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?


Wayne said...

I am a medical student. During my pediatrics rotation at a local medical institution, I noticed that the term Primary Medical Doctor (PMD) was used instead of Primary Care Physician/Provider (PCP). The term is very clear; when we asked patients who is their primary medical doctors, there was never any confusion as to what we were asking. I think the term Primary Medical Doctor captures the essence of the role of "PCPs" very well -- they are not just a service provider among many providers of the same identical service, easily exchangable regardless of level of training. Rather, they are the doctors who have primary charge of the health and medical care of this patient, even when he or she is admitted and under the care of a hospitalist. Isn't that closer to the tradition of internal medicine?

PCP said...

How can we distinguish ourselves when our own ACP has stated in their position paper on ANPs in primary care, that they be allowed to head up "advanced medical homes" as one model of care delivery?
There is no vision on this issue. If we shirk on the demand that each patient must be allowed to have for themselves a Physician of record, even if/when they receive the majority of their primary care form an ANP, then why even bother with this moot discussion.
Again the model of care delivery in Primary care is very diverse as say compared to Cardiology,where only a Cardiologist does X or Y.
When the lines are so blurred, and we can't/won't advocate for any clear differentiation, (earned and deserved) by virtue of our training, skill and experience, then there is no way we will convince our younger colleagues to look to this as a viable long term career option. We are at such a crossroads. Unless we define our role in Primary care we, will have none.
The respect, compensation, and other benefits usually follow with that differentiation.
We need to advocate for the building of Primary care teams, with Internists, FPs, Pediatricians as the leaders of these teams, supervising and taking on the most difficult cases. Politicians should be made to understand that they are deciding on not just the future of primary care, but on whether it would involve Doctors at all. Otherwise our roles will once again be ill defined and with that the confusion that ensues and the resultant negatives for our profession.
Then as our numbers wither, the system will define primary care and it will not involve Doctors.
Sadly for us, the default pathway has been settled. It falls on us to change the trajectory if we wish for a future of Physician led Primary care.

Jay Larson MD said...

Heck, many people don't even know what an internist is, let alone what they do. Outside my practice sphere there may be some importance in semantics. Inside my practice sphere I know what I do and my patients think of me as their doctor.

The Happy Hospitalist said...

Perhaps internists should introduce themselves as specialists in complicated diseases. Talk about respect from patients.

As a hospitalist, I introduce myself as a specialist in hospital medicine. It makes patients stop asking when the specialists will be there. I tell them that's me.

DrJHO7 said...

The designation, "primary care", is here to stay, whether we like it or not. The health care professions, the government, the insurance industry and the public all think they know what it is, and will continue to refer to "it" as a sector of health care. "It" is a mode of care, an orientation, a designation, a sector, but "it" is not a medical specialty.
I read a research report this morning by a local university on "primary care" in our state and it included ob-gyn's, gp's, internists, family physicians and pediatricians. If the nurse practitioner is the captain of the ship, then he/she's "primary care", too.
"Primary care" has been puffed up alot recently because of how great it can be in terms of reducing costs and improving outcomes and because of the potential "it" has to improve our medical system in the US. All of this, and yet, "primary care" gets less respect than Rodney Dangerfield. Why: it's at the bottom of the food chain for income, the majority of the garbage paper work/scut work rolls downhill to that bottom, and even within our profession there is a sometimes unspoken sense that most other medical specialties are somehow superior to "it". PMD/LMD/PCP are references that were contrived by non-"primary care" specialists that denigrate the person they refer to, even if unintentionally.
Some would call for "primary care" to become a specialty, uniting its component specialties and changing its training programs to produce generic primary care providers, but such action would be the death nell of "primary care".
I believe that our identity as physicians is rooted in our specialties. We know that family physicians, internists and pediatricians are not superimposable, but overlapping, complementary and unique. Our self-respect, and the respect we earn from patients and colleagues is intertwined in how we define ourselves as medical specialists. "Primary care" may be here to stay, and it may be an important part of our job descriptions, but it should not be how we define ourselves.
This is not semantics, it's deeper than that. What's in a name? Identity. I'll keep internal medicine, thanks.