Primary care has a marketing problem

I recently saw a sticker on a bus shelter. It was an arrow about 10 inches long and 6 inches wide. It seemed to be pointing to the bus map. “This is Public Health,” it said. The sticker, part of a larger campaign, gave me pause. Sure, a bus stop is public health because it a marker of mass transportation; it symbolizes improved access and decreased pollution from individual cars. Looking around, I saw a lot of places that would be appropriate for that sticker.

Later, I had the opportunity to talk with a few students who had participated in the campaign. They were thrilled with the neat places they had labeled, such as a bike path, a farmers market and a park. And they were particularly happy that the exercise had led them to a clearer understanding of public health, which is that it is pervasive and promotes healthy choices.

Given a sticker that reads, “This is Primary Care,” I wonder where I would put it. How would I define primary care? For a long time, primary care doctors were derisively called “just generalists.” Our discipline was the fallback for medical students who couldn’t get into another specialty. We were also the least understood discipline since we address such a wide range of health issues.

I’ve read essays from pre-medical students who wanted to go into medicine in order to understand and serve the human condition. Idealism is a strong component of the drive to go into medicine. And then, as we’ve all heard someone say before, “Medical school beats it out of them.” One way or another, career choices are skewed away from primary care during medical school.

Primary care has a marketing problem. We need “This is primary care” labels to stick in diverse places around our towns.

Primary care has the unique ability to keep one foot in clinical medicine and one in public health. But we lean towards the clinical side and need to explore the wide world of public health. Restrictive payment models combined with the enormity of public health work and our lack of familiarity with it have kept us in the clinical realm. We need to counterbalance the pull and the top heaviness of “sickness care” with a move to public-health-focused “wellness care.” It would be more productive and complete the holistic approach that most of us crave.

I’m not alone in my thinking. The Institute of Medicine has challenged our field to better integrate primary care and public health in the context of improving population health. Merging the here-and-now of clinical medicine with the long-term horizon of public health brings with it challenges and opportunities. But it is in this particular niche area that we can thrive. Keeping individuals in mind, aiming for community-wide impact and shaping the future of larger swathes of society should be the goals of the primary care physician of the future.

Merging public health and primary care would close the loop on issues identified in clinics with input from homes and communities. It would put into context environmental factors that worsen a child’s asthma and would link community groups who would then be partners in developing means to address those factors. Well child visits would include college preparation activities. Activities that start with the immediacy of a clinical encounter would lead to activities that make a broader community impact. For example, a clinical encounter dealing with domestic abuse would lead to building or strengthening battered women shelters.  It would add out-of-clinic population management activities to our current in-clinic encounters, such as creating walking groups for people with peripheral vascular disease.

Besides improving population health, I believe this approach would help address the vast physician burnout. Could a move to a more holistic approach to care and wellness decrease the existential angst of dealing with emotionally draining clinical scenarios one at a time?

The Affordable Care Act’s requirement that not-for-profit hospitals develop community assessment and create community assistance funds and the law’s provisions for more preventive services bring opportunities to change our current care delivery models. We need to embrace this opportunity to move out of traditional clinical settings, go into the communities that we serve and understand and function in the manner that communities want us to. The newer models of care, such as patient-centered medical homes and accountable care organizations, provide us with a rubric for population management. Moving out of traditional settings and into the community will empower us to better use our skills. It is this opportunity of working in communities, using biopsychosocial paradigms, emphasizing wellness care with sickness care that will make future physicians more satisfied with their work.

And as we do this, migrating from the current restrictions within the four walls of the clinic to the communities that we work in, we will be able to place labels all over our communities that read “This is Primary Care.”

Shailey Prasad is a family physician who blogs at Primary Care Progress.

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  • Margalit Gur-Arie

    I’m not sure I understand all the suggestions above (e.g. college preparation activities during well child visits), but in general, I don’t see how having full blown physicians cut back on clinical activities and do more community organizing stuff is going to lead to better health or lower costs.
    I do agree that primary care needs to change, but I think it may need to change precisely the other way around, by restoring itself to providing more comprehensive clinical services, and yes, by leaving the four walls of the clinic and going back to admitting patients and providing some continuity of care when it really counts.
    Public health is important, but there is no need for a complete medical education to do good public health. On the other hand, cutting down on expensive specialty visits and decreasing fragmentation of care for individuals, does require well educated physicians. It’s usually better for all involved, and more cost effective, to match the skills to the job.

    • Dr. Drake Ramoray

      Maralit, your suggestions are good ones, and diametrically opposed to those in this article that belongs in Pravda.

      Marketing doesn’t matter at all though in the end when what is being sold is more headaches, more red tape, and lower reimbursement when compared to specialty colleagues.

      PS the lack of continuity is also a reimbursement and a corporate medidicne problem becaus seeing patients in the hospital is a money loser.

      • Margalit Gur-Arie

        Not seeing patients in the hospital is also a money making proposition for the hospitals, and I suspect that this is the stronger driver, but I agree, we get exactly what we pay for.

  • Deceased MD

    The answers all lie in the RUC.

    • NewMexicoRam

      I agree.
      Enough of slogans and good feelings.

    • buzzkillerjsmith

      Pretty much. If the money ain’t right, ain’t nothin’ right. Some people never get this figured out.

  • Ron Smith

    I don’t think that public health, primary care, and immediate care can be equated. I also don’t think they can meld into one entity. Immediate care is the antithesis of primary care. That’s kind of like saying I’ll buy health insurance when I get sick and need it cause now I don’t have to worry about preexisting clauses. Public health has a macro focus. I and my two nurse practitioners take care of the 10,000-15,000 children in the practice. We are focused on them. We take time and consider each child’s case carefully. We don’t do drive thru Pediatrics, and we really don’t care about meaningful use as it currently defined.

    I am interested in us becoming a Patient Centered Medical Home practice, but not because of what it currently is. I want to add the good things I’ve developed in my practice to improve it. Currently there are only 5 such practices in the state of Georgia. That seems worthwhile to me, especially since we already do much of what a PCMH certification requires.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • southerndoc1

    So we should spend less time with our patients and get out of our offices so we can build domestic abuse shelters and lead walking groups?

    Sorry, but your post is condescending in the extreme: you devalue the work of both primary care physicians and public health specialists.

  • Dave Mittman, PA, DFAAPA

    Don’t forget PAs and NPs deliver primary care also.
    Include us in your thinking.

  • Michael Wasserman

    As I’ve often said to my patients, “the cardiologist takes care of your heart, the dermatologist takes care of your skin, the opthalmologist takes are of your eyes…I take care of you!” That’s what primary care is:)

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