The current issue of JABFM has a very important article – Family Medicine Outpatient Encounters are More Complex Than Those of Cardiology and Psychiatry – that reinforces ideas discussed on this blog over the past 8 years.
Results: There is minimal difference in the unadjusted input and total encounter complexity of general/family practice and cardiology; psychiatry’s input is less complex. Cardiology encounters involved more input quantitatively, but the diversity of general/family practice input eliminated the difference. Cardiology also involved more complex output. However, when the duration of visit is factored in, the complexity of care provided per hour in general/family practice is 33% more relative to cardiology and 5 times more relative to psychiatry.
Conclusions: Care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists. This may account for a lower rate of completion of process items measured for quality of care.
Generalist practice has some inherent complexity, because patients come to see us with varied problems. Most subspecialists see a narrow problem focus.
Now any objective observer must admit that this study did have a specific agenda. Nonetheless, the data and analysis support ideas that others have expressed for the past 10 years.
Because primary care patients present earlier in the course of their illness and with less differentiated disease, we would expect that the input in family medicine would be less clear and, hence, more complex. This agrees with the conclusions of the Future of Family Medicine Project. In addition, primary care physicians, potentially filtering out those with uncertain diagnoses, have already evaluated patients who were referred to specialists. Recognition that the probability of disease is lower in primary care may explain higher rates of testing in specialty practice. Thus, the complexity observed in family medicine versus cardiology is understandable based on the patients who present and the referral process. What characterizes family medicine the most is the diversity that defines it.
Given the complexity that family physicians and internists face daily, why do we call their practices primary care? The term primary care implies a hierarchy, and in fact we talk about secondary care, tertiary care and even quartinary care. This hierarchy suggests that primary care is simpler and less sophisticated.
In fact, all physicians deal with complexity. We should not imply a hierarchy with our labels. Generalist care differs from specific disease care, and both are important and difficult.
This hierarchy has confused wonks, insurance companies and politicians. They assume that we can take nurse practitioners or physicians assistants and have adequate primary care. They assume that our family physicians and internists need much less training because their job is simpler. They are wrong.
The nomenclature is the problem. We need to agree on a new nomenclature as the current nomenclature has perverted thought processes and therefore policy.
