficient.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
You probably still remember your pediatrician. Your relationship with her may have influenced your decision to become a physician. She was your parents’ go-to source for pretty much anything to do with your health. You had a primary care physician in large part because your parents felt that children were particularly vulnerable to disease and wanted to avoid any missteps on your road to maturity. On the other hand, while you were growing up your parents probably were much less concerned about their own health. Their peers and friends seemed healthy enough; why would they need annual checkups? Your folks made sure they had life insurance because accidental death and injury felt like more pressing concerns. If they had a primary physician, they may have visited him infrequently. They may have been more likely to visit their dentist, in part because the office put a strong emphasis on the value of preventive care.
A recent survey from Harvard Medical School, Boston, determined that, in 2015, 75% of adult Americans had an established source of primary care. (“Fewer Americans are getting primary care,” Jake Miller, the Harvard Gazette, Dec. 16, 2019). This number sounds pretty good and not unexpected until you learn that in 2002 that number was 77%. While 2% seems like a drop in the bucket, remember we live in a very populous bucket, and that 2% translates to millions fewer Americans who are not receiving primary care than did more than a decade ago.
While the researchers don’t have data to explain the decline in primary care, they suggest raising the pay of primary care physicians, incentivizing rural practice, and making health insurance more available and affordable as solutions. Of course these recommendations are not surprising. We’ve heard them before. More supply might translate into more usage. But could some of the decline in primary care be because it no longer feels relevant to a population that has become accustomed to instant gratification? One click and the thing you didn’t feel like waiting for in line today is on your doorstep tomorrow, or even sooner.
If we want to create meaningful change, we need to learn a thing or two about marketing from the competition and from the successful businesses who are shaping consumer behavior. It’s not surprising that, when people feel healthy (whether they are or not), they will devalue primary care. But if they sprain an ankle or have a cough that is keeping them up at night, they would like some medical attention ... now. And that will drive them away from primary care toward sources of fragmented care – the doc-in-the-box, the walk-in clinic, or even more unfortunately to the local emergency department.
If we want more people to establish relationships with primary care providers, we need to welcome them in the door ... when they feel a need. Once in the door we can establish rapport and show them there is a value to primary care while they are feeling grateful for the prompt attention we gave them. But too many primary care practices are shunting potential patients into fragmented care by appearing unwelcome to minor emergencies and by creating customer-unfriendly communication networks. Most people I know would be happy to go back to the old days of “take two aspirin and call me in the morning” primary care. At least you had talked to a doctor in real time, and you knew that he or she would see you the next day if you still had a problem.
You may think I’ve suddenly gone utopian. But there are ways to run a practice that welcomes patients with minor complaints on short notice. It requires some flexibility, some willingness to work longer on some days, and being more efficient.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Return of the Wild?
Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.
There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.
As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.
These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.
One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.
When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.
However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.
No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.
So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].
Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.
There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.
As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.
These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.
One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.
When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.
However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.
No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.
So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].
Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.
There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.
As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.
These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.
One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.
When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.
However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.
No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.
So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].
