At The Forefront Live: Putting Primary Care First
July 31, 2019
The following is a paid program from UChicago Medicine.
Primary care doctors are very important in your medical care. They are the first physician a patient typically sees on a regular basis. Now, these are the doctors you get to know over years of treatments. These physicians know you and your family and provide basic diagnosis and treatment for a wide range of common illnesses, and some not so common illnesses. We'll talk to a couple of primary care physicians and discuss some of the treatments they offer. And we'll take your questions for the doctors. That's coming up now on, At the Forefront Live.
And today on At the Forefront Live, we have Dr. Solmaz Rahmani and Dr. Lisa Vinci joining us. Welcome to the program. We appreciate you being here.
We want to remind our viewers that this show is not designed to take the place of a visit with your physician. But please ask as many questions as possible because we want to ask these doctors, get their expertise on a wide variety of topics. And let's start off with each of you just kind of talking a little bit about yourselves and where you practice. And we'll start with you.
Sure. My name is Solmaz Rahmani. And I practice in Flossmoor, Illinois. I'm a part of Ingalls Memorial Hospital as well, and I'm a Family Medicine Physician.
Perfect. Dr. Vinci?
Hi, I'm Lisa Vinci. And I'm a Primary Care Doctor, General Internist here on the main campus of the University of Chicago. I practice mostly in the DCAM.
And we're going to start off with, it just sounds like kind of a general question, kind of a basic question, but what exactly is primary care? And if you could answer that us, that'd be great.
Would you like me to start?
So, in my opinion, a primary care physician really is your first go to physician. We do a lot of health promotion, disease prevention, patient education, and manage acute and chronic illnesses.
Dr. Vinci, I think to me, primary care physician, the relationship between the physician and the patient and the patient's family is very important. And I know, just from my personal experience, I've had the same primary care physician for a quarter of a century now. And it's nice to walk in and see that person and they know you. And you really do develop relationships with the people you treat, and that's important.
Absolutely. I mean, I think for primary care doctors, it's one of the greatest things about being a primary care doctor. I think it's so important to get to know people over time. Often, people will have problems that are not just simple diagnoses, but relate to stress in their jobs and their family and their family history. And primary care really allows you to get to know someone over the time course and really manage and help them with a multitude of different stages of life and questions that arise.
Now, Dr. Rahmani, why did you decide that you wanted to be a primary care physician? There's lots of different areas of medicine that you could go into, and you picked this.
Yes. I think what really drew me to this field was kind of what Dr. Vinci just touched on, you really are allotted to become family to the patient. You can pretty much see everyone from their child all the way to their grandmother, and really kind of distinguish any type of illness that comes your way, whether that us directing you to a specialist, or something that we can manage on our own. But it really allows you to see and treat every type of illness.
We want to remind our viewers, you can enter your questions in the comments section. We'll get to as many as possible, as we do the program over the next half hour. Now, what is the difference between internal medicine and family medicine?
I would say it's actually mostly based on age. General internists will take care of basically late adolescents, 17, 18 years old, up until elderly patients. And are very focused on a lot of chronic disease management, hypertension, diabetes, but also wellness, screening, vaccinations. But probably the largest distinction is age. And the training is different. As a general internist, I do not do obstetrics and I do not do pediatrics. But generally, there's a lot of overlap between internists and family medicine.
Dr. Rahmani, your thoughts?
Yes, I actually completely agree with her. It is basically an age distinction. And like she mentioned, family medicine does have training in pediatrics, as well as OB/GYN. We do tend to have a little bit of a heavier focus on women's health, as well, but I think that all depends on where you train. But that is the major distinction.
So, when you select a primary care physician and you see this person on a regular basis, I think there's always the question, what kind of frequency should you see your primary care physician? Obviously, if you don't feel well, if there's something wrong, but are there other visits that you should make with your primary care physician? And how often would you suggest that a person see their primary care physician?
I think the typical standard, are the typical expectations, when you're younger and healthier, from your early adulthood probably till your 40s or 50s, maybe once a year, every few years. It really depends on your concerns, your family history, how you're feeling. After the age of 50, it becomes increasingly important to see a primary care doctor yearly because many of the screening tests and vaccinations become more important and to sort keep up with mammograms and pap smears and colonoscopy, you need regular care.
But it's really individualized. Some patients see me two or three times a year because they want a lot of coaching, they need a lot of guidance, and they have a lot of questions. Other people see me, especially younger people, might see me every two or three years. Generally sort of think of, if you've seen the person within three years, you still sort of belong to them. If you call me when I haven't seen you in three or four years, I'm kind of not familiar and will often ask people to come in for a visit so we can catch up.
Now, Dr. Rahmani, you said you practice at the Ingalls location, is that correct?
And Ingalls is now part of the UChicago Medicine family. We're very excited to have everybody down there. Oh, there's some video of Ingalls right now.
Good job. Thanks, guys. But it's really neat because again, this kind of offers some care and some treatment a little bit farther south than what the campus here is located and to more people. And we're happy to have you guys on board.
Well, thank you. I appreciate it.
So, tell us a little bit about, from your standpoint, kind of the importance of being part of the UChicago Medicine family and what that means in your mind.
I think one of the largest benefits that has come our way has been to have the opportunity to have access to such specialized physicians. Especially with me doing pediatrics, we don't have a lot of that within the Ingalls system, unfortunately. But now, partnering with UChicago Medicine, we have the opportunity to work with several different types of specialists that are not available in our area. And we're able to give our patients better care that way.
We do have some questions coming in from viewers. And the first one is, if a patient wants to move to University of Chicago, how does my info transfer to you? I guess, patient records. Any thoughts on that from either one of you?
Yeah, it's actually-- more and more medical records systems are getting connected. So if you've got your previous care at an institution that uses the same medical record, we can actually see your medical records. If you went to say a smaller hospital or a hospital that doesn't use EPIC, which is our current EHR system for UCM, it's much harder and unfortunately, you have to try to bring in some paper records or a disc.
So, there are national efforts to try to consolidate medical records so that they can be viewed by different sites and different physicians. It's not there yet, but often one of the first things we do is, we can sort of send a query out to see if your previous records are available, and then can view them. Rarely is it all of the medical records, sometimes it's sort of bits and pieces from hospitalizations and emergency room visits. It's getting better, but it's still not optimal.
Yeah. So I can speak to this because Ingalls actually does not currently share the same EPIC EMR as UChicago Medicine does. So, a lot of the times we're asking for records to be faxed, and like Dr. Vinci stated, it is usually bits and pieces. So it is not totally encompassing everything. Although, we can get the important things.
Yeah. You know, one of the things that's kind of interesting-- and again, this is the future, but I do know that, here at UChicago Medicine, we're working towards this and as are other health care providers cross country, and part of that is having your medical records travel with you electronically. And it's getting closer and closer to reality, where you'll bring your phone in or whatever when you see your physician and be able to transfer those records. And be able to do that anywhere in the country. If you're vacationing somewhere, you can do that. Not quite there yet, but getting closer. We are getting more viewers for questions-- or questions from viewers, excuse me.
Here's one, how does a primary care doctor work with specialized doctors? And why is that important?
So, primary care doctors have a very close relationship with specialists. Anytime that there's something that comes about that we don't feel comfortable, or that it's out of our scope managing or it needs more specialized care, it is typically your primary care doctor that will refer you to the appropriate person that can help with that specific disease state.
Right, I agree. It really runs the gamut. Some specialists will then take over care of that problem, but some specialist-- I mean, if you are referred to an endocrinologist because of your difficult to manage diabetes, that person may help to get your diabetes under control, then send you back to your primary care doctor, who then manages your problem going forward, unless you need your endocrinologist again. In other situations, you may get referred to some specialists, who will then take care of you on an ongoing basis.
The EHR has really made this much easier. Now I can see anything that the specialist that I refer to record, recommend. I can double check it years later, if an issue comes up again. It's made the coordination between primary care doctors and specialists much easier.
I'm sorry, another viewer question about mental health screening, and wants to know if that comes under your stewardship. Not 100% sure what exactly is meant by the question, but I do know that mental health screening is certainly available.
I actually think we're typically the first people that patients will see in regards to their mental health. So that is something that frequently comes our way. Depending on what the situation is, I manage a lot of mental health illnesses, just within my own practice. And, when need be, do refer out to psychology and psychiatry. But, yes, I think it's something that we manage pretty frequently, in my opinion.
And Dr. Vinci, I would imagine when you see patients come in with you, and you see them over a period of time, you'll notice things, if maybe a patient is beginning to be stressed, depressed, that sort of thing. And could kind of make suggestions if necessary.
Yes, absolutely. Primary care doctors address a lot of behavioral health and emotional issues. We actually, in our clinic, actually do standard screening for everybody. So once a year, anybody who comes in for a visit gets a quick screen for depression. And we actually can push out screens for depression via the MyChart. If you're connected to a MyChart account, we can actually send you a screen. And if it's positive, can call people up. And really trying to make sure that everybody's mental health issues are increasingly recognized and addressed. Often people don't recognize them or don't want to come in and see the doctor with that as their first complaint. But it's increasingly understood that we need to always be aware of this, and actually screen people for it, and not assume they're going to call and make you an appointment.
Here's kind of a fun question, at least I think it's a fun question. We'll see if you guys think the same thing. What are some of the challenges you face in your day-to-day activities. I imagine that runs the gamut, probably.
Well, being a primary care physician, although it is a privilege to get to manage the patient in whole, it also can be rather cumbersome, addressing every single complaint that a patient may have and making sure that we take care of every complaint, just within that time allotted to us. So, I think that would be the largest barrier.
Time may be the biggest--
--it may be your biggest challenge.
Absolutely. Time is the biggest challenge. As patients get older, they get more and more concerned and chronic diseases and there's more screening recommendations and preventative health. But docs have some time constraints, it's typically 15 to 20 minutes for a return visit. So we all have to work on our system to be as efficient and as organized as possible.
I think one thing we haven't sort of figured out, that's going to become an increasing issue in the future that you see us trying to address is, how do you get people the care they need? Much of the care my patients need, they do not have to come in for a visit for. There are things we could do over email or over the phone or MyChart messages. And so how do you address this telehealth issue, so patients can get the care they need, and don't always have to come in for visits. But, how do you do that in sort of a reliable way that's really best high-quality care?
But I feel like, talking about social media, there's just so many ways I can get questions and concerns that come to me from patients. And the patients would really like to work on these things on an ongoing basis, and not always be limited to a primary care visit. So, I think that's going to be the next wave of health care is, how do you sort of provide continuous care, without being anchored to a scheduled visit every day. Sort of like the bank, right? You can do your baking online now, any time you want.
Yeah. You know, it's funny you bring that up because I do know that there is a committee or a group here that's working on exactly--
--what you're talking about. And as we move forward, I mean, that's the future. People are going to want to again pick up the phone.
They're going to want to be able to talk to their doctor and maybe do a FaceTime or something like that, Skype with their docs, and hey, look at this rash that I have. What do you think I need to do? And I think know we're moving into the future, and it's going to be exciting to see how it all works.
I think it will be exciting. A challenge, I think, that will definitely exist is, how do you reliably make a diagnosis or give information without actually physically being there and being able to examine the patient and see everything and speak to them the way that you'd like to speak to them? So I think it will be interesting to see where it goes.
Yeah, obviously, there will always have to be office visits. But it's just like we see on the show. You can ask questions, but there are certainly conditions that we're going to tell you to please go see your physician--
--and not just don't rely on something like this. So what are some of the basic conditions that primary care doctors treat?
I was just going to say.
All of the above.
Yeah, everything that you can think of, whether it be something as simple as an upper respiratory infection, allergies, diabetes, hypertension, high cholesterol, up to your dementia, I think it's all encompassing.
Asthma, knee pain, shoulder pain, fatigue.
Shortness of breath, dizziness. I think that the value of primary care is this diagnosis-- or one of the values of primary care is this diagnostic ability. I can see someone who has vague symptoms, say fatigue. The diagnosis-- the possible diagnoses that give you fatigue is probably 20 or 30 things, but with a good history, a good physical exam, a good social history and emotional history, and a couple lab tests, I can often arrive at a diagnosis in a way that if you try to figure out what some specialist you could go to, it would be very difficult. There's a lot of a broad very-- symptoms that can be caused by a lot of different things. Some, serious, some, less serious. And your primary care doctor can help you wade through that and rationally sort of approach a problem.
I also think that's where the importance of the relationship that you have with your patient comes in. Knowing who your patient is and how they typically present and look, I think that holds a lot of value.
I couldn't agree more. And this is just why I think the value of what you do, the two of you, is just so critical because once you develop that relationship, and you kind of know the person, and that's something that always made me feel really special. My physician knew me I'd walk in, and he would look at me and say, I can tell you gained weight or whatever.
That was usually good, but not the best, but he could tell things about me. And just from interaction over the years, and I think it made a difference. I mean, I think it really had a significant impact in my health.
So we've got some more questions from viewers. Here's one, does a University of Chicago offer a service to help refer a new patient to connect with a new UC doctor? So I think the short answer is, yes. I don't know if you know more detail about that, but maybe you could--
We do both. We have two different phone numbers. One, and they-- they're both like use-- One, I think, is Ingalls Connect.
And the University of Chicago, the original academic medical centers is, I think, UCM Connect.
Yeah, we have a name and number we can up on the screen.
Yeah, can we put those up? And they're basically phone numbers that anybody can call, and they will help navigate you to tests, specialists. They can answer questions.
They can schedule appointments. Our docs, actually, sometimes use them to sort of figure out who they can see. Who's available? Who specializes in what area? And it's in--
And the website as well. You can also jump on the website. You can look at physician bios. You can lean about the different docs, and you can make appointments and that sort of thing through the website as well.
So there are various avenues to try to get you to one of our fine physicians. Another viewer question, how should I prepare for a first visit with the doctor? And should I be prepared for-- how should I be prepared for any visit with my primary care doctor? Are there things you should do in the lead up to that first visit?
I think first off, would be to have any medical records that you have available to bring them with you. And other than that, just come prepared with your questions. I mean, other than that--
And be honest with your physician.
Yeah, and be honest. And I also think it's really helpful to have family history. Often, people will have a vague idea of what happened, but if you can dig in a bit to family history, that can be helpful, sort of to know especially, your parents and grandparents.
Be open, be honest. And I think the value of primary care builds over time. Sometimes, that first visit does not answer all the questions and problems and does not get absolutely every preventive health measure done, but over time you and your doctor can partner to improve your health.
Also bring your medications that you're currently taking.
We're going to keep thinking of more stuff as this goes on.
We'll keep adding to it throughout the show. I am curious. So we hear from people all the time that oh, I looked this up on the internet, or I read this on the internet. Does it drive you crazy?
It can be slightly frustrating at times because, as Dr. Vinci touched on earlier, one symptom can be a plethora of different diagnoses. The differential diagnosis for a symptom is very wide, and that's what we're here for. We're here to try and narrow that and figure out exactly what the core of the problem is. So it can be frustrating although, I do appreciate an educated patient at the same time.
Yes, yes, yes, my feelings about the internet and looking up symptoms on the internet have changed. I actually think it's great. Like, I love when my patients tell me, I worry that I have diabetes, so I went and read all about diabetes on the internet. That is actually reassuring that here's a person who's going to try to figure things out and learn.
I think it is really tricky for some diagnoses, and it's really tricky about what websites. I mean, sometimes will you have a minor symptom, and some website will lead you to the frightening possibilities. And you have to-- it is hard for patients to sort of decide or pick out sometimes what's reasonable information that they can rely on.
One rule of thumb is look on the Mayo website. Look at the University of Chicago website. We have all kinds of videos. Look on reliable large health system websites for reliable information. But I got to say, I Google stuff for my kids and my family all the time.
I sort of look stuff up when tests come back, and I'm not sure why they were done for my kids.
And why I asked that, and this kind of leads me to my question. Immunizations, there is a lot of stuff online and a lot of controversy surrounding immunizations when I don't think there should be, but there is. Why are immunizations important, in your mind?
You're the pediatrician.
Well, immunizations are important for a lot of different reasons, but most importantly, it's to help eradicate disease. Things that used to be very, very detrimental to society such as smallpox-- or now the big topic is measles. That's been coming up more recently-- is eradicated by immunization, or at least it provides herd immunity. So it's very important to try and get the entire society and public on with getting all of their immunizations on time so we can decrease the prevalence of all of these detrimental diseases.
And this is an area where you probably shouldn't read the internet too much.
We also-- they're also important to help disease to progressing to something more fatal such as the flu shot or the pneumonia vaccine, so.
Can we talk a little bit about HPV vaccinations because that's something we hear a lot more about? And it used to be, I think, it was for four pediatric patients, primarily, but it's extended a little bit, hasn't it?
Yes, so the HPV vaccine, which is the Human Papilloma Virus, has now been approved to be given, I believe the start age is 9, and I believe the end age is now 45 if I'm not mistaken. So I start to recommend it to most of my adolescent patients when they come in for their 11-year-old vaccines, 11 to 12-year-old vaccines. I try to have an informed conversation with the patient, as well as the parent, get all of their questions answered in regard to it because I know there's a lot of controversy in regards to it. So it is something that we're recommending at this time.
Let's talk about vaccinations for older folks because I think, again, we've heard a lot about measles lately. Do older people need-- do older folks need boosters? What should people be aware of?
Oh, boy. This is a--
This is a hot topic. Thing about older people, the vaccines that are recommended are pneumonia shots, and there's two of those. Tetanus, pertussis diphtheria, which is one shot which is recommended every 10 years or once every 10 as you get older. Influenza every year. I mentioned shingles. What else? Pneumonia, influenza.
We hit the major ones.
Shingles has been a big deal. There is a new shingles vaccine came out about a year ago, and it's now recommended for everybody over the age of 50. And there's been a shortage of the shingles vaccine. So some people are still trying to sort of catch up and get those shingles vaccines.
But the thing about vaccines, as you get older, your risk of pneumonia goes up. Your risk of shingles goes up. Your risk of if you get pertussis from-- a young, healthy adult, if they get pertussis, they'll have a cough for a couple of weeks and probably be fine, but an elderly patient who's getting more frail gets pertussis, it's life threatening
So vaccines just do-- they help both you, but they help your family also. If you have young children, you should get a pertussis vaccine to prevent you from possibly getting pertussis and giving it to a baby that you were taking care of or around. So vaccines help you as an individual reduce the risk of illness, but they also help your family, your neighbors, if you're a health care worker and taking care of patients.
It reduces your risk that you will transmit something to patients. So they just become-- people ask me if I get my flu shot? I'm like, I have gotten my flu shot every year since I was a medical student--
You have to.
--without fail. And it doesn't even faze me. We walk around the clinics just with the residents, we just walk on the kinds of vaccines and just give them to them as you're walking through the hallway in the hospital. In flu season, you literally just have to stop at a desk, and someone will give you a flu shot.
So let's discuss measles just for a minute.
Oh, measles, right.
Because it's been the news quite a bit. Do people need to be worried about that? Do they need to do anything? I mean, obviously vaccinate your children, but beyond that?
I have had several adult patients come in and ask if I could measure their immunity levels to measles? And I have done that. Some of them are immune, and that provides some peace of mind. And when they're not, that's another conversation. But yeah, it is a hot topic.
The measles outbreaks, we are tracking them very closely. If there is an outbreak in Chicago, there is resource to vaccinate very quickly anybody who could be exposed to that patient or goes to school with that patient. There is no recommendation currently to try to revaccinate everybody.
Just personally, I remember I was in that group that didn't-- receive the old measles vaccine that didn't work.
I told my mother. I'm like, mom, didn't you realize the vaccine did work? She didn't. And I was revaccinated probably 15 or 20 years ago. So the fact that there this measles vaccine that didn't work very well or hadn't been stored in a period of time, that's been known for a long time. Most health care workers have been revaccinated.
There still are patients-- there are still people, though, in the general public who have not been revaccinated. But there will always be this option to re vaccinate everybody, but right now, there is not a huge-- I do revaccinate people who are concerned about a risk. They work at a college, and the outbreaks have often been around schools.
They travel a lot. I mean, we kind of vaccinate now. If you want to be vaccinated and you're worried about something, as long as it's not like an unusual vaccine, I mean, there's a lot of vaccination that goes on, especially amongst people who travel. There's a lot of recommended travel vaccines.
And the final thing, get your flu vaccination.
Get your flu vaccination.
You said it a second ago, and people-- Oh, I get sick from it-- you don't.
And get it anywhere. I mean, people come to the hospital, and they make an appointment. And I say, we're just giving the same flu shot Walgreen's is giving. So just get it.
Yeah, very, very important. We're out of time. That 30 minutes went by pretty quickly.
It went by fast.
You guys were fantastic. That's all the time we have with this program. Thank you for being on the show, and thank you for your wonderful questions. If you want more information about some of the stuff you saw and heard today, please visit our website uchicagomedicine.org, or you can call 800-824-0200. Thanks for watching. Have a great week.
This was a paid program from you UChicago Medicine.