Friday, July 10, 2009

Are doctors and non-physicians speaking the same language when they define primary care?

I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.

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.

The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.

As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.

The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices 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." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

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.

I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.

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.

Today's question: Do you think primary care means the same thing to the different health professions?


Todd Staub said...

As the health care system shifts incentives toward primary care, it will be important that we defend a complete and accurate definition of primary care. The IOM attributes that you describe are essential - first contact, comprehensive, continuing,integration, access, sustained partnerships, social context. Thanks for reporting to us on the roundtable at the White House.

Steve Lucas said...

Primary care does not mean the same to different health providers, nor does it mean the same to the general population. I, like many patients, am willing to accept a nurse or PA/NP as my primary care giver if they solve my problems and listen to my complaints.

Pharmacist are often our only source of information concerning prescribed medication and the underlying issues associated with disease management. Psychologist/social workers often become the only medical contact for those dealing with multiple medically induced issues.

While I see the value in having a physician involved in my personal care, often the physician is not there to support me or answer my questions. In many offices the real contact takes place between the nurse and the patient, not the doctor and patient.

Doctors need to raise their profile in the primary care setting, not try to demean those who are filling in the gaps we, as patients, so often see.

Once again this comes down to time. I know this is an old song on my part, but doctors need the time to sit down and have a meaningful conversation with their patients, not blow in, write a prescription and say "the nurse will explain everything." The nurse then becomes the medical provider since they are the ones answering questions and interacting with patients.

Doctors need to become the "go to" person for those less than obvious issues. As long as others are answering our questions, doctors will not have the respect they need to achieve the professional standing they desire.

It is not just a question of ability, but of perception.

Steve Lucas

DrJHO7 said...

Today's question: Do you think primary care means the same thing to the different health professions?

Primary Care Medicine Specialties:
General Internal Medicine
Family Medicine

Obsolete (probably not enough medical training - 1 year of internship - to be of value to patients in 2009):
General Practice

Primary Care Medicine practiced by nurses, as allowed by some state licensing boards:
Nurse Practitioners

Medical specialties that MIGHT be able to say they provide primary medical care IF they are willing to expand their usual spectrum of services to include ALL of those that are typically handled by primary care physicians:
Sports Medicine
Infectious Diseases
Probably others that I haven't considered...

Clinicians/stakeholders who will proclaim themselves "primary care" if there is more money flowing through it:

I've commented on this "primary care" moniker before. Better for us to refer to "primary medical care", that narrows the playing field a bit. In this, definitions are important. eg: There are lots of "doctors", but a physician is a physician, etc.

How we define primary medical care is going to draw the lines as to who receives payment incentives for this, and who could captain a PCMH. This defining and line drawing will obviously be very important in the near future.
ACP needs to be sure that it is at that table.

Jay Larson MD said...

Unfortunately several different health care providers consider themselves primary care. They, though, only supply care for just one organ system or have a limited scope.

Personally I like the Institute of Medicine definition: Primary care – “the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community”

Four main features of primary care services:
First contact access for each new need
Long-term person (not disease) focused care
Comprehensive care for most health needs
Coordination of care when it must be sought elsewhere

If a health care profession meets these criteria, then they should be considered primary care. Every one else should be considered “Limited” (but still every important) care. With the complexity of health care reform, it is best to use language with a consistent meaning.