Episode 2: Family Medicine – Your Personal Healthcare Advocate

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Episode Summary:

A primary care doctor is a critical partner, and a gateway, to a healthy guy’s life at all ages. Learn how and when to access the health care system, and start building your health care map for life.

Episode Guest:

Paul James, M.D., Professor, and Chair of Family Medicine, University of Washington School of Medicine.

During This Episode We Discuss:

  • What a Family Medicine physician can bring to your care.
  • The importance of having a personal advocate, your family physician to anchor your care.
  • When to start goals, milestones of care for physical, emotional, and mental health.
  • How to choose a family physician.
  • How to get the most out of your appointment.

Quotes (Tweetables):

“A distinguishing characteristic of what family doctors do is attempt to take care of you as an individual in the context of you as a social organism within a larger social unit. So, in the context of your work, in the context of your play, and in the context of your passions, what you care most deeply about.”

Paul James, M.D.

Recommended Resources:

Episode Transcript: 

Dr. Pelman (00:06):

A baseball game, a day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health is presented by the Washington State Urology Society to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body? After all, it makes better sense to retire healthy and enjoy your future. If you take care of your car and maintain it, why not do the same for your personal machine, your body? If you know you should but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast as we explore men’s health with renowned experts and embark on a journey towards better health. Family medicine is for everyone, whether you’re single or have a family, whether you’re healthy or unhealthy. Today, we interview the chair of family medicine at the University of Washington, Dr. Paul James.

Dr. Pelman (01:56):

Welcome to today’s episode of the Original Guide to Men’s Health. Today, we’re going to review choosing a family physician and we’re fortunate to be interviewing Dr. Paul James. Dr. James is the chair of family medicine at the University of Washington, previously serving as the chair of family medicine at the University of Iowa. Dr. James is an active clinician, educator and researcher, and he has held notable positions in leadership in many key national organizations. It’s a pleasure to have to Dr. James review with us family medicine, choosing a primary care provider, and helping us look at why you should. Dr. James, thank you for joining us. 

Dr. James (02:36):

Thank you, Dr. Pelman. 

Dr. Pelman (02:37):

I think most folks wonder what is the difference between a family doc primary care physician versus an internal medicine rimary care physician? And what do they need?

Dr. James (02:48):

So first of all, they are both excellent sources of primary care. There are a few differences. Predominantly, family physicians are trained to take care of the majority of your healthcare needs, which would include things like your mental health concerns. So things like depression, anxiety, or concerns about memory loss. They also may take care of more musculoskeletal* problems. So sports medicine injuries, musculoskeletal, things such as that, or even trauma. So if you cut yourself, the family doctor usually is well-trained to sew up the laceration or look at a broken bone. An internist is going to be more focused on internal problems, like chronic diseases and things such as that. But general internists may actually be also very well-trained in mental health care issues and dermatology issues. So what I find is it usually is dependent on the unique training that a specific doctor has and their interests.

*Musculoskeletal: https://my.clevelandclinic.org/health/articles/12254-musculoskeletal-system-normal-structure–function#:~:text=Your%20musculoskeletal%20system%20includes%20bones,problems%20with%20movement%20and%20function

Dr. Pelman  (03:55):

I think growing up, we had a family doc and took care of my brother, myself, my parents. And we went there because they’re my parents’ doctors. People wonder, “Well, do you have to actually have a family to join into a family practice and a family physician?” You could take a young adolescent person and have them come into your practice. Correct?

Dr. James (04:15):

That’s true. Most of the time we are taking care of individuals. So, hopefully no one is going through life without some sort of family. And we now define families in a much broader way than the traditional sense of a mother and father and brothers and sisters. We all have communities that we, that are supportive for us. And so I would say that the, perhaps a distinguishing characteristic of what family doctors do is attempt to take care of you as an individual in the context of you as a social organism within a larger social unit. So in the context of your work and the context of your play and in the context of your passions, what you care most deeply about.

Dr. Pelman (05:01):

I think the model of family physician has resonated with people because some people grow up with their family doc, and then the family doc takes care of their family. And primary care physicians have seen multiple generations. 

Dr. James (05:17):

Yes. And that’s particularly true in rural communities where many of us deliver babies, and we’ll do women’s health care. And not only do you deliver babies, but you also are helping grandparents transition into later life stages that are equally important to the health of the family. 

Dr. Pelman (05:38):

So a full spectrum of care.

Dr. James (05:41):

Yes

Dr. Pelman (05:41):

Have you seen the primary care physician relationship change as far as the ability to do what primary care had historically done? I mean, if I think back 50 years ago, surgery, obstetrics that you mentioned, subspecialty areas, now at least here in a urban area with all the specialty around, how does primary care still deliver what they need to? 

Dr. James (06:12):

That’s a great question, Dr. Pellman. One of the major changes that has occurred in primary care over the last few years is that primary care is now predominantly delivered in teams. And it is the whole team within the office, which could include the medical office, assistant the nurse. It may include physicians assistants or nurse practitioners in addition to the doctor who are working oftentimes in a coordinated fashion to ensure your health. Ideally, you would come in for an annual wellness visit, for example. And at that visit, there would be an identification of opportunities to improve your health. And so other members of the healthcare team, in addition to those that I’ve just mentioned, could include a pharmacist. They could include physical therapists. They also could include a behavioral health specialist, which is someone like a psychologist. All of these are members of a new primary healthcare team.

Dr. James (07:09):

And the goal is that together, they can deliver even better care than the single family doctor of the past. I do think it’s a challenge today with large hospital systems. It’s more difficult for your primary care doctor or family doctor to take care of you in the hospital. But we do have opportunities to improve communication not only between the hospital and your doctor’s office, but with the multitude of great specialists that we have within our healthcare system today. So one of the wonderful opportunities we have is to make sure that we are getting the best communication between your primary care doctor and your specialists, and for them to communicate in effective ways that ensure that we’re delivering the best care for you as a patient.

Dr. Pelman (08:00):

I see the primary care physician as a anchor. The specialist may be a one time or two time encounter. Patients then have their family doc primary care physician to come back to is kind of the anchor for their care. And while they might go out to have a particular need met through a specialty, they’re always going to come back to seek your opinion.

Dr. James (08:24):

I do think that’s one of the joys of why many of us chose the primary care specialties. Because there is a desire to have a relationship and to get to know you as a patient, and to understand what your values are and what your goals are for your health. One of the ways of defining a family doctor is that we are the doctors that specialize in you. And our goal is to learn as much about you, as an individual, as we can so that we can help guide your healthcare decisions to better understand, for example, who may be the best specialist for your needs and the goals that you have, and to then be your advocate within the healthcare system. 

Dr. Pelman (09:08):

And I think that’s what I truly love about primary care is you are my advocate. If I’m seeing you in the context of my parents brought me in, you’re still my advocate. When I grow up, you’re my advocate, and you know me. And I’m the person who’s getting the care, but you’re the person that I trust for an opinion. 

Dr. James (09:27):

Yes, I think that’s absolutely true. 

Dr. Pelman (09:30):

Now, when you look at individuals, what would you prescribe, if you could, as a care plan for when you would want to start seeing a young individual or an older individual? When should they enter into healthcare?

Dr. James (09:45):

So, there are stages in one’s life. For, for young adults, so for example, for young men in their twenties, we like to assess your cardiovascular risk. So that would be a visit sometime in your early twenties to have your cholesterol checked. At that time, we would have discussions about appropriate nutrition, diet, and exercise. We would talk about weight. One of my favorite things to discuss with someone in their early twenties is to ask them the question. Let’s say you only gained three pounds for the next 30 years. So you’re 25, you’re going to be 65, and you only gained three pounds. That’s not much, but by the time you’re 65, that 180 pound person is now 280 because that’s 90 pounds of additional weight gain. And so we have discussions about the importance of monitoring portion size and being attentive to the fact that we’re not getting taller anymore.

Dr. James (10:53):

And we need to look at our at healthy lifestyles. In our thirties, we continue those discussions. And we also talk about the importance of building good social relationship, healthy relationships. I often say to young men, “Be sure that you tell the people that love you, that you love them and look after them throughout their life.” Because those relationships are the ones that are going to be important to you as you get older. In your forties, cardiovascular health becomes more important, especially concerns about blood pressure and cholesterol. We also then begin to ask about your family history and cancers. And specifically whether we need to start screening for any cancers earlier. Most of the cancers we began to think about screening are at age 50. So for men, one of the discussions that’s really important to have with your primary care doctor is about, for example, prostate cancer screening*. It is a controversial area, but it’s an area that I think it’s important to talk about and consider testing for, especially if you’re in a high risk group, or if it’s in your family history.

*Prostate cancer screening: https://www.cdc.gov/cancer/prostate/basic_info/screening.htm 

Dr. Pelman (12:02):

What about a adolescent male who may not have a pediatrician who is wondering about sexual health issues? How would they go about getting an appointment as a teenager?

Dr. James (12:16):

Yes. So it’s important that they know that if they come to a primary care doctor with questions about sexual health, first of all, all of that visit and healthcare information is private. And it’s not shared even with parents of a younger adolescent, because issues regarding sexual health or potential family violence, or even mental health concerns, are protected health information. And they should feel comfortable that they are going to be protected by the doctor in asking the important questions that need to be asked. Your question also highlights for me that is one of the areas that I forgot to talk about, which was sexual health. And so we oftentimes will do screening for things such as sexually transmitted illnesses throughout young adulthood to ensure that that someone is maintaining health. And we also spend significant time discussing safe sexual practices. 

Dr. Pelman (13:18):

So if a teenager picks up the phone calls, a primary care office and they of course say, “Well, what are your needs? And how old are you?” They’re not going to be told, “Well, you can’t come without a parent.”

Dr. James (13:29): 

That’s correct. 

Dr. Pelman (13:30):

They’d be able to make the appointment. They’d have to figure out some means of coverage. 

Dr. James (13:36): 

Yes. 

Dr. Pelman (13:37):

But still, they’re able to come on their own. So it shouldn’t dissuade them from the potential of making an appointment. 

Dr. James (13:42): 

That’s absolutely true.

Dr. Pelman (13:44):

 And the relationship would then continue as that person ages, and they’ve entered into the healthcare system. When would you like to first see somebody?

Dr. James (13:53):

Well, I think anyone who has questions about some symptoms that they’re having that are not explainable. Or, if they have questions about how they can maximize their health. I think that’s a good time to come see your physician. There’s not a right age. So as young as 18, or being a teenager when you have questions such as this. I’m not sure there is a bad time to come see your primary care physician.

Dr. Pelman (14:25):

And then usual young, healthy person. What would be a care plan for frequency of visits? I mean, is that a yearly or?

Dr. James (14:33):

So if someone is doing well and is healthy, and the doctor has not identified any health risk, between the 20 and 30 range every few years. So three years is perfectly fine. If there is a health concern, like a question about your blood pressure, then the physician will likely ask to have you be seen more frequently.

Dr. Pelman (14:58):

So as needs come up. Sports injuries or pains or colds or something that is worrisome to somebody, they would then make the appointment then. But just routine would be a interval, if they’re healthy, of a few years at that point. 

Dr. James (15:12):

Yes. And so I will say that this is a really great question to ask your doctor when you’re at your visit. What would they recommend? Because they’re going to be able to give a much better answer to that question based on your personal health history and your physical exam.

Dr. Pelman (15:30):

So you just set up the next important topic is how to find a family doc, and how to get the most out of the visit. How to come prepared?

Dr. James (15:39):

So in today’s world, I think central to this question is who will your insurance pay for? I think we’re all concerned about the cost of healthcare. And so I think I would first begin by asking your insurance provider who are the doctors that are within their plan. Because those are likely to be less expensive for you as an individual. Understanding that, the things I would look for aare they a board certified family physician? So in family medicine, those would be certified by the American Board of Family Medicine*. Other things to look for though are offices that are affiliated with health systems that you may trust. So for example, here at the University of Washington, we’re part of UW medicine. And I think many people may choose to go to a family doctor that is affiliated with a hospital or health system that they trust. Other important contributors are how accessible are they. An office where you can be seen at a time that’s convenient for you, and it’s reasonable for you is an important consideration. And I don’t discount at all the importance of asking family and friends about doctors that they have seen, that they trust, and have found to be good.

*American Board of Family Medicine: https://www.theabfm.org/ 

Dr. Pelman (17:05):

Now if I’m making my first appointment with family physician, is there something I should do as a patient to get the most out of the visit? How should I come prepare it? What should I be ready to ask? Or what material would you need to know about?

Dr. James (17:20):

Most of us now we’ll send you a questionnaire before your visit, and this is intended to help organize your thoughts about your own personal health. So most of us then we’ll have questions about your diet and your exercise, your family history, your medical history. So what surgeries have you had? What operations? What medications do you take? And in addition to medications, if you other things such as supplements, your doctor would want to know those things. And so to have all of those things written out would be extremely helpful. Other things that we’ll ask about are your exercise habits, your smoking habits, your drinking habits. We’re concerned about substance abuse. And it’s a real hidden issue that we think we might not have a health problem, but based on some very clear guidelines, we can help people identify if they are at risk, for example, of an alcohol abuse disorder or concerns about smoking. For example, smoking is still a significant health threat in our society. And our job is to help patients identify the best strategy for them that can help them achieve the health goals that they would like. While we may think there are reasons why it is beneficial to us, one of our tasks is to help people identify strategies to say, “Hm, maybe I didn’t need that as much as I thought I did.” 

Dr. Pelman (18:52):

The smoking. 

Dr. James (18:53):

Yes. 

Dr. Pelman (18:55):

I like to have patients at least have list because if it’s something that they may be embarrassed about, they may be waiting for the physician to ask. And the physician just doesn’t hit on it. They may not bring it up, and leave without getting that pertinent question to answer.

Dr. James (19:12):

That’s a really important point. And many times the visits may be compressed because the doctor is being expected to then go to their next patient. So having your questions written out, and I would say, then prioritizing your top two questions, is really, really important because the doctor may not have time to get down to questions number eight and nine if you have a long list. So I would really emphasize the importance of prioritizing your questions and making sure that you get to those top two.

Dr. Pelman (19:47):

I always appreciate patients who understand that there is a visit time. I mean, we can’t go all day or we wouldn’t see anybody else. But say, “Can I make another appointment to follow up on this?” And that’s perfectly legitimate, is yes. So let’s set another time slot. Maybe that will be a longer time slot once we know what the issue is. It’s very fair to come back.

Dr. James (20:08):

Absolutely. And that is an important element that many excellent primary care doctors do. The first few minutes should be about agenda setting. And at the very beginning of the visit, many times I’ll have to say to a patient, “Well, you know, we’re going to have to save those things for a later visit. Let’s address this important thing today.” And I think that’s the hallmark of good physicians. Is they’re clear about what we can expect during this visit today.

Dr. Pelman (20:39):

And then referring back to concerns, say smoking, we now have strategies that work very well for issues of smoking sensation, addictions, depression. It’s really an emphasis now on making certain that we’ve covered these topics, but the patients seem to make us aware of them. And then there are strategies for dealing with them.

Dr. James (21:01):

That’s absolutely true. And that’s why it’s important that today’s primary care offices have some of these support personnel, such as the psychologist that can immediately provide strategies for patients to begin to change their health behaviors. None of us are perfect at living our healthiest lifestyles. And yet, we do find that all of us have opportunities to do a little bit better if given the right encouragement and the right strategies. And I think that’s an important role of your primary care doctor.

Dr. Pelman (21:40):

Again, the difference between a practice that’s here in an urban population versus being out in a rural population where the primary care doctor may be the only health practitioner for miles around. We’re going to see a difference there.

Dr. James (21:53):

There will be, although many family physicians are well-trained in behavioral health strategies. And they also have access to some community support services. They may be at the local rural hospital. They may be affiliated with organizations within their community. And I think many family doctors have learned that they need to identify those resources for their patients. But you’re right. The best way, though, to have them addressed is to bring them up with your doctor.

Dr. Pelman (22:23):

With your experience of rural medicine and broader practice, what are some of the key things that happen in a rural population? Is it surgery? Or deliveries? Pediatric care? What other?

Dr. James (22:39):

So in a rural practice, because you’re the only doctor in the community you’re taking care of everyone. And that means newborns and mothers who are pregnant and GYN, gynecologic care. As well as elder care and taking care of patients in nursing homes, or even making home visits, which are a very rare thing in urban settings. Maybe more frequent in rural communities. And I think in part though, that also helps you in some ways to get better care because the doctor tends to not just know you from your visit, but they may know you from taking care of your mother or your spouse or your children. And there’s a certain joy that comes with that even for the doctor. 

Dr. Pelman (23:25):

Yeah. I think that connection with the whole family and understanding their environment, where they’re living, certainly has changed over time. But I think it’s the essence of taking care of people. Well, if we wanted to then look at primary care physician…

Dr. James (23:41):

Dr. Pelman. It’s important to remember that in rural communities, also, the family is also taking care of the patient in the hospital, Likely delivering the babies in the hospital, in the nursing home, and actually even doing in the emergency department. That’s a stark difference than what we have available today in our urban environments

Dr. Pelman (24:03):

And in the urban environment, the primary care physicians used to go to take care of people in the hospital. But it wasn’t very efficient for them. They had to leave the office, travel, go back. And so in our current situation, at least in an urban environment, we now have hospitalists.

Dr. James (24:21):

Yes. And so it has been more efficient from many different perspectives, especially from the hospital perspective, to have a physician that’s available all the time in the hospital who doesn’t have to run out quickly and go back to their office. These larger health systems today I think are doing better jobs at communicating between the hospitalist and the primary care physician. That still remains an opportunity, though, to improve communication. There are actually studies under that are being done by actually internist, looking at the role of having a primary care doctor assist with the hospitalist in the hospital. And there are opportunities possibly for doing that even by telephone, where you can still have the benefits of having your doctor involved in care. And I think that’s an area for future research and

Dr. Pelman (25:20):

Telehealth and telemedicine.*

*Telehealth and telemedicine: https://www.aafp.org/news/media-center/kits/telemedicine-and-telehealth.html 

Dr. James  (25:23):

Yes, absolutely. So telehealth is a strategy for actually even getting your care at home, but also then to improve communication across our specialty care environments and within the hospital.

Dr. Pelman (25:38):

If we were to design a perfect delivery system, what would you like to see as part of the most efficient and patient-accepted care team?

Dr. James (25:49):

Yes. I think the most efficient and effective one is one that is accessible, easily accessible for patients that delivers care to them when they need it at the right time, at the right place, and with high quality. In order to do that, we have to create an efficient and effective primary care system that is not a gatekeeper, but a gate opener to the high tech, highly skilled specialists that our healthcare system has, but ensuring that patients are getting to the right doctor at the right time. One of the challenges is if a patient doesn’t have their primary care physician as their quarterback, and they’re seeing a subspecialist who takes care of one very focused area of care, they may bring up concerns about other things. And that doctor is not as focused on those areas. There’s a tendency to think, “Oh, but this is a doctor. They will know everything about this.” And I think it’s important for patients to know that they need to come back to their primary care doctor when they have unanswered questions to just, again, look with fresh eyes and make sure that they’re getting the right care at the right time at the right place. That’s probably what I would recommend. 

Dr. Pelman (27:23):

I will ask you just for one last piece of information. Many patients come in and they’ll encounter a physician assistant or a nurse practitioner. And how has primary care incorporated the, we call them physician extenders but these are practitioners who are really linked to the practice, how have you incorporated them into the practice of medicine?

Dr. James (27:45):

Yes, they are. I think ideal members of the primary health care team, Many patients may actually have a physician assistant or a nurse practitioner as their primary continuity provider. I do think in the ideal setting of primary care, it is optimal if they are working with well-trained physicians so that we are taking advantage of the full resources of the primary care environment.

Dr. Pelman (28:19):

So in summation, the bulletproof young man who has nothing wrong, he says, “Why do I need a doctor?” Your advice would be?

Dr. James (28:29):

Exercise, eat healthily, come in and see your family doctor to get your cholesterol checked and your blood pressure checked. So for, for that young, healthy guy who says, “I’m invincible.” I would caution that we don’t always know how invincible we are, and you may be overweight and not know it. Your blood pressure may be up. That is the silent killer. Your cholesterol may be high. For those reasons, I do think at some point in your twenties, you need to see your primary care physician, and they need to do a thorough assessment of your health risk. In that way, we can assure that you can achieve your life goals by avoiding premature death and disability, by achieving your goals of being the best person you can be, and living a long and healthy life.

Dr. Pelman (29:31):

Well, Dr. James, thank you. We truly appreciate your taking the opportunity to give us some perspective of having a primary care physician and family. Thank you very much. 

Dr. James (29:43):

Thank you, Dr. Pelman.

Dr. Pelman (29:46):

This completes another podcast chapter of the Washington State Urology Society’s Original Guide To Men’s Health. This is Dr. Richard Pelman reminding you to take care of yourself. Washington State Urology Society wishes to thank all contributors who volunteered their time and knowledge. The information presented is the opinion of the speakers. The society also wishes to think Shawn Fox for his invaluable technical assistance, music theme, San Juan Bell’s, written and performed by Dr. Dave Whiting. The podcasts are the property of the Washington State Urology Society. Reproduction and use without the express consent of the society is strictly prohibited. For more information about men’s health visit wsus.org, or visit your physician or care provider.

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