Stop Using the Words Primary Care To Describe Medial Doctor Care.

I think it's time to stop using the words primary care to define what internists and family medicine doctors do.

From a PhD, presumable someone who is highly educated and capable of logical thinking skills. The lack of critical insight into what defines primary care is striking. Here is the comment in its entirety.

I just thought I'd jump in here with an outsider's opinion. I'm a different kind of "Dr" (PhD in astrophysics). I'm also married to a Nurse Practitioner, to whom I would happily entrust my primary care over most physicians that I know.

While I am well aware that many NPs are not "fully qualified" to be primary care providers, I would submit that neither are many MDs. I would further assert that, from my experience, what many NPs lack in training, they often make up for in diligence and compassion, making them preferable by far as providers than a well-trained but apathetic physician who thinks himself (or herself) superior to the task at hand (not meant to be a blanket condemnation, but rather a description of certain individuals I've encountered).

But that is not the point I wanted to make. It seems to me that much of your argument depends heavily on an erroneous definition of the term primary care. You speak frequently of inpatient primary care, and I would submit that there is no such thing. Once a patient has been admitted to the hospital, they are no longer undergoing primary care. An inpatient is, at the very least, undergoing secondary, if not tertiary, care. As a hospitalist, you are not a primary care physician. By definition, primary care represents the first contact of a patient with the health care system, and one of the most important characteristics of a good primary care provider is knowing when a patient's condition is beyond his/her scope, and it is necessary to refer them on to the second tier of health care.

As a doorway to the health care system, different primary care providers may be able to handle a wider or narrower scope of care, and thus one provider may be comfortable handling patients that another would choose to refer to a specialist. As a rule, I would expect an NP or PA to have a lower threshold of acuity for referring patients than a DO or an MD, and I think that is entirely appropriate. It should be viewed not as a weakness of the practitioner, but rather as a strength in the recognition and acknowledgment of their own limitations.

As MDs have abandoned the field of primary care in favor of more challenging (and lucrative) specialties, mid-level practitioners have moved in to fill the gap that they have left. In doing so, they have provided an efficient and cost-effective alternative, for which they should be applauded, not vilified.

First of all, let me say, I have no doubt in my mind that there are good doctors and there are bad doctors. And there are some really, really bad doctors out there. Doctors who have no business practicing medicine.

With that said, I would counter that preferring to pay someone for compassion instead of a medical evaluation is like paying for sex. And that makes you a John. In the appropriate situations, both should be free 100% of the time. If you aren't getting compassion from your family, your friends, your church or your priest, then paying a nurse practitioner $75 because your husband won't listen to you is the same as paying a prostitute $75 for sex because your spouse cut you off.

Compassion is not something I would ever consider paying someone for. And anyone who accepts money just to dish out compassion is no different than the prostitute selling their body.

Before you slam me, this isn't to say that health care workers shouldn't be compassionate. They should be. But to pay someone because they make up in compassion what they lack in clinical evaluation and management skills is simply ludicrous. I would take an apathetic but competent clinical evaluator 100% of the time. I would kindly get my compassion for free from those who aren't being paid to dish it out. Exchanging money for compassion is a denigrating proposition in and of itself. It turns something which should be free of financial interference into nothing more than a service.

You are also sorely mistaken when you believe that inpatient medicine is not "primary care" Primary care is not the doorway you like to believe. It is the house. Primary care's role is not to screen the patient to see what other subspecialists can get involved. The role of the primary care physician is to be the physician that takes care of them. I take care of many patients from start to finish with no subspecialist consultation. What does that make me if not the primary care physician

What you seem to believe is that NPs, in general, have a lower threshold to refer. I would agree with that, in principle. Certainly in practice, variation in referal patterns are influenced heavily by payer mix and volume models. Perhaps what you envision is a system where all patients are shuttled through NPs who siphon off the "easy" patients (by MD standards) and move the more complicated patients on to subspecialists. Patients that many internists could handle without referral.

What you seem to be saying is that it's OK for NPs to have a lower threshold of referral. I'm saying it's not. It's not OK for us to create a medical system where complicated patients are farmed out to multiple subspecialists in a never ending game of pin the tail on the procedure. I am saying that such a model increases costs by increasing FREE=MORE medicine. The role of the primary care "provider" is not to farm out complicated patients. It is to manage complicated patients. If primary care was simply there to be the glorified triage artist, primary care's value is zero. Perhaps this is the model of care you invision, one who's value is zero.

Any model of care that has, as its basic foundation, a provider who's main duty is to consult with others is a model doomed for economic failure, UNLESS, you ration with unfettered impunity, the costs associated with the proceduralization of such a model. If you want a model that uses subspecialists and not internists as the foundation of comprehensive care, be prepared for the most expensive model of care known to man. That which has no boundaries or limitations. Good internists define that boundary for which to work with.

What you seem to be saying is that internists have abandoned their field for highly lucrative procedural fields and therefor the solution is to allow NPs and to take over their role.

This is so completely backwards on so many levels, it's frightening to suggest that the solution to better care is to have providers who have a lower threshold to seek subspecialists who have entered the field because of the lucrative procedures. What NPs cost less on the front end, they loose exponentially on the back end, assuming you believe they have a lower threshold to refer than internists (at least good ones).

The solution is not to replace internists with NPs who have a lower threshold for referral. The solution is a model where fewer referrals are made. Where primary care is not viewed as a front line access to care, but rather the care, in its entirety. Until internists are paid for their time to take care of complicated patients, they themselves have become nothing more than triage artists farming out their patients in a volume mill of economic survival. And in fact bring little value to their role.

As for your assertion that subspecialties are more challenging. Hardly. Here's my experience with community based "more challenging" cases. If a case is really hard or time consuming, they get referred to the academic mecca where the "real experts" in the field get to tackle the latest and greatest case of reallyhardandtimconsumingitis. It is a rare subspecialist in Happy's Hospital who thrives on the interesting case. Rather the bread and butter pays the bills. And the bread and butter procedures pay for thrills.

Your entire thesis as to the appropriate role of "primary care" provider is why those two words need to be abolished from any association with internists and comprehensive care. Primary care is not the doorway to care. It is the care.