Portland Direct Primary Care
PDPC logo small.png

Beyond 7 minutes

I trained as a Family Doctor so that I would be ready to help patients with any challenge. The old school family doc used to take that skill set out into the community on house calls, sports sidelines, and town hall meetings. At some point the job description was boiled down into a job that started and ended with a 7 minute office visit. That setup is not good for patients, and it's not good for doctors. In this column I hope to start to push the boundary of where the doctor patient interaction takes place - onto the page, into the community, and beyond 7 minutes.

The top 3 primary care impacts of 2019

The top 3 primary care impacts of 2019

Medicine is a constantly evolving field. We are always reviewing new research and re-reviewing old research in order to find the best path to health. What was once gospel can sometimes be overturned with a seminal paper. Although it’s daunting, change can be good. It assures that we do not take our assumptions for granted.

As a primary care doctor who cares for all ages and the full spectrum of maladies, I must stay up to date on the latest research and guidelines. My practice is centered around applying these guidelines to each unique patient. Much of the nuance of medicine is in finding the personal within the labyrinth of data which can feel at times very impersonal.

Below are the top 3 advances that changed my practice this year. As always, these points are illustrative only and do not take the place of personal care from a primary care provider you know and trust.

1. Timing of Blood Pressure Medication

We long assumed that a medication worked the same regardless of what time of day it was taken. That logic was turned on its head with a remarkable paper comparing morning to evening timing of blood pressure medication. People who took their blood pressure medication at bedtime had a close to 50% reduction in cardiovascular events. What’s most remarkable about this intervention is that it doesn’t cost a penny! If this result is replicated in future studies, it may turn medication timing recommendations up-side-down.

Hermida RC, Crespo JJ, Dominguez-Sardina M, et al, for the Hygia Project Investigators. “Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial.” European Heart Journal 2019 Oct 22. Pii

2. A baby Aspirin per day

Aspirin used to be routinely prescribed for primary prevention of heart disease. Primary prevention is stopping a disease before it has started. This is in contrast to secondary prevention where someone already has a disease and the goal is to prevent progression. For example, preventing a second heart attack is secondary prevention.

The game changing (albeit controversial) ASPREE trial followed older adults for five years and did not find a reduced risk of heart attack on aspirin users. The challenge is in interpreting what this data means for those younger than 70 years old.

McNeil JJ, Wolfe R, Woods RL, et al, for the ASPREE Investigator Group. “Effect of aspirin on cardiovascular events and bleeding in the healthy elderly.” New England Journal of Medicine 2018;379(16):1509-1518.

3. The new era of genetic testing

Genetic testing has reached the point where the United States Preventive Screening Task Force now recommends screening women for patterns of heritable cancer and referring for BRCA genetic counseling and testing where appropriate. This does not mean every woman should have genetic screening. The screening tools can help a woman and her primary care doctor understand her risk and make the right choice for her.

US Preventive Services Task Force. “Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer.” US Preventive Services Task Force recommendation statement. JAMA 2019;322(7):652-665

Oren Gersten, MD