New skill sets are raising the prestige of primary care

Prestige in medicine often follows research. Physician-scientists who do basic science research have often been considered among the giants of medicine. As the field of medicine advanced, the gap between what we knew from basic science and how we practiced grew. This created a need for more translational researchers: physicians who could bring what they knew from the laboratory bench to the bedside through large clinical trials.

Now, the next great gap in medicine is the gap between clinical guidelines and actual patient outcomes. Since the Institute of Medicine published To Err is Human and Crossing the Quality Chasm, which highlighted the hundreds of thousands of deaths caused by medical errors and showed that unnecessary medical errors were in fact the third leading cause of death in the U.S, new medical research has focused more acutely on the gap between what we know we should do and how we actually do it. Every year, the fields of outcomes research and quality improvement in medicine are becoming increasingly important.

We are now transitioning to a new level of understanding medicine. We’ve already gone from understanding that hypertension is a risk factor for heart attacks to now understanding that everyone who has a heart attack should be on an ACE inhibitor and or a beta-blocker in order to control their blood pressure. Now, we face new challenges. How can we make sure that patients who experience heart attacks are actually prescribed the ACE inhibitors and beta-blockers that they need? How do we ensure that patients have access to these medicines? And what methods can we use to ensure medication compliance, helping patients to actually remember to take the medication as prescribed?  Because ultimately, it’s the application of the clinical knowledge we’ve acquired that will actually affect patient outcomes.

As electronic medical records (EMR) become increasingly prevalent, primary care physicians can readily query databases of their patients.  For instance, a question that would have taken days of painstaking paper chart review, such as, “Who in my panel of patients with diabetes has not had their blood sugar checked in the past six months?”  Or,“Who in my panel of patients has had a heart attack and is not on a beta-blocker?” can now be answered in minutes with EMRs. These patients can be called into the office, a visit to their home could be made, or a group visit could be organized for people with this condition. Over time, as more and more physicians get on board, all of these interventions can be measured, evaluated, published and disseminated. And primary care physicians will be at the forefront of this research.

EMRs allow doctors to think in terms of patient panels rather than solely in terms of individual patients. This doesn’t mean that primary care physicians will no longer value and cultivate the close patient-doctor relationships that are characteristic of the field. It simply means that physicians can take a more broad sweeping approach to carrying out clinical guidelines, such as verifying that all patients who’ve had a heart attack are taking the right blood pressure medication.

This change in thinking is sweeping across family medicine residency curricula around the country. Now family medicine residents are spending months of their training learning to manage panels of patients and to lead teams of caregivers comprised of social workers, nutritionists, medical assistants, PAs and NPs, Thirteen family medicine programs that received a government grant last year have increased the length of their programs from three to four years in order to advance residents’ training in exactly this skill set.

Attendings and residents are very excited about acquiring this new skill set. Adding these new clinical responsibilities, outside the day-to-day clinical routine, marks the first time in a long time that the scope of primary care is expanding instead of contracting. The new opportunity to conduct research on outcomes and quality that meaningfully contribute to the medical literature is elevating the profession of primary care once more. In other words, the prestige of being a primary care physician is back on the rise.

Anoop Raman is a family medicine resident who blogs at Primary Care Progress.

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  • Dr. Drake Ramoray

    deleted by the author.

    • DeceasedMD1

      MBA flavored I think. Definitely toxic.

    • DeceasedMD1

      MBA flavored I think. Definitely toxic.

    • NPPCP

      This new skill set has been practiced by me as a family NP in my private clinic for years. I can’t believe this piece was even written. As Dr. Drake said, I don’t need your skill set and NPs in 20 states don’t either. You are being fed a load of sausage my friend. In a practice like mine, you and your new “skill set” would just get in the way and eat up more of our already scarce resources. Sorry.

  • John C. Key MD

    Oh my, where to begin! Prestige, how thy definition is dumbed down. Using an EMR or properly implementing the fad-du-jour treatment guideline is scarcely on a par with developing valvular heart surgery. I fear that future practitioners will indeed be complacent and self-satisfied if Dr. Raman’s summation is any indicator.

  • ninguem

    The primary care doctor enters the crowded amphitheater.

    “Holding the form steady with the left hand, with the paper at an angle of fifteen degrees to match the radius of my right upper extremity. One must take care to use a surface that is firm, but slightly yielding to allow the ball point to transmit the hydrostatic force between the reservoir and the cellulose fibers. Too firm of a surface may cause too thin of a line, making photostatic duplication problematic, while too yielding may result in perforation of the cellulose fiber surface.

    Having verified the proper line, and taking care to apply gentle but steady pressure with the pigment transfer device, the signature is applied with the technique of Barchowsky Fluent Handwriting. You may notice, this is in contrast to the technique of Professor Fowler, who uses D’Nealian Cursive Script.

    Having confirmed and entered the current date, the preauthorization form is now complete for electronic facsimile transfer to the pharmacy.

    This concludes today’s operation.

    • Suzi Q 38

      You are too funny.
      How long did it take you to write this witty piece of narrative?
      Time to go back to you patients and make some money so you can pay your bills.

  • PrimaryCareDoc

    “EMRs allow doctors to think in terms of patient panels rather than solely in terms of individual patients.”

    And my heart weeps for this final nail in the coffin for primary care.

    Patients- do you want to be considered as “part of a panel” or as an individual?

    • EmilyAnon

      I am weeping. But what can patients do about it.

    • Patient Kit

      An individual, always. If I cease to be treated as an individual in our healthcare system, my inclination will be to avoid doctors as much as possible. I am not a widget or primarily part of a patient panel or population. I am PatientKit. And there is only one of me.


    And by definition as you describe FPs above – they would be called “Nurse Practitioners.” Except for the procedures part, gyn, and fracture care. I do LOTS of those things and more.

  • guest

    Um. No doubt it’s all this increased prestige that is leading our medical school graduates to avoid primary care in droves? Forget about avoiding primary care, they are avoiding clinical practice, most likely for the very reasons outlined above. If I had wanted to become a medical bureaucrat, I would have saved myself a lot of time and money and gotten a degree in hospital administration. But I like taking care of people, so I went out of my way to get an M.D. instead.

    Using my EMR to identify which patients in my practice are “out of compliance” with getting their blood glucoses checked and then using that information to harass them into obedience, does not seem like a gratifying prospect to me. That’s not caring for people, it’s managing them into neat little boxes and rows and columns. It’s not what I went to med school for.

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