Shadowing Experience: Dr. Jennifer Jeremiah, Primary Care Internal Medicine

Dr. Jeremiah is a part of University Health Foundation, a group of physicians associated with RIH. She has responsibilities both as a clinician in the UHF office, as well as a ward attending and as someone involved in the internal medicine residency program.

I stayed with Dr. Jeremiah from 10:30 AM to 1:30 PM. We saw six patients, all women, mostly elderly. They varied across race, education, class, and age; the visits were approximately all 15 minutes long. Dr. Jeremiah said that she felt rushed a lot of times because of the need to be reimbursed by fee-for-service payment, and that it forced her to budget her time with each patient. I noticed the way in which she talked with patients, professionally and with an objective in mind (trying to be efficient with time), but allowing them time to talk about their issues and always asking if they had any questions for her. Dr. Jeremiah seemed like a wonderful PCP: caring, kind, and able to pick up on subtle cues and put them in context of patient history.

I was really impressed by the familiarity with which she addressed the patients. You don’t have to be a “country doctor” to have healthy, long-term relationships with your patients. Some of these people she’s known for 15 years! She said she was able to understand their situation, which allowed her to better assess their queries and complaints; for example, an old woman who enjoyed being miserable and making her daughter feel guilty, a man in a wheelchair who liked to argue with his case manager, which you wouldn’t be able to pick up on if you had just gotten to know a patient. She said that this allows her to understand if their complaints are serious, she can tell when they look sick and when they look healthy, and to understand their history and what their baseline health is—so one woman who had terrible lab results was actually doing well because she had eight chronic conditions, and she knew that because of the history. I felt that these long-term relationships were really valuable to creating trust. For instance, the patients trusted me, an undergrad, to be there because Dr. Jeremiah was there, too.

Trust is important for honesty, as when one patient said that she couldn’t afford her Advair even though she was on Lipitor. PCPs are often the ones to break bad news like new diagnoses, cancer, etc. They are in it for the long run with the patient. They refer patients to specialists, get the information back, and then discuss the results with the patients. If the problem develops further, they send the patient to see the specialist for that reason. A PCP is a coordinator, and has to know a little bit about a lot, whereas a specialist has to know a lot about relatively little. But even though the specialist may ultimately “solve the problem” a PCP is the one who facilitates that meeting in the first place. There's a lot of potential for the PCP to become a powerful coordinator of a patient's health...if reimbursement and legislative issues can be addressed.

Dr. Jeremiah said that cost is a huge issue, and she tries to do everything they can to reduce costs for patients. So for that above patient, she told her to call her cardiologist and request the generic. She gives out samples, even though it’s not a long-term solution. Interestingly, she also said she was feeling “trepidation” towards EMRs, which everyone has been so enthusiastic about. she explained that (1) it’s difficult to transfer literally thousands of pages of documentation/labs/etc. to a computerized system because the practice is already established, though it’s not that difficult if you’re just starting from scratch and (2) having a template doesn’t allow the doctor to make individualized notes or talk about random symptoms that may lead to something later—the checkbox syndrome, I suppose, an interesting contrast to Dr. Gawande's article. She talked about how she used to get these personalized letters from a GI practice she often refers patients to, and now they just send her papers with four lines with codes on them. it’s just different. She also insinuated that EMRs were really touted by the insurance industry as a way to reduce medical waste, which is good, but no one would listen if doctors were touting the same thing for patient care reasons.

I asked her if there were differences between her office appointments and her ward visits. She said her ward visits were basically acute care; to make sure that person’s immediate problem is fixed, and then also to do a basic maintenance checkup because you might as well treat them for other existing problems while they’re in the hospital. Whereas for her office visits, the patients are insured, and the goal is to keep them out of the hospital, and just make sure that they’re doing okay.

A couple of the patients were also doing acupuncture, which I thought was interesting, and Dr. Jeremiah said that she didn’t go out of her way to recommend it, but she didn’t dissuade people from pursuing it if it was from a reputable source. She was involved in a trial where one of her patients was scammed by someone claiming to have found “green parasites” in his blood at the price of $6,000.

She said that there was a desperate need for primary care doctors, and whenever she explained why I was there to the patient, she said that she hoped she could convince me to join the field. I have great respect for what she does every day: in 3 hours, she saw 8 patients for follow-ups and physicals, having come from a residency workshop at the hospital that began at 7:30 AM, and the other half of the work day ahead. I don’t think she was going to have lunch. She said she thinks that primary care will be much better in the future…by the time we're in residency, basically. Overall, I really enjoyed my visit today. I felt like it was a good mix of detective work and just talking with patients, getting to explore the non-biomedical aspects of their health.