When specialists try to practice primary care

Recently a good friend asked me to recommend an excellent primary care physician in New York City. When no one immediately came to mind, I asked a couple of doctor-friends who trained in New York. One friend, a cardiologist, gave me two names—one was a rheumatologist, who also practices general medicine, and the other an infectious disease doctor by training. My initial reaction to my cardiologist friend’s suggestion that a patient should see a subspecialist for primary care was one of slight annoyance.

In my view generalism is a specialty in its own right, and the concept that primary care would be as well-delivered by a physician whose main field of interest is a medical subspecialty seemed flawed. Sure, medical subspecialists go through training in Internal Medicine just as general internists do, but I question whether they really spend time keeping current with the broad range of primary care topics that fall outside of their domain of expertise. Is primary care really something that one can practice on the side, while trying to maintain an in depth knowledge of a medical subspecialty as well?

Much attention has been drawn of to the described shortage of primary care physicians in our country. Is this why patients in New York City are seeing subspecialists for primary care? Or, is it that a general internist alone, without a subspecialty practice on the side, cannot afford to live in New York City? Another friend warned me that most primary care physicians in Manhattan are “cash only.” Relatively lower pay for primary care doctors in the United States health care system has been blamed, in part, for the primary care physician shortage. I believe that it’s more than just pay.

Just how should subspecialists and primary care doctors interact? This has been the subject of debate for years. With the advent of managed care the general internist went from the role of esteemed consultant to the role of “gatekeeper.” A term that drives many of my older colleagues into a maddened frenzy. More recently we have become “primary care physicians,” a label that I personally don’t take issue with. In the United States patients are more likely to visit a subspecialist than a primary care physician. We refer patients to subspecialists more often than in other countries who have reported better performance on quality of care parameters. In the UK patients are referred to subspecialists at about half the frequency that patients in the US are referred. Care delivered by specialists is more expensive than that delivered by primary care physicians. Are there a quality of care differences? Studies have been conflicted on this point and it seems that it depends in part on the condition in question and also on the health delivery system that the care occurs in. An interesting study in the Annals of Family Practice found that many subspecialty visits are routine follow-up of chronic conditions, or preventive, as opposed to consultation requested by a primary care physician.

In many cases a specialist serving as primary care physician may refer to other subspecialists when conditions emerges that are beyond his or her scope of expertise. For example the cardiologist PCP may refer to an endocrinologist when a fasting blood glucose of 150 is detected, or the infectious disease PCP may refer to the nephrologist when a serum creatinine is 1.6 is detected. In my experience patients who have been managed for primary care by specialists tend to have many more doctors than those who are managed by a competent primary care physician. In some cases patients enjoy and benefit from these additional medical consultations, but many times patients come to me overwhelmed by the number of doctors they are seeing and the myriad of uncoordinated opinions that these various physicians have generated.

In our country over 100 million people suffer from a chronic condition. Amongst Medicare patients, over half have two or more chronic conditions. The Patient Centered Medical Home, with its team-based approach led by a personal physician, has been proposed as a solution to improving care within our health care system. Other primary care physicians have rejected this vision in favor of maintaining a more traditional doctor-patient relationship. However, in order to continue to provide the type of general medical care they feel is best for their patients some primary care physicians are choosing alternative models of care delivery, including retainer fee practices, which come in a variety of models, or micropractices with very low overhead and high tech solutions to improve efficiency and outcomes.

Accountable care organizations have been promoted as a means to support high quality and lower cost delivery of care. Primary care practices that exist in isolation may find it increasingly difficult to survive. Such practices should make attempts to establish linkages and improved lines of communication with their subspecialist colleagues and hospitals. The hope is that meaningful use of electronic medical records will allow such communication– if these electronic records are not too expensive for the small medical practice to adopt.

However, it should be emphasized that whether or not primary care succeeds is not only in the hands of primary care physicians and policy makers. Placing a higher value on generalism as an esteemed specialty from within the field of medicine will help enhance the standing of primary care in our country. Medical specialists will need to embrace a changing role with better shared care if we want to solve the primary care shortage and entice new trainee into this most fascinating specialty of medicine.

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    Didn’t that ID or rheum doc do a general IM residency before fellowship?

    • Juliet Mavromatis

      Ninguem,
      Thanks for reading. Sure they did, and on their first day after IM residency they were just as good at practicing primary care as the next guy, but after fellowship training and ensuing years of practicing a medical subspecialty, the perspective changes from generalist to specialist.  Keeping abreast of medical information with a broader view, and how to best manage patients in a more holistic way makes the perpective of a generalist quite different.
      Juliet

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

        Whatever………that’s the sort of attitude that gets the primary care docs shut out of endoscopy, obstetrics, the nursery, etc.

        The same attitude that renders ALL specialists completely unfit to do primary care, justifies the specialists when they shut the family docs out of the ICU and the endoscopy suite and the ER and the obstetrical suite and the nursery, because NONE of them are qualified. Then everyone wonders why no one can find FP’s in the hospital anymore.

        • Juliet Mavromatis

          good point. I wouldn’t consider consider doing an endoscopy or caring for a patient in the ICU–too much to know in ambulatory general medicine for me to be skilled in these areas. I wil,l however, see my hospitalized patients on admission and at discharge to help with care transitions (I don’t bill for that however). 

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

            Whether you do, or do not do, these procedures, there are primary care docs who do. I’ve been around the block enough to have been in the privileging fights where the primary care docs wanted to do certain procedures responsibly. Put on committees in the middle of fights with anesthesia and the ER docs over sedation, and between radiology and OB over ultrasound imaging. I like to let all the doctors play nice and responsibly. I like to think I won’t be like the specialists who stonewalled the primary care docs. I won’t stonewall them if they want to do primary care.

            Sheesh, you’ve got nonphysicians who want to do full-spectrum primary care with no physician involvement at all. Nurse-practitioners do not need physician supervision in my state. And that’s OK, but you have a problem with a specialist who wants to do more general medicine?

  • http://twitter.com/DrPlumEU David Lewis

    Good essay.  First contact doctoring defines primary healthcare.  IMHO, specialists are not blessed with managing this properly.  One role of first contact healthcare is acting as gatekeeper to specialist care.  Most problems are self-limiting.  General Practitioners (and their equivalent) are trained to appreciate this.  The failure of the normal pattern is what causes our senses to become alert and prompt further evaluation.  This is one of the keys to reducing healthcare costs.  In UK, GPs are a threatened species.  We do so much that is not measured or costed, and we manage uncertainty in ways that probably shock physicians trained to hospital specialty standards.

    Yet, we are often correct in our judgement.  Few folks die on our watch, hundreds are sent away with advice, prescription or scheduled review without involving any other healthcare provider.

    The author is right – ID and rheumatologists cannot really do this work.  To every carpenter, every metal spike is a screw.

  • Anonymous

         Like Dr.
    Mavromatis, I too have puzzled over the recent proliferation

    of focal subspecialists, and whether or not this is a good
    thing for the

    health care system—particularly as regards the system’s cost
    of care.

         In the past times,
    the majority of non–primary care specialty

    physicians accepted only referrals made to them by another
    physician.

    This gradually began to change around the early eighties,
    and begs the

    question, “why?” After all, if non–primary care specialists
    were

    sufficiently busy and financially happy plying only the
    specialty

    techniques and skills of their self-chosen limited fields,
    why would

    they feel the need to see greater numbers of patients,
    especially if

    those patients might turn out not to require their specialty
    techniques

    or skills? Greed is always a potential possibility, but the
    universal switch, by

    subspecialists, to accepting self-referred patients has
    become

    too widespread for greed to be the only factor. A much
    simpler and

    plausible reason might be that, today, focal specialists
    increasingly are

    finding it difficult to stay busy enough if they confine
    themselves

    strictly to seeing only patients who unequivocally have need
    of the

    expertise of their particular specialty, for achieving a
    better result than

    could have been achieved with seeing a non subspecialty
    primary care

    physician.

         Ironically
    medicine, over the past thirty years, has been co-opted by

    business in every principal but one, supply and demand.
    Currently it

    would appear that supply of many of the high-profile,
    high-pay

    subspecialties is now exceeding bona fide needs for their
    services. If

    so, this creates the ideal conditions for producing an
    increase in

    unnecessary procedures and surgeries and, for the same
    reasons, creates

    a temptation for subspecialist physicians, trained in very
    focused areas

    of medical practice, to begin dabbling in areas of medicine
    unfamiliar

    to them in order to remain sufficiently busy.

          Those old enough
    for doing so would remember the fifties to the

    early eighties being a period characterized by high patient
    satisfaction,

    high doctor satisfaction and economic stability within our
    nation’s

    health care system. It was also the time frame in medical
    history where

    primary care physicians were the work-horses of our health
    care

    system. During this period they far out numbered their
    specialty

    colleagues and provided competent, efficient and cost
    effective care

    for the lion’s share of all of America’s injuries and illnesses.
    In doing

    so they also identified and directed the small percentage of
    patients, in

    need of a specialty other than primary care, to their most
    respected and

    reliable colleagues within the appropriate specialty for
    dealing with the

    particular problem. In short, primary care physicians,
    serving as gate

    keepers to the nation’s health care system of the past,
    provided a much

    needed service for their patients, their specialty
    colleagues and the

    economics of our health care system. —Alan D. Cato MD,
    F.A.A.F.P. (past),

    and author of The
    Medical Profession Is Dead and the Doctor Is “Critically ill!” (Oct., 2010)

     

     

  • Juliet Mavromatis

    Criticaldoc,
    Thanks for reading and adding the historical perspective here.
    Juliet

  • Anonymous

    I happen to believe that the shortage of Primary Care Physicians is contrived. I happen to believe that Primary Care should be a “specialty” and the Primary Care Physician (PCP) should not be the first person you see when you initially seek health care in any form. I believe nursing professionals are sorely underused and is not given the credit they deserve to perform routine primary care. My PCP says the nursing profession can perform most primary care. My PCP tells me that around 85 percent of primary care is routine. In my mind, that means we pay a highly trained and highly paid doctor to do what a nurse professional can do for much less cost. If my PCP is correct, only about 15 percent of the cases he sees require the care of someone more qualified than a nurse professional. In my opinion, those 15 percent of cases requiring a more qualified opinion could be referred, exactly like all other specialist care. 

  • Anonymous

    All physicians (primary care and specialists) take the Hippocratian Oath.  Hippocrates was a PCP and he was poor.  It is not fair in our medicalized society to compartmentalize the human being that is in a state of disease or illness.  It is also not just to “miss the forest to save a single tree.”  In other words, the lack of coordination between the PCP and the specialist could not have adverse effect on the care of the patient.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      Amazing how much nonsense abounds with Hippocrates. He was a physician, no different from others. He was not a “PCP”, there was really no such thing. There is no evidence he was poor; in fact, he appeared reasonably well-to-do.

      http://www.notablebiographies.com/He-Ho/Hippocrates.html

      The Hippocratic Oath contains many promises to do certain things and avoid others. Hippocrates crafted an Oath that would help with his retirement plan and his kid’s college fund:

      “…..To hold him who has taught me this art as equal to my parents and to
      live my life in partnership with him, and if he is in need of money to
      give him a share of mine, and to regard his offspring as equal to my
      brothers in male lineage and to teach them this art–if they desire to
      learn it–without fee and covenant; to give a share of precepts and oral
      instruction and all the other learning to my sons and to the sons of him
      who has instructed me and to pupils who have signed the covenant and
      have taken the oath according to medical law, but to no one else……”

      http://en.wikipedia.org/wiki/Hippocratic_Oath

      And I doubt may physicians are using anything even close to the classic Hippocratic Oath anymore. Physician participation in abortion and in suicide were specifically prohibited in the classic Oath.

      “….I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work…..”

      Sounds like compartmentalization to me.

      Although Hippocrates may have come from a wealthy family, he was politically unpopular in certain circles, and was reportedly imprisoned at one point in his life. Twenty years, according to Wikipedia. That may well have made him poor. Fortunately, the Hippocratic Oath may have helped with his retirement plan,.

  • Juliet Mavromatis

    The shortage of primary care may be somewhat contrived. There was a New England Journal of Medicine article to that effect a few years back. The problem may have more to do with where primary care doctors are practicing–there are shortage areas.  I disagree with your PCP . I think part of helping patients with complex problems and diagnostic dilemmas is knowing them well on a routine basis before and while these conditions develop. My own opinion, which may be controversial, is that nurses in primary care are wonderful in their adjunctive role –counselling, helping with chronic illness care/disease management–but not as a substitute for a primary care physician.