Primary care and the NEJM


Category : Medical Rants

Today’s NEJM has an article, a perspective and an editorial on primary care and the mismatch between physicians and nurse practitioners perceptions of each other’s skills. The perspective an editorial follow the increasingly familiar trope that advanced nurse practitioners are needed to solve our lack of physician primary care.

But nowhere in these pieces did I see the key point. Primary care is not one thing. Primary care is not “simple care”. Primary care (like Dante’s Hell – no implied analogy) has many levels. Primary care as a term is really a Rorsharch test. As an internist, when I consider primary care, I think of complexity – patient complexity, disease complexity, and balancing multiple problems. I suspect when policy wonks consider primary care they think of simple stuff – BP control, adjusting hypoglycemic drugs to achieve a “desired” Hgb A1c, sore throats, uti’s, smoking cessation.

Primary care physicians are our first line of diagnosticians, thus they need the experience and depth of knowledge to consider diagnoses, or at least know when the diagnostic possibilities need referral. Primary care physicians must juggle multiple problems, especially in our older patients. They must know when to follow guidelines and as important, when guidelines really should not apply.

We will continue to have uncomfortable and unproductive debates on this issue until we settle issue #1.

What is primary care?

As I write above, primary care is not one thing, and thus the conversation will never achieve a dialogue until we agree on the definition(s) of our topic.

Comments (4)

I am a primary care doctor. I saw a patient today who has several subspecialists that he’s not too satisfied with. He felt like they didn’t seem to have time for him anymore. He came because he wanted to transfer his care to “the big hospital”, and he just plain didn’t feel good. I listened to his concerns, reviewed his medicines (and stopped quite a few of them), and made suggestions. We decided not to refer him to anyone else.
It took an hour, and threw the rest of my clinic off, but was the most satisfying encounter of the day. That is primary care, and there is no algorithm for it.

ObamaCare, through amendment of the Social Security act has defined primary care service as any E/M service as defined by HCPCS and administering of vaccines. So I’m not sure there is a debate to be had. So yes, your cardio thoracic surgeon can be your primary care doctor thanks to ObamaCare.

Any questions?

I think it’s not just “policy wonks” but even in the field, subspecialists also view primary care as titrating bp meds and referring for anything more.

The problem is that the definition is highly varied by practice location and patient population. If you live in a large urban center with largely privately insured patients, there will be a plethora of specialists and your patients’ insurance will enable self referral for even the most mundane issues. In this setting, patients will tend to have an “ologist” for every complaint and diagnosis and if they have a primary care provider at all, he or she will provide access for acute episodic care and maybe some wrangling and oversight of the specialist care. I think that np’s can actually service this role nicely. While patients in these settings think they have excellent care, they actually have worse outcomes.

In rural America where there is limited access to specialists and patients are uninsured or on public insurance, generalists provide broad spectrum, continuous care that is complex, and often diagnostically and therapeutically challenging. You are more likely to “see” a specialist by your pcp, behind closed doors, discussing your case by phone with a consulting specialist. In these settings, with few exceptions, np’s (and many docs) are overwhelmed and uncomfortable with the complexity.

A large amount of the difficulty in defining primary care comes from the fact that there are such wildly different versions of it being practiced in this country. It’s not clear that it is possible or desirable to try to make primary care in the US more homogenous as it is in much of Europe, but as it stands, much of what passes for primary care in the US can easily be done by non-physicians.

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