The Whole Patient
You are reading Ask The Patient by Dr. Zed Zha, a doctor’s love letter that gives patients their voices back. If you enjoy it, please comment, like, share, and/or subscribe!
Have I ever told you the cheesy story of why I became a doctor?
“What do you want to be when you grow up?” Random adults asked me when I was a kid.
“A doctor,” I said every time.
So, I grew up to become one.
The end.
Thank you for reading today’s newsletter!
Just kidding. It’s not quite like that. I’ll come back to it.
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I am a family physician by training and a country doctor at heart. We do everything.
Chronic illnesses, preventative care, urgent care, deliveries, C-sections, hospital rounds, office procedures, nursing homes, hospice, research, teaching students, supervising new clinicians, etc. You name it, I’ve done it. During the pandemic, many of us even ran mini-ICUs. While others bowed out because it was “not their department,” we stepped up.
Knowing I had a huge knowledge gap in dermatology, a few years ago I went back to “school” and did a fellowship in it. Now, I provide dermatological care in the primary care setting. And colleagues consult me for their patients’ skin concerns.
One such consult was for a little boy with “brittle nails.” Let’s call him Jimmy.
The first thing I noticed when I saw Jimmy was a pink rash on his face. The second was the big bags under his eyes. The third was how skinny he was. None was normal for a nine-year-old boy. My heart sank a little.
After briefly greeting Jimmy’s parents, I followed these clinical clues and asked what seemed like a million questions while examining Jimmy’s full body: he’d been sleeping a lot, too tired to play, he hadn’t gained any weight in the past year, he had a faint rash on his face, his knees were swollen, eyes red, and where he had scratched his back a few minutes ago there left streaks of pink hives.
My brain turned fast, desperately trying to put these puzzle pieces together. This was when I heard a quiet sob from Jimmy’s mother.
Oh crud, I thought, what did I do?
Sometimes, I forget to read the room when I am too focused on the clinical findings. I am especially “attracted to” puzzling cases and have gotten numerous feedback that I was “too inquisitive.” I quickly ran down the list of my past mistakes until it hit me:
A ha! I was consulted for the nails but have been totally distracted by all the other things and haven’t even looked at the nails yet! Parents must be bad. My bad.
“Oh, I’m so sorry!” I ran to grab some tissues for Jimmy’s mother and said: “I know you were sent here for Jimmy’s nails. I will get to them, I promise.”
“It’s not that,” Jimmy’s dad said. I thought he looked…angry.
If not that, then what? What else did I do?
Jimmy’s mom wiped her tears, “We’ve been telling doctors something is really wrong with Jimmy for a year now. But everyone just brushes it off and says ‘We will keep an eye on it.’ To be honest, in the past 10 minutes, you’ve examined Jimmy and asked more questions than all of our appointments combined!”
I doubted my little 10-minute visit so far was anything more than ordinary. But what she said didn’t feel like flattery. It felt real. What a lonely journey it must have been.
I stepped back from smothering Jimmy on the exam table and really looked around the room for the first time:
Jimmy’s mom had soaked two pieces of tissues with her tears. His dad was pacing when I did my exam. But now he was standing by his wife to stroke her back. The look on his face was a lot more complex than just anger. Jimmy’s younger sister, a 7-year-old girl I hadn’t even noticed until now, curled herself into the corner. She looked at her parents and then at her brother, worried and scared.
And Jimmy. Jimmy looked so small and alone on the table with his hunched back. I could see his ribs through his little shirt. The little boy blinked his huge eyes to hold back tears. But the downward corners of his mouth gave his sadness away. He peeked at his mother longingly, as if waiting for “permission” to cry.
I fought the lump in my throat.
“Ok sweetheart, you can go and sit by your mom now.”
Jimmy carefully extended his legs to find the ground and reached for his mom as he walked toward her. The minute she embraced him, his tears flowed.
“Dr. Levy, I’m worried the kid has something autoimmune, like juvenile rheumatoid arthritis. I’m going to order some labs and get an X-ray of his knees.” I sent a message to the colleague who referred Jimmy.
“Don’t take it personally but I consulted you for his nails only.” He replied.
Translation: Stay within your department of skin/hair/nails. Let the pediatrics department worry about the weight loss and the rheumatology department worry about the joints. OK?
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Not OK but before we get to that…
There was an unexpected twist in my cheesy story of “I want to be a doctor when I grow up.”
When I said, “a doctor,” I meant the doctor. Not in a grandiose way. But someone whom families came to regardless of their gender, sex, age, or which organ system their problems lay in.
In 2006, I graduated first in my high school class in Beijing and was accepted into the 8-year M.D. program at Peking University – one of China’s best. Coming from an ordinary family that hadn’t produced a college graduate, my mother was so proud that when I handed her the acceptance letter, she cried in front of me for the first time. Never did she anticipate that just two years later, I would quit medical school and go to the other side of the world.
The reason I left medicine in China was my disappointment that even after almost a decade of training, I couldn’t become someone’s the doctor. Everyone specialized in China at the time. Family Medicine as a specialty and primary care as a concept did not yet exist. When people got sick, they triaged themselves into departments and saw specialists. Every. Single. Time. No one was there to put it together. This burst the bubble of my “romantic” idea of what a doctor was. So, to pursue a career in primary care, I hopped on an 18-hour plane at age 20 to come to the U.S. to start over.
Long story short, I’m now a proud family doc.
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In recent years, despite an uptrend of medical graduates in the U.S., only 12.6% go into family medicine. Among internal medicine and pediatrics residents, only 12.4% and 36.5% go into primary care. Yet this year (2025), we face a 52,000 shortage of primary care physicians.
To make matters worse, due to high patient volume, increased complexity of healthcare, and insurance plans’ dictation of clinical practice, more and more primary care clinicians focus on making referrals rather than providing comprehensive care.
In 2019, researchers interviewed patients and clinicians about how they viewed healthcare fragmentation. Many patients didn’t know the scope of family practice and were unaware of the benefits of having a primary care provider. The primary care clinicians expressed they often didn’t have time for all of a patient’s medical issues and therefore chose to refer. Then the specialists referred to other specialists, bypassing primary care completely.
Indirectly, this creates an “us vs them” mentality in medicine. Primary care, as the lowest-paid specialty of healthcare, is considered the least “prestigious” field of medicine in the U.S. Perhaps one of the most hurtful moments in my career was a classmate’s questioning of my choice of specialty: “Why would you want to go into a field so lowly?” In a medical school where only a handful of graduates go into family medicine each year, this question was not surprising.
This fragmentation and specialty-leaning healthcare and educational system don’t just hurt the egos of us country doctors, they hurt patients. Compared to countries where primary care is allowed to be a truly all-encompassing specialty, American patients have poorer health outcomes. Patients are left confused about conflicting medical advice, suffer more medication interactions and medical errors, get unnecessary tests, receive misdiagnoses, and pay more for their care.
When I #AskThePateint if they felt healthcare had become too fragmented, 817 voted and 98.9% said yes! In fact, I’ve never had a poll with such a uniform response.
One commenter said when she told her cardiologist about her uterine bleeding, he literally drew a little box in the air and said: “I only deal with the heart.”
There are only two possible outcomes of dividing the patient into disconnected boxes:
The whole patient disappears. Instead, they become a collage of body parts: the parts within our department and the hot potato that gets tossed to the next department.
In the turf war called “Who’s the expert?”, there is no winner. The patient, who is left to navigate healthcare alone, almost always loses.
As someone who has seen the extreme of a fragmented healthcare system by design and moved across oceans to pursue something different, trust me when I say this:
In caring for our patients, united we stand, divided we fall.
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As an elevated human and a mature individual, I stewed over Dr. Levy’s "don’t take it personally" comment for two days—while, of course, taking it completely personally.
Finally, I responded, “Let’s work together to figure this out.”
(You can applaud now.)
In a way, it is a “personal” matter. Because a person embodies experiences that can’t be divided up neatly, only organ systems belong to different departments.
So, my department is the patient, the whole patient, and nothing but the patient.
Anyone who truly shares this mission is welcome to join my department. We are recruiting.
