I spent some time with Bob Doherty yesterday. The first thing he said when he saw me was – check out my blog, it addresses the definition of primary care.
Many readers know that I have had great angst over the term primary care for years. In 2006 I wrote this post – Whither primary care. In it I said
Why have we reached this stage? Several problems have lead to the current status. First, we (family physicians and general internists primarily) made a huge mistake in the 1990s. We thought that managed care was the answer to improving the quality of life of primary care physicians. Just like politicians, we failed to carefully consider the externalities of the managed care movement.
The managed care movement cause the semantic drift in the meaning of primary care. ‘Dictionary.com’ now has this definition – “The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.” This definition implies the gatekeeper concept (another big mistake was accepting the label of gatekeeper). This definition is the truth, but only a small part of the truth.
When I first joined the GIM faculty in 1979 as a primary care internist, I understood my job. I believe that the current graduates of both internal medicine and family medicine programs understand their jobs. The above definition does not adequately describe those jobs.
The primary care physician cares for the patient, whether the problems are episodic or chronic. He/she provides care in the context of the patient’s medical problems and their psychosocial situation. When the patient has multiple problems (as occurs with increasing frequency), the primary care physician has the responsibility of weighing the various treatments to maximize quality and quantity of life. The primary care physician takes responsibility for preventive medicine (both primary and secondary prevention). Finally, the primary care physician coordinates the patients journey through the health care system. He/she arranges appropriate consultation when necessary.
This job is in my opinion the most challenging and satisfying job in medicine. The breadth of knowledge necessary to meet our patients’ needs is remarkable.
Yet, politicians generally do not understand. Bob’s entry is classic – Are doctors and non-physicians speaking the same language when they define primary care?
The White House’s primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to “What’s my line?” style questioning, I think it would be become evident that their lines (roles) were very different from each other.
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Many of the professions represented at the White House’s primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address “a large majority of personal health care needs” or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM’s definition, but their skills and training are complimentary–not equivalent–to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.
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But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.
Bob and internists understand the difference. The ACP has chosen to advocate for primary care using our definition. Unfortunately, we say the words but the politicians, insurers and health administrators hear a different meaning. We are losing a semantic battle, and I do not know the way to redefine the battle.
In the wonderful book I am reading – 52 Rules of Thumb – Rule #32 is content isn’t king, context is king. I fear we have lost the context of the term primary care. We know the content, but they do not. And they make the big decisions.
