In response to a comment yesterday, for the first time I reprint a rant. This rant is so important that I consider it classic for this blog.
A reader writes:
My question: Is there a plan to move MD’s away from primary care and turn this function over to NP’s and others who will cost the system less? I raise this issue since from an economic stand point if I wanted to create a massive change in the medical delevery system I would follow the patteren now being set by Medicare and the insurance companies. This may not be the best system for the patients, but when did we, or doctors, count when there is profit to be made by an insurance company, or cost to be contained by the goverment. Not trying to sound like a nut case but when you stand back and look at the system as a whole I see a trend that will result in MD’s becoming a refural service only and clinics providing most primary care. A great loss to everyone.
I am often accused of overemphasing semantics. However, I believe that that this concern revolves around semantics. Let us start by defining semantics – “The meaning or the interpretation of a word, sentence, or other language form” So to really answer the questions which the reader poses, we must use a common definition of primary care.
Defining Primary Care Since its introduction in 1961, the term primary care has been defined in various ways, often using one or more of the following categories to describe what primary care is or who provides it (Lee, 1992; Spitz, 1994). These categories include: * The care provided by certain clinicians—Some proposed legislation, for example, lists the medical specialties of primary care as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. Some experts and groups have included nurse practitioners and physician assistants (OTA, 1986; Pew Health Professions Commission, 1994); * A set of activities whose functions define the boundaries of primary care—such as curing or alleviating common illnesses and disabilities; * A level of care or setting—an entry point to a system that includes secondary care (by community hospitals) and tertiary care (by medical centers and teaching hospitals) (Fry, 1980); ambulatory versus inpatient care; * A set of attributes, as in the 1978 IOM definition—care that is accessible, comprehensive, coordinated, continuous, and accountable—or as defined by Starfield (1992)—care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness;
Dictionary.com defines primary care – “The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.” Which of these definitions do we mean? The big problem in discussing primary care stems from a misunderstanding of what physicians think primary care means. Some subspecialists, some policy wonks and some patients equate primary care with simple episodic care – e.g. sore throats, urinary tract infections, ear aches, runny nose, etc. When you discuss primary care with general internists and family physicians (I am restricting my comments to adult medicine because pediatrics is very different), they assume the primary care includes episodic care and the ongoing care of patients who often have multiple chronic diseases. Do we need a specialty trained MD (both GIM and Family Medicine are specialties) to deliver primary care? If you take the dictionary.com definition or the simple episodic care concept, or even add routine hypertension and similar single conditions, then specialists are not needed. However, the patients that General Internists and Family Docs see rarely fit the constrained definition. Most often our patients are complex (defining complexity either by number of significant diagnoses, number of medications or the addition of complicating psychosocial issues). I do not believe that the majority of patients are well served if they do not have a well trained specialist in the care of the complex patient (my definition of GIM and FM). As I see the problem that we face, many have perverted the meaning of primary care and the term no longer adds to useful discourse of our problem. I generally avoid using the term for this reason. I hope this discussion emphasizes the importance of the semantics.
