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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  • buzzkillerjsmith

    Harrison’s, the standard “primary care” textbook, is 3000 pages long.

    PC, as many IM, FM, and peds docs realize, can be very complex indeed. That said, much of it is routine, especially once the diagnoses have been made and the pt is stable.

    Our clinic has 10 docs and 2 NPs. I suspect the proportion of NPs will increase over time. We can’t hire docs very well because they don’t exist in sufficient numbers. Hell, we have a hard time getting NPs and PAs. We prefer NPs over PAs in our clinic because NPs can practice independently here in WA and so it is less of a hassle to supervise them. Otherwise whether to hire a NP or a PA would come down to the qualifications of the individual.

    A model that makes sense is having physician and non-physician PC folks working together in the same clinic, so that instant consultation is available if needed. In addition, very complex or acutely ill pts could be sent to the most appropriate provider, who would be a physician, at least in our clinic.

    This model makes clinical sense. Unfortunately, it makes no business sense whatsoever for the upcoming medical students, as primary care itself makes no sense for them.

    • trinu

      Does your clinic run on a model which prevents patients from seeing an actual MD/DO if they’re labeled as “simple”?

  • edpullenmd

    This is just one of many debates that are essentially meaningless without better defining the issues. Much of the debate really boils down to turf battles about access to health care dollars in communities where there is competition for patients. In most communities there are more than enough patients to keep us all busy, and I agree collaborative practices are optimal.

  • LIS92

    Collaboration means that you won’t have a relationship with “your” doctor, that a receptionist will decide if you are simple or not. If you are unfortunate to seem simple but are complex, you will suffer for a while until you can figure it out yourself.

  • Medical Revolt

    I feel those specialties where an unevaluated patient comes looking for a diagnosis are by definition the most complex and require the most training. Yes neurosurgery and orthopedic surgery spend more time in training but that is because the majority of what they have to learn was not covered in medical school. But family practitioners, internal medicine doctors and emergency room physicians really have to use everything we learned in medical school and put it into practice. That is why I feel even the training I received to be an internal medicine physician was a little inadequate and I had to learn a LOT more on the job. So to put someone in that position with LESS training than me seems ridiculous and dangerous

  • Bob

    Like it or not, when the Carter Administration developed the term “Gatekeepers” Primary Care providers lost their profession and the practices became specialties that were only accessible by referrals. So today it’s easier just to refer patients to them, especially since GP pay for entitlement programs are squeezed as 4 million more are added to Medicare and 30 to 45 million are added to Medicaid, while we are woefully short on all physicians and nurses.