Part 2: Realizing I Was In The Wrong Specialty

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I went into primary care because I was passionate about intervening before there was a problem. 

It turns out, patients are less enthusiastic about prevention. 

Storytime: one day, a patient came into my primary care office. It had been months since she’d last been seen and she was overdue for a referral to endocrinology for management of her pituitary adenoma. 

“What brings you in today?” I asked, as I always do. Internally, I was already formulating a plan for an endocrinology referral. 

“My rosacea.” I was surprised. I treated her rosacea, but spent most of our time together convincing her to refill her dopamine receptor agonist.

Every day she looked in the mirror and saw her rosacea. It shaped how she saw herself and how she imagined others saw her. Her pituitary adenoma was hidden, silent and not affecting her life. Taking a pill every day for something you can’t see or feel is a tall ask.

Let me be clear: I don’t blame her at all. Why would she add more friction to her life if she doesn’t have any symptoms?

As a primary care trainee I was preparing for a broad scope of practice and the two diseases I was most passionate about were heart disease and diabetes. These are two of the most common chronic diseases in the U.S. and ones for which we have incredible screening tools and medications to reduce risks of complications down the road. 

One of my favorite things was to diagnose young people with hypertension or pre-diabetes. Catching disease early and being able to intervene was energizing for me. After seeing the devastating effects and end-stages of heart disease and other diseases associated with HTN or diabetes (kidney disease, stroke, certain cancers) in my hospitalized patients,  the payout was clear. For my patients, that connection was harder to see. Many patients did end up filling and taking their prescriptions. 

Still, I often felt like a bad salesman. My patients would come into my office happy but leave sad. They came in feeling good, seeing me for a “well” visit, but would leave with bad news that they have diabetes or high blood pressure. 

When my patients left with new diagnoses, I sometimes felt like I had drained the joy out of their visit. That’s when I started questioning whether I could do this work for the rest of my career.

One of the reasons I was so passionate about preventing diseases before they started is because I saw how both diabetes and heart disease affected the Puerto Rican side of my family. These diseases do have a genetic component, but they have a lifestyle component as well. Medications and early intervention help, no matter the cause. I wanted to be the doctor that helped make a meaningful difference so that decades later, people could live healthier, more vibrant lives.

‍That personal history made prevention feel urgent to me, but urgency isn’t the same thing as motivation. Even when patients had the access and resources to make changes, many still struggled.  Prevention is a tough sell. No one wants to take medication for something they can’t even feel.

‍My patients with dermatologic concerns were always the most motivated. Dermatologic diseases matter to people. Patients can see and feel dermatologic disease (hidradenitis suppurativa is incredibly painful and chronic itch from eczema can ruin your quality of life). But they affect self-concept and how people believe they’re being perceived. I felt like my derm patients were always eager to fill their prescriptions and happy when they left with a diagnosis and treatment plan. 

I admire all the incredible primary care physicians who can build rapport with their patients and convince them to take a pill for a disease they can’t feel. When I had an hour with each patient at the beginning of intern year, I found getting to know my patients, building trust, using motivational interviewing, and recommending a treatment plan to be rewarding. As visit times shrank and complexity grew, I had less space to build trust—the one thing needed to make prevention possible.

I am still passionate about preventing chronic disease and hope to use my platform as a dermatologist to encourage patients to see their primary care physicians and treat their chronic diseases. Even diabetes and cardiovascular disease are associated with dermatologic conditions.

There are so many reasons I loved primary care, but feeling like a bad salesperson made me realize I wasn’t best suited to be a PCP. In dermatology, I found a specialty where the patient’s urgency matched my own, and where I could still connect prevention with the visible and the meaningful.

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Next up: Part 3 How I told my program I was leaving & their reaction

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