Jan Anderson, a 28-year-old woman, visits her doctor because her lower back has been hurting for a week. She has been a patient of Dr. Bloch, a family physician, since she was 10 years old, for a variety of problems. Dr. Bloch has been involved in treating her scoliosis (when she was a young girl) and in managing, over the years, a recurrent kidney infection, irritable bowel syndrome, and, before she used contraceptive pills, painful menstrual cramps, all possible sources of her pain. Dr. Bloch also knows that Ms. Anderson is an avid exercise enthusiast. Dr. Bloch evaluates the low back pain to determine if it is related to one of the earlier problems or to exercise. After he has diagnosed her problem, he treats her and makes arrangements for follow-up care.

Helping patients sort out and resolve such symptoms and dilemmas is an essential feature of primary care. Sometimes evaluation may reveal that, in addition to the patient's stated reason for a visit, an even more important problem or concern lies unspoken and perhaps unacknowledged or unrecognized by the patient.

Caroline Clark is a 40-year-old married woman who manages her own business. She visits her primary care team and sees the nurse practitioner, Donna Washington, complaining of insomnia. Ms. Washington knows that in the past year, Mrs. Clark has had a severe allergic reaction to a bee sting and lithotripsy for a kidney stone; she also knows that Mrs. Clark's 10-year-old son is being treated for leukemia in a nearby medical center, which causes many trips to the hospital, repeated difficult laboratory tests, and frequent school absences; she is aware that Mr. Clark's profession requires frequent and long trips away from home. Ms. Washington prescribes Mrs. Clark a mild sleeping pill, renews her prescription for adrenalin in case she suffers any bee sting in the future, and advises Mrs. Clark about what she may expect in the future regarding kidney stones. Ms. Washington also provides support in coping with these personal and family stresses that may affect her current and future health, including information about how she can, if she wishes, arrange an appointment with a clinical psychologist who is part of her health plan.

These vignettes illustrate that in addressing the "large majority of health needs" the primary care clinician and the patient benefit from the characteristics of primary care, including integration, the development of a sustained partnership, and attention to the context of family and community.

Guiding Patients in Using the Health Care System

A major element of good primary care is the ability of primary care clinicians to diagnose and manage their patients' health care problems. In many cases, this may require considerable understanding of the local health care scene and how best it might be navigated. When patients (or family) are new to an area or otherwise lacking in knowledge of the full range of resources open to them, the

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