The ACP Advocate Blog
by Bob Doherty
Tuesday, May 5, 2009
A primary care doctor by any other name ...
Would still smell as sweet, right? Yet some internists argue that the description "primary care" is one of the reasons why younger physicians are not choosing general internal medicine, and why some established ones feel disrespected. This is what Dr. JH07 had to say in response to my recent post:
"I sensed respect from all of the colleagues I interacted with at IM '09, last week. I sensed love and enthusiasm for our specialty, Internal Medicine, at that conference by its diverse group of attendees. So what is not respected? Answer: "primary care". Primary Care is a label that some physicians were dubbed with in the late 80's, early 90's with the rise of managed care. It's a moniker that, like HIV to the mononuclear cell, like a worm virus to the code of a computer program, some physicians are inextricably and incurably infected with. When these physicians became "PCP's, with the second P standing for provider, we lost our identity as medical specialists, and we became something less than physicians, at times indistinguishable from other providers of medical care who are not physicians. The only way out of this is to throw off the yoke of "primary care" and become the physicians/medical specialists that we are, again. This will not be easy because "primary care" is now well known to the public, the legislators, the insurers, and various medical/surgical specialists, and like many infamous nick-names in the history of our culture, will not be easy to shed."
Dr. Bob Centor, an ACP regent, makes a similar point on DB's Medical Rants:
"Words matter. Hospitalists have succeeded in part because their name carries instant recognition. Primary care suffers in part because so few decision makers really understand how complex primary care is. So I recommend that we no longer use the phrase to describe this important, complex and rewarding profession. The phrase has suffered semantic drift. Until "primary care" physicians understand that the nomenclature is at least half the problem, we will not be able to solve the problem."
I can understand the desire to shed the words "primary care", but I think this would be unwise at a time when politicians and policymakers alike seem to buy into the idea that "primary care" is the keystone of a high performing health care system, as Senate Finance Chair Max Baucus (D-MT) has famously described it. Whether legislators will do enough to live up to primary care's billing as the "something on which other associated things depend" is still to be determined.
The word "primary" itself has many meanings. One is to be first, such as in primary school. General internal medicine, pediatrics and family medicine are about first contact, continuous and comprehensive care. Primary also can mean most important - as in lack of health insurance is a primary reason why people do not have access - and I think this also fits.
What is wrong with being the "first" and "most important" physician in the health care system? Here is how ACP's recent "solutions" paper on primary care defines it:
"The IOM defines primary care as 'the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.' Primary care physicians provide not only the first contact for a person with an undiagnosed health concern but also continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The hallmarks of primary care medicine - first contact care, continuity of care, comprehensive care, and coordinated care - are going to be increasingly necessary in taking care of an aging population with growing incidence of chronic disease and have proven to achieve improved outcomes and cost savings. Without primary care, the health care system will become increasingly fragmented and inefficient - leading to poorer quality care at higher costs."
The paper goes on to describe the unique training of internists:
"General internists provide long-term, comprehensive care in the office and the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. Internists receive in-depth training in the diagnosis and treatment of conditions that affect all organ systems. General internists are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health. Internists' training is solely directed to care of adult patients; consequently, internists are especially focused on the care of adult and elderly patients with multiple complex chronic diseases."
I would think that the above descriptions of primary care physicians and general internists are something we should be proud of, instead of demeaning primary care by associating it with a lower and less important level of training and patient care.
Today's question: What do you think - should internists define primary care on our terms? Or would you describe yourself as something different?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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