The first time I saw the patient, they weren’t sure if they wanted to take the medications I recommended for lowering their cholesterol and blood pressure. Primary care appointments are conversations. My assessment of their health after reviewing their labs, vital signs, and story suggested that making lifestyle changes (like more exercise and diet adjustments) and starting a few medications would help the patient be healthier and reach their goal of living a long, healthy life. I explained the reasoning behind my recommendations and the patient agreed to think about them. We planned to continue our discussion of possible medications and lifestyle changes at future appointments. As I like to remind my patients, it doesn’t help anyone if I prescribe them medications they won’t take. I’d rather have an honest conversation about the medications I think would help them but only prescribe the medications the patient would like to try.
Primary care is proactive. In other words, the goal of primary care is to prevent the development of disease in the first place or, if a disease is present, to prevent its progression. Contrast primary care with the reactive approach of hospital medicine. The goal of hospital medicine is to treat disease that is unstable or so far along in its course that it can’t be safely managed outside of a hospital. We know we can help people live longer, healthier lives when they have good access to primary care. However, the challenge with primary care is that often the interventions it promotes don’t create visible changes in the present.
For example, people generally don’t feel any different if their cholesterol is high or low. However, we know that high cholesterol over time can lead to clogging of arteries which, in turn, can lead to heart attacks, strokes, and blockages in arteries that feed the legs (causing pain, poor healing, and tissue death). If a patient has high cholesterol and chooses to lower their cholesterol through diet, exercise, and (possibly) medications they are taking important action to prevent heart attack, stroke, and the other complications of clogged arteries. Yet, it can be hard for people to find the motivation to change their lifestyle and (possibly) take medications every day when those changes don’t change how they feel, and the health benefits are intangible (though very real).
I saw the patient who agreed to think about my medication recommendations many months later. They had lost weight and looked more muscular. They’d revamped their lifestyle – they started a balanced exercise program at least 3 days a week and minimized sugars and carbohydrates in their diet in favor of lean meats and vegetables.
“I’m ready to try the cholesterol-lowering medication,” the patient said, bringing up the topic before I did.
It was a complete transformation. “What motivated you to make all these changes?” I asked.
“I decided I want to live a long time still. I have things I want to do,” the patient said.
I found myself smiling long after the patient left. Many people struggle to make all the changes that this patient had to support their health. Yet, this patient had taken their health into their own hands. And, while I’ll never be able to say exactly how their actions changed the course of their life, every bit of research suggests these choices would shape the patient’s future. They’d lowered their probability of dying from heart disease or stroke. They’d lowered their risk of developing heart failure and diabetes. And such a positive transformation, though rare, is the dream of primary care.
Connecting the Dots 