Steven H Miles, MD
For the first part of my medical career, I worked in intensive care units, hospitals, clinics, and nursing homes. Every morning I got a note telling me which of my patients were hospitalized. I was expected to see them. I made house calls to families in crisis (although this was being suppressed and so I did this off duty). When families or patients were frightened, usually by medical instability or the imminence of death, I wrote my phone number on my business card and gave it to them. (Many colleagues assured me I would be abused by this practice; I never was.)
My territory was gradually constricted. Intensivists took over the ICUs. I could visit, perhaps write a consult note but was not to meddle. Hospices took their slice. I was allowed to see my hospitalized clinic patients as a courtesy. Nursing home patients disappeared.
For the last decade of my career, I was a hospitalist teaching residents Internal Medicine. I tried to encourage them to the probing conversations of psychiatry, the subtle intimacy of hospice care, the extraordinary relationships of caring for individuals for years (although not decades, since I focused on people over 80 or 85).
One by one, many residents were seduced by the high-technology drama of emergency medicine or critical care specialties. It is exhilarating to pull a person back from the brink of death but, it is draining as a steady diet. The adrenalin and post-adrenalin, might-have-beens, grief, flashbacks are all part of it. I burned out twice. Sometimes I would ask such residents, “Do you really want to be wearing athletic shoes at work when you are in your forties?” The young do not see their future selves very clearly. For all its intensity, rescuing a life is mostly a superficial and short-term relationship. The survivors are passed to rehabilitation and from there back to primary care.
Studies show that the United States has the most specialty centered health care system on the planet. This low “primary care orientation” is part of how the coronavirus could invisibly incubate among the dispossessed in nursing homes and prisons and in shelters. It was easy for New York to simply conceal 8,000 nursing home deaths (other states did the same in their prisons, nursing homes and welfare clinics). Such administrative disappearances were facilitated by the fact that these persons were not personally known by primary care providers.
Public health is the outcome of a primary care healthcare system.
Miracles are the individual outcomes of a specialty intensive care centered healthcare system.
Now we are in a pandemic, a crucible into which we have poured all those critical care physicians. The media endlessly trumpet the burnout of ICU staff, the tidal wave of hospital and ventilator patients. Health official properly bullhorn, “Get vaccinated!”
A viral pandemic was inevitable. Omicron and future Pi, Rho, Sigma and Tau variants are easily foreseeable as well. We cannot confront a pandemic from ICUs. Bullhorns are no substitute for conversations with a time-tested and trusted clinician. To address a public health crisis, we must have a primary care system that is built on personal relationships.
I can’t help but believe that if our healthcare system had properly valued primary care and nurtured the human dialogues that can grow in such long-term relationships, that we would have higher vaccination rates (and therefore a lower demand for hospitals) and a more appropriate use of hospices, palliative care, home care over the use of ICUs for those who refused them. I would like to believe that those same relationships would not have allowed tens of thousands of marginalized persons to invisibly die while this virus infiltrated broadly among us.
Steven H Miles is Professor Emeritus of Internal Medicine and Bioethics at University of Minnesota.