Our primary care and scope of practice debates make no sense

The Wall Street Journal has a question that I cannot really answer in their article, Nurse Practitioners and Primary Care.

This question has an implicit assumption that primary care is one thing, and that that thing is relatively straightforward and simple. I have written about this problem incessantly for the past 11 years on this blog. The term primary care has become the equivalent of a Rorshach test. When we read the term primary care we understand different things.

I recently wrote about the differing levels of primary care. Primary care is not one simple thing. Some primary care is simple and episodic. Some primary care focuses on addressing one common problem, like hypertension management. But some primary care is very complex.

Primary care can mean, and often means to internists and family physicians, comprehensive, continuous, complexity care. Primary care includes patients with multiple medical problems that defy strict adherence to guidelines, because the guidelines conflict among the various diseases. Primary care includes diagnosing diseases that are not routine. Primary care can be the most complex and difficult variety of medical practice, because almost any problem can present to your office on any day, and the primary care physician can be ready to evaluate that problem.

This level of primary care requires a combination of knowledge, careful thought processes and experience.

We often note that great physicians do not know everything, rather they know what they know and what they do not know. We all must remain humble in our approach to patients. Patient care requires our careful consideration and reconsideration.

So depending on the level of primary care, we need different training and expertise. Since I assert that complex primary care is not an oxymoron, who do you want doing that care? Asking who should do primary care without defining what the questioner means by the term primary care is akin to asking who should teach your child. Is your child 6, 13, or 21? What grade? Grade school, high school, college or graduate school? It all depends.

And thus our endless primary care debates and scope of practice debates make no sense, because we have not defined the terms for the debate. We should demand an end to the generic use of the term primary care, because that term has no clear meaning in 2013.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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