Maggie McKay (Host): Welcome to Total Health Talks, your Cook County Health podcast, where we empower your journey to better health. I'm your host, Maggie McKay. And today, we're going to talk with Chief Medical Officer, Dr. Lauren Smith, about the power of primary care. Thank you so much for being here, Dr. Smith.

Lauren Smith, MD: Thank you for having me. I'm excited for the conversation.

Host: Me too. Let's start off with the importance of primary care. Why do I need a primary care doctor?

Lauren Smith, MD: Yes. So, I would say a primary care doctor is probably your most important commitment and connection for your long-term health. And so, having that person involved in your care, et cetera, is probably the most important step you're going to make in your healthcare journey. So, throughout your entire life, they are very essential in coordinating your care, understanding your care, understanding the specific aspects of you as an individual patient. And so, I think that is the most important relationship you're going to have throughout all of the interactions that you might have across a healthcare system and hospital.

Host: I always think of my doctor as like the umbrella doctor who knows everything about me and then sends me off to the specialist if I need it. For people who don't know what's covered under primary care, what does a primary care physician do?

Lauren Smith, MD: Yeah. So when we speak about primary care, specifically, we're talking about those physicians that are trained with an Internal Medicine, Family Medicine or Pediatrics. So depending upon your age, you may fall into a pediatric, or if you have children, you may see an Internal Medicine physician, but your child may see a pediatrician. And so, those are the specific types of physicians we're referring to. And what they do really is work on a couple of aspects.

So, one, preventative care, so they are responsible for the various screenings that you may need. Also, vaccinations, which obviously are very prevalent in the pediatric population. But also, as you get older, there's specific vaccines that you may require as you get older that you didn't need as a child. And so, those primary care physicians really help kind of keep you on track for all of that as well as they work to coordinate your care. So for instance, if you need to go see a specialist, they can make those referrals, they can share your information with that specialist, telling them your story. So when you go to see the specialist, that specialist knows more about you and can say, "Okay, I've already heard from Dr. Smith. I know this is the area of concern that we're working on," et cetera. So, they work as your referral, your preventative care, and then also your chronic management.

So for instance, if you have a diagnosis already, such as diabetes or hypertension, they can really help you manage that. So whether you're in the early stages and they want to prevent you from getting the diagnosis, so you're pre-diabetic and we want to prevent that next step. They can be very helpful having those conversations or, if you have that diagnosis, managing it so you deal with fewer of the complications as well as if we are able to get that controlled. So again, the primary care physician is really the crux of your care and how you should interact with the entire system.

Host: What would you say to somebody who says, "Ah, I don't need a primary care doctor. If I need a doctor, I'll go to the emergency department. I have a PCP"? Can you share some examples of when maybe it's actually a good idea to go to the ER instead of waiting until I get to see my primary doctor?

Lauren Smith, MD: Yeah. So first, that is my training. So, I am emergency medicine-trained. And I think that experience has really reiterated even to myself the importance of primary care because when we see someone in the emergency room, sometimes it's a failure of the system. They haven't been able to connect those dots between a primary care and a specialist, et cetera, or they don't have a primary care to make that referral. And so, then we see them unfortunately in the emergency department.

So while emergency departments are great, you really need that primary care so that your care is not fragmented. And I think that's the biggest challenge when you don't have a primary care, is you have that fragmented care. So, you're going from one emergency department to another. You really have no one that is kind of owning your care and making sure you're getting to the right places at the right time.

And so, we're happy to see you in the emergency room, but we really are trained in the emergency room for those acute injuries. So if you've fallen and you think you may have broken a bone, that's the time to go to the ER. Obviously, there's a couple of areas, you know, if you have a stroke. So if you notice like facial asymmetry, your face is twisted, your speech is slurred, you're unable to move one side of your body, those are concerning for stroke and you need to get to an emergency room. Again, signs of a heart attack, those are emergencies. So, chest pain, shortness of breath; obviously, if you're passing out, those are also very concerning symptoms that you would want to go to the emergency room for.

If you have a chronic problem, like your back has been bothering you for six months to a year, an emergency department is not really the place that you want to go to because, again, we are trained in acute care, so those emergent things. If you've had a problem that's been plaguing you for six months, you probably need to see that specialist. If it's back pain, you may need a referral to physical therapy, which, again, really in the ER, we are not set up to do. But if you have an acute injury, a fall and it's a trauma and you have back pain, that's where we are great for taking care of you.

So, we really want to ensure that you're kind of getting the right care at the right place at the right time. And a primary care physician can really help you with that. And in the ER-- we're great and, of course, I'm biased-- but we're really only good at specific niche things: that emergency fracture, that heart attack, that stroke and, you know, if you are having severity of symptoms. So if you have severe abdominal pain that's making you drop to your knees, that could be something significant going on. But if it's the same belly pain you've had for like three months, six months, the ER is probably not going to give you an answer and you may be a little bit dissatisfied with whatever we tell you in the emergency room.

Host: So for those in the research phase, so to speak, how does one find a primary care physician, and then how do they narrow it down and choose one?

Lauren Smith, MD: Yeah. And that's an excellent question. I think, first and foremost, because we know the expense of medical care, you want to make sure you're operating within your payers' platform and provider. So if you have an insurance plan, you want to make sure that that physician that you're going to see, or that APP is within that network, because that'll have the lowest out-of-pocket cost. So, you do kind of want to start within your network.

And then, it's really not necessarily a list of questions, but I look at it as, if you're going to look for a job and you're a specific type of employee, if you're a librarian, you're going to go to libraries and every library has books, et cetera. So, you're going to go to a hospital that doctors trained in internal medicine or pediatrics. So, you really want to assess the fit. And so, you want to go to a company where you're going to like your coworkers. So, you want to go to a physician that you're going to like, or an APP. And so, if you're a direct person, you want a direct doctor. If you don't like that style... So, it's a lot about communication, if it fits you. I'm a very direct doctor. And so, I think it's really important that you have a fit.

I will say one question that you might have, if you have a specific chronic disease or chronic illness, you probably do want to assess, "Has that physician taken care of a lot of patients with my disease?" especially if you have something that's not very common. You really want to say, "Do you have a lot of experience working with patients with diabetes?" which most primary care physicians will say yes. They have a significant comfort level with that. But if you have specific autoimmune diseases like rheumatoid arthritis, Crohn's disease, some of those are a little bit more specific. And so, some primary care physicians may not feel as comfortable in that space. So, I would say that's a fair question that you could potentially ask. But again, it's about communication style. Are they culturally competent? So if that needs to be considered, if you have a different lifestyle, those kind of things should be considered when you're interacting with a physician and making that choice.

Host: I have to laugh at myself, Dr. Smith, because I remember back when my son was a baby and I was pregnant, and I was looking for pediatricians. I don't know what I was thinking. I took in a list this long of questions. And she was referred to me by my OB-GYN who used her for her own children. So, why did I even have a list? I should have just gone with it. She looked at me like, "Are you kidding?" But she was so sweet and so gracious, and I used her all the way up until he was like 16. And I said, "How long have you been doing this?" And she's like, "Twenty years." And I'm thinking in my head, "Twenty years, that's nothing." But, you know, when you're a first-time mom, and your hormones, you're just crazy. So, what do you think the top five a patient should ask a potential primary care doctor that they're thinking of going with?

Lauren Smith, MD: I would just kind of, in general, like, "What's your approach to preventative care?" Again, "Do you have expertise or do you feel comfortable with patients with my diagnoses?" And I would kind of more ask, like, "What's your approach to treating hypertension?" And whether they kind of say, "I believe in a lot of diet, lifestyle changes and modification," or "I just want meds." Some patients, they want to skip the lifestyle. And also, maybe another question would be like, "What can I expect in a visit? So when I show up, what should I expect?" And they can kind of lay out for you how their clinic operates, the things that they like to cover on a visit. So, maybe things like that. But again, I would keep it very kind of short and sweet, and go also just a lot of on the vibe and the style and the relationship that you build in that short time with your physician.

Host: So, what are the consequences of not having a primary care provider?

Lauren Smith, MD: Then, you show up in the emergency room and you see me. And so, the risks are, one, you potentially don't have medications, right? And so, you need monthly refills. A lot of your meds, you take every day for the rest of your life. So if you show up in emergency room, we will usually only give you a short supply, so a couple weeks, maybe a month. We're not giving you those refills either. And so, you really want to be able to have access to someone that can answer your questions, that can refill your medications. And it's really, again, about at the right time, the right place that you're getting the right care.

And so, what happens is if you don't get these things treated, if you don't get a diagnosis, because your primary care is also doing prevention, right? And so, they're screening you for the colon cancer or the breast cancer, or making those referrals. So, what could happen is you get diagnosed, but you're getting diagnosed much later. And so, your options are fewer. So if we can catch a cancer early on, your options are a lot better than if you're further in the process. Same with diabetes and hypertension, you know, we call hypertension the silent killer because so many people walk around with it. They don't know they have it, they're not seeing a primary care doctor. And then, they have a massive stroke and end up in the emergency room. And then, we look, and their blood pressure is extremely elevated. And then, we also see maybe a little bit of kidney damage, other evidence where we can say, "Yes, you've probably had hypertension for quite a long time, and it was untreated. And that's kind of what led to the stroke." So unfortunately, it can be very catastrophic. You can't emphasize enough the importance of primary care and having that one connection that's making sure you're guided through the healthcare system, because it is not easy to navigate. I'll be the first one to admit it.

Host: Not kidding. You mentioned health equity earlier. Is there something that you think could be done to address these inequities?

Lauren Smith, MD: So, health equity, it's a huge topic and it needs to be addressed in many levels, right? And so, one is access. I think the biggest is we have to expand access to communities that they don't have access or they don't feel that they have access. So, sometimes the access is there, but they don't know how to get it. And so, we, as a larger healthcare community, need to focus on that.

But then, there's also root causes, right? And so, we need to look at are there social interventions that need to occur? And then, there's a lot of policy that we need to look at. So from a federal level to state level, there's policies that probably need to be evolved and changed to help eliminate some of the healthcare inequities that exist and disparities, because we know that is out there. But really, the first step is access. And so, we have to be able to have access and people need to know how to utilize that access.

Host: Well, I read somewhere that the United States spends less on primary care and more on specialty care than other high income countries, although primary care is the lifeline of a healthcare system. So, why do you think that is? And what are the consequences of not spending enough money on primary care?

Lauren Smith, MD: Oh, this is actually one of my favorite topics to talk about. And I've had the opportunity to look at other countries' healthcare systems. And what you've seen is, especially in Europe and other countries that have universal healthcare meaning it's a right and everyone has it, is they have realized that you can spend the dollars upfront, and it's less than spending them on the back end.

And so, what this looks like is they pour a lot more money into the front end, so the vaccines, the screenings. And so, that way, you're spending a lot less on the acute care. So when patients come into the emergency room with a stroke-- it's a lot easier to prevent diabetes than it is to treat diabetes. And so, if you're going to a primary care doctor, they're checking your A1c and they'll tell you, "Hey, you're in the pre-diabetic range. Let's do some diet modifications now, let's increase your exercise now so you're preventing that diabetes. Once you develop diabetes and we're treating the diabetes, that's monthly medications that you're paying for." Then, there's a lot of complications with diabetes, right? So, you have to get the eye screening, there's visual complications. Your kidneys have to be checked more frequently. And so, all of that costs, and then if you end up needing dialysis or an amputation as a complication, you can see how all those costs start to compound. And so, it's much more expensive to you. It's much more expensive to the system. And really, if we are able to prevent all of that, even though we spend a little bit more upfront, we're saving us tons on the backend. And I think a lot of those other countries have really taken hold of that for a ton of reasons, which we don't have time to get into today. But yeah, that's the cost we're paying right now kind of for the system that we have. So, I think we as a healthcare system also need to invest more in our primary care physicians because they really are the backbone of our system.

Host: You touched on this earlier a little bit, but tell us how your experience is helping you now in your leadership role at Cook County Health.

Lauren Smith, MD: Yes. Well, I was fortunate enough to have trained at the Cook County Emergency Department residency. And so, I kind of grew up at County. So, I really understand the patients that we serve. I think that obviously is huge as I'm looking at this level now, how can we serve more patients and serve them better? And so, I have that context.

 As well as I do feel emergency medicine is really great for building leadership because, one, it's such a team sport. When you have a critical situation and you're leading the team, so you have nurses and techs and learners in the room, and you have to just basically-- like coordinating an orchestra as we run a resuscitation and try and save someone's life. And so, having those type of leadership skills, I think, have served me well. And I've also, throughout my career, have done leadership outside of healthcare. And so, I think when you're able to see leadership in different venues and different industries, you can still glean from them. And so, basic leadership skills about communication and listening, because it's not just about speaking.

Communication is about listening and hearing the patients. And so, being able to take just basic leadership skills to apply. And again, in the ER, you have to listen real subtly, because sometimes patients will just slip in a little tidbit that is kind of like the key to their diagnosis. And just listening and listening, I can hone in on that, like, "Wait, no, let's go back to this one thing you just brought up." And then, they'll tell you like, "Yeah, I did that on Saturday." I'm like, "That's what's going on." And in their mind, they didn't even think about it, but I'm like, "Actually, no, there's an affiliation with the X and Y to Z." And so, it helps. So, really listening and being able to hone in on certain things. So, all of that again, I think, has led up to me being able to serve in this role now.

Host: Given your specialty in emergency care, can you share some common misconceptions people have about that field?

Lauren Smith, MD: The first one kind of gets back to what I was alluding to earlier about, I think, some folks will say, "Hey, I'm up. They're open. Let me just go for this." Like, "Well, I'm awake and I'm thinking about it. Let me just go in and see the doctor now." But it really goes back to getting the right care at the right time and at the right place.

So while emergency medicine physicians are great and can do a lot of things, we are probably not the best at managing your blood pressure. So if you know you have hypertension and your numbers are not controlled, we're not going to be the best ones to sit down and run your list of meds and say, "Hey, let's change this dose." Again, we're trained in the acute management of issues, not necessarily the chronic management. And so, I think some people are like, "Well, it's open--" and I get it because some folks have jobs where they can't get away or families, and the ER is the only thing that's open when they have that time. So, we understand that.

But again, we're not the best for certain diagnoses and for certain problems, we're really there for acute issues. So, that acute pain, that trauma, those acute changes in your normal symptoms, you're like, "Yeah, at baseline, this is my baseline," and you notice a large variation from baseline. Like, "Normally, I can walk up a flight of stairs and I'm fine, and now I'm only going up two stairs and I'm short of breath," that's an acute change and that probably should prompt you to go to the emergency room or call your primary care doctor and then they can say, "Yep, you should go to the ER," or "Nope, that I can see you tomorrow in clinic."

And so, again, that's another benefit of a primary care doctor, is you have access to that physician or a group of physicians when you have those questions like, "Should I go to the ER or should I go to clinic?" Then, that primary care can help guide you.

Host: So just in closing, is there anything else you'd like to share with our audience today that you think is important as they seek support for their healthcare needs?

Lauren Smith, MD: I really would like to encourage everyone to take ownership of your health. It is your health. And so, you should be very well aware of the things that you've been diagnosed with and the medications you're taking. And I know the list of meds, the words are long and the syllables are very often off-putting. And I will say in med school we had to learn how to pronounce a lot of the words, that it's not intuitive. Like, you're reading it and, you know, I'm like, "Wait, what is that?" So. It's not for everyone. But you don't have to pronounce it, just have it written down and carry that on your phone. Have your list of meds on your phone. Take a picture of the bottles bottle and have them on your phone. Or if you're old school and you want to write it down, write it on a note card and keep it with you, because if something happens, not every hospital system can see every hospital system. So, I would definitely say take ownership. Have your doctor write down your diagnoses if you have diabetes, hypertension. If you can't remember it, that's fine, just write it down and have it accessible. Same with your list of medications.

And then, the other thing is don't be afraid to ask questions. So when you are seen , sometimes-- you know, doctors were not the best at explaining things at a level that everyone can understand. And so, sometimes, say, "Can you repeat that?" or "What are you really telling me?" And then, kind of just ask them to explain it again in a different way so that you can understand it, because you really need to take ownership. So, we're not going to quiz you on the names of all your meds. Like, we'll let you look it up. So, have the cheat sheet. Have the cheat sheet.

Host: Thank you so much for sharing your expertise. This has been so informative and a lot of fun.

Lauren Smith, MD: Thank you. I've enjoyed it.

Host: Again, that's Dr. Lauren Smith. And if you'd like to learn more, please visit cookcountyhealth.org/podcast as we wrap up another insightful episode of Total Health Talks. Make sure to visit cookcountyhealth.org/podcast and subscribe to our podcast, share and connect with us on social media. Stay tuned for more engaging discussions. This is Maggie McKay signing off from Total Health Talks. Stay well.