Take advantage of the vision of primary care physicians

In the ancient and oft-told story of the blind men and the elephant, several sightless men seek to learn the nature of the great beast, none of them familiar with it prior to the encounter.  One, who feels the trunk, describes the elephant as powerful and snake-like.  Another who examines one of the mighty legs, opines that the animal is like a great tree.  Still another, having first touched a large floppy ear, speculates that this must be part of a wing, leading to the suggestion that pachyderms might be able to fly.  In his own way, each was correct, but being deprived of sight and focusing only on that part he was able to examine, missed entirely the true form of the elephant.

My father, who for many decades practiced medicine in the small Georgia town where I live and practice primary care, once told me of an older gentleman who presented to the doctor’s office with an advanced carcinoma of the descending colon, a diagnosis that would eventually take his life. When asked why he had waited so long to come to the doctor, he replied rather indignantly that he’d been under a doctor’s care for a couple of years.  Several doctors, in fact.

The patient had been in remarkably good health until he suffered a myocardial infarction that led to a series of cardiovascular complications. In the process, a thyroid disorder was discovered and he was referred to an endocrinologist.  As all this was going on, he developed persistent back pain, and sought the care of an orthopedist. Scarcely a month went by that he did not have one or more scheduled appointments with one of his specialists. All of his doctors were quite competent physicians, and ministered well to the individual problems for which they were following him.

During the course of his treatment, he began to develop some vague abdominal complaints, and even noted a little blood in his stools. He said he told each of his physicians about his symptoms, but was dutifully advised that such problems were outside of their specialty. He was told to see his “regular doctor.” The problem was, he didn’t have one. The way he put it, “They didn’t seem all that concerned about it, and I figured I shouldn’t be either. And I was seeing too many doctors, anyway.” His heart, thyroid and back problems were well managed, but by the time he got around to seeing my father for his stomach complaints, the only option available was palliative treatment.

The range and depth of medical care available to the average American is among the best in the world.  Many, perhaps most, patients have direct access to specialists and subspecialists.  Their decision to seek a more specialized (and frequently narrower) level of care is oftentimes driven by their own perceived diagnoses. More than once over the years, I have seen patients seek orthopedic care for the back pain of a dissecting aortic aneurysm. The care rendered was excellent, but resulted in unneeded costs and unnecessary delays.

As we move forward into the twenty-first century, medical care delivery remains one of the larger problems faced by our ever more complex society.  With limited resources, and—in many areas—a shortage of physicians, we must seek ways to promote efficiency while not degrading the level of care rendered the patient. I believe one major trend that will persist and grow is the concept of the “medical home,” the idea that each patient be linked to a personal primary care physician who assumes responsibility for the overall short- and long-term direction of that individual’s health care. The advantages of such an arrangement are multiple.

First and foremost, patients will receive competent individualized care. Despite years of efforts to “standardize” medical care delivery, the use of treatment algorithms and the like, the practice of medicine is and will remain the ultimate cottage industry. Each patient, each problem set, and each complaint is so unique and so individual that care is best delivered by a provider who knows and understands the vagaries of the patient at hand. Chest pain can be a sign of serious illness, or—like the patient I saw earlier this week—a manifestation of anxiety over a daughter’s failing marriage. Many, perhaps most, problems and complaints can be successfully managed in the primary care physician’s office, resulting in significant conservation of scarce resources.

Second, many referrals to more specialized practitioners are diagnosis-driven.  A problem is identified and treated, which is appropriate.  Over the long haul, however, many problems can be avoided with a greater emphasis on prevention.   The obese patient who sees the pulmonary specialist for treatment of his sleep apnea will benefit by significant weight loss, not to mention monitoring for associated problems of diabetes, hypertension and hyperlipidemia.  Primary care physicians, especially those in a long-term relationship with patients, are best suited for that aspect of medical care.

A “medical home” relationship tends to lessen the problem of access to care. Pity the poor patient with an acute, but minor, problem on a Friday afternoon. Without a standing relationship with a physician, even one he or she sees infrequently, the prospects are a delay in treatment or a more costly visit to the emergency room or urgent care center.  Many studies have shown that patients who have an ongoing relationship with their physicians report a higher level of satisfaction and tend to be more compliant in following directions for their care.

Finally, in many ways, medicine—like politics—is local. It is of value when a locally based primary care practitioner knows the general health of the community, together with its risks and resources. The county where I live has a large mining industry. For many years prior to modern industrial hygiene efforts, dust-related respiratory conditions were common and quickly recognized.  The “local doc” may know of community groups and others that offer support for everything from weight loss to caring for patients with Alzheimer’s.

A single medical practitioner (or group) often cannot provide the complete answer for all patients.  But as a basis of referral for more specialized care, the arrangement offers many unequaled advantages. Primary care providers see and appreciate “the big picture,” offering patients a coordinated, coherent course of care. Moving into the future, we need to take increasing advantage of their vision, hoping to avoid the plight of the blind men and the elephant.

William Rawlings is an internal medicine physician who blogs at Primary Care Progress.

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  • Drsqamar

    Fantastic insight into the importance of primary care. As many are well aware, however, the reality today is quite different. As reimbursements continue to fall, just to manage business overhead, primary care doctors in private practice are driven to see more and more patients – until a point where lifestyle, or business (because private practice is a business), or quality of care (or all three) suffer. It is up to us to create new methods of practice that return primary care to the greatness it once enjoyed. Practice models such as direct primary care, for instance, that increase time spent with patients, increase patient access to care, and increase physician revenue.

    • kjindal

      such models as direct primary care will actually EXACERBATE access issues for patients overall, as more doctors give up on more wholesale change and contribute to (more of a) 2-tiered system.
      Rather I think its important to become engaged in trying to influence policymakers thru our advocacy groups to push for improved medicare reimbursement, and perhaps even a special per-patient subsidy for primary care docs. And FREE electronic record systems from medicare would help – after all, who benefits from better coordination in terms of reduced costs? medicare.
      I agree that the AMA has been quite disappointing in terms of the above. But our state societies (at least in NY) seems to get it, and seems to be more directly able to access politicians at the highest levels of state government, as opposed to the impotent AMA.

      • PcpMD

        How is focusing your practice to the number of patients that you can truly care for, and provide with the best care possible, wrong? That it would REVEAL (not create) the massive primary care shortage that we’ve been warning about for years is a sad commentary on how our medical system has devolved in the last 20 years. The fact is that primary care medicine done right takes a lot more time than the average 15 minute visit, and therefore would require a near doubling of our current PCP force to do right. These models allow for that reality. If universally adopted, the outcome would be more people becoming primary care doctors, as the reimbursement and job satisfaction (both sited as reasons for the PCP shortage) go up significantly.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    This blog entry is an amazing piece, and very well written. But now I have a question about this medical home that I have done quite a bit of reading about. How is this similar to and/or different from the HMOs that used to be so popular back in the 1990s that some may still have even today? The reason I ask this is because of the consistent thought by some that a Primary Care Physician is the “gatekeeper” of the person’s healthcare team even though elsewhere I have read that this term is now considered to be outdated.