From the Editor

How is health care changing?

To answer that question, we look this week not to a medical journal, but to The New Yorker. We consider an essay not on new drugs or imaging, but on the quiet rise of… primary care.

Primary care and the future

Dr. Atul Gawande writes a long essay on the virtues of primary care. Considering how medicine has shifted from acute care to chronic illness, he describes the importance of primary care, drawing on his own training and thinking – and the cardiac issues of his son.

Though this essay doesn’t directly consider mental illness, it is very relevant.


Care and Primary Care

“The Heroism of Incremental Care”

Atul Gawande

The New Yorker, 23 January 2017


By 2010, Bill Haynes had spent almost four decades under attack from the inside of his skull. He was fifty-seven years old, and he suffered from severe migraines that felt as if a drill were working behind his eyes, across his forehead, and down the back of his head and neck. They left him nauseated, causing him to vomit every half hour for up to eighteen hours. He’d spend a day and a half in bed, and then another day stumbling through sentences. The pain would gradually subside, but often not entirely. And after a few days a new attack would begin.

Haynes (I’ve changed his name, at his request) had his first migraine at the age of nineteen. It came on suddenly, while he was driving. He pulled over, opened the door, and threw up in someone’s yard. At first, the attacks were infrequent and lasted only a few hours. But by the time he was thirty, married, and working in construction management in London, where his family was from, they were coming weekly, usually on the weekends. A few years later, he began to get the attacks at work as well.

He saw all kinds of doctors—primary-care physicians, neurologists, psychiatrists—who told him what he already knew: he had chronic migraine headaches. And what little the doctors had to offer didn’t do him much good. Headaches rank among the most common reasons for doctor visits worldwide. A small number are due to secondary causes, such as a brain tumor, cerebral aneurysm, head injury, or infection. Most are tension headaches—diffuse, muscle-related head pain with a tightening, non-pulsating quality—that generally respond to analgesics, sleep, neck exercises, and time. Migraines afflict about ten per cent of people with headaches, but a much larger percentage of those who see doctors, because migraines are difficult to control.

Migraines are typically characterized by severe, disabling, recurrent attacks of pain confined to one side of the head, pulsating in quality and aggravated by routine physical activities. They can last for hours or days. Nausea and sensitivity to light or sound are common. They can be associated with an aura—visual distortions, sensory changes, or even speech and language disturbances that herald the onset of head pain.

Although the cause of migraines remains unknown, a number of treatments have been discovered that can either reduce their occurrence or alleviate them once they occur. Haynes tried them all.

Atul Gawande

So begins an essay in The New Yorker by surgeon Atul Gawande on primary care. The essay is enlivened by the story of Haynes, who struggles with migraines.

He notes the history of a health-care system that is focused on specialty care – and the limitations of this approach:

· “We have a certain heroic expectation of how medicine works. Following the Second World War, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heart, transplanted organs, and removed once inoperable tumors. Heart attacks could be stopped; cancers could be cured.”

· “A single generation experienced a transformation in the treatment of human illness as no generation had before.”

· “Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.”

Dr. Gawande considers his own training and a life-and-death moment:

[The patient] arrived in our emergency department in hemorrhagic shock. His pulse was rapid and thready. The team could barely detect a blood pressure. We rushed him to the operating room. By the time we got him on the table and under anesthesia, he was on the verge of cardiac arrest.

The resident opened the young man’s belly in two moves: with a knife he made a swift, decisive slash down the middle, through the skin, from the rib cage to below his umbilicus, then with open-jawed scissors pushed upward through the linea alba—the tough fibrous tendon that runs between the abdominal muscles—as if it were wrapping paper. A pool of blood burst out of him.

Working quickly, the resident and the attending surgeon saved the patient. The scene is dramatic but Dr. Gawande notes the evolution in his thinking on medicine – and his growing understanding of the importance of primary care.

He taps the literature.

· Studies show that “states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke.”

· “Other studies found that people with a primary-care physician as their usual source of care had lower subsequent five-year mortality rates than others, regardless of their initial health.”

· In the U.K.: “a ten-per-cent increase in the primary-care supply was shown to improve people’s health so much that you could add ten years to everyone’s life and still not match the benefit.”

· In Spain: heath reforms have focused on strengthening primary care and, “after ten years, mortality fell in the areas where the reforms were made, and it fell more in those areas which received the reforms earlier.”

“It doesn’t put great value on care that takes time to pay off.” In the end, he calls for recognizing the “heroism of the incremental.”

A few thoughts:

1. This is a good essay.

2. Dr. Gawande only makes passing mention of mental illness – but his consideration of chronic illness and the need for ongoing care naturally ties into mental illness, since so many of these disorders are chronic if episodic.

3. To focus more on mental health: a Canadian Journal of Psychiatry paper found that 84% of mental illness is treated by primary care clinicians. According to “Taking Stock,” a recent Health Quality Ontario report, 10% of physician visits are for mental health problems, with two thirds of those visits to family doctors.

4. The essay lends itself then to larger questions about the way mental health clinicians work. How much time do we spend helping primary care doctors and nurse practitioners? What are effective ways of doing this?

5. There are also implications for education. How much time do family doctors in training spend in mental health rotations? How much time to psychiatrists in training spend in primary care settings?

6. Of course, it’s important to recognize that progress has been made. Collaborative care is widely discussed and increasingly used. Training has significantly changed in recent years – at the University of Toronto, for example, residents spend part of their PGY5 year working in family medicine clinics. These are all steps in the right direction (though it’s difficult not to feel that there is greater enthusiasm south of the 49th parallel for collaborative care).

7. Remember: at the end of the day, there aren’t mental health patients and primary care patients, there are patients, and they are in need.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.