Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The hidden work of primary care

Michelle Nall, MPH, ANP-BC
Policy
December 11, 2017
175 Shares
Share
Tweet
Share

It was nearing the end of my day at the mobile health clinic where I work as a nurse practitioner, providing free, comprehensive primary care to uninsured patients in central Florida. Clinic was officially over, and we were no longer taking patients; I was signing notes and finishing up some teaching points with a PA student when a woman walked up and asked me if she could “talk to me for a minute, just to ask a quick question.” After many years working in community health, I know these types of requests are rarely “quick,” but, understanding our patients’ limited opportunities access to care, I obliged.

As soon as we walked into a private space, the woman, whom I’ll call Alice, began to unload.

“I’m having all this belly pain. I think it’s from my cervical cancer which has spread to my ovaries. I went to the ER, and the doctors didn’t do anything. They did a pap smear, and I think they’re hiding my cancer from me.” This stream-of-consciousness deluge went on for several minutes while I listened and nodded despite my growing anxiety at having gotten myself in over my head with this unplanned clinical visit.

When Alice was done speaking, I asked for her permission to review her medical records from her recent ER visit, which our clinic is fortunate to be able to access. These records indicated she had indeed been to our local ER, where she was evaluated for pelvic pain, tested for gonorrhea and chlamydia, treated for pelvic inflammatory disease, and given a pelvic ultrasound to rule out ovarian torsion – a rare but possible cause of lower abdominal pain. She was appropriately and safely sent home on antibiotics. So why was she so confused and angry about what had occurred?

As we talked further, I began to understand that Alice had a history of cervical dysplasia for which she had undergone a LEEP procedure many years ago, with minimal follow-up since. She has limited health literacy, so when she began to experience pelvic pain, her greatest fear was that her “cervical cancer” had “spread to her ovaries.” Over a few brief moments, we discussed cervical and ovarian cancer and how the two are not related, that her ovaries appeared normal in her pelvic ultrasound, and that the ER did not, in fact, perform a pap smear but had tested her for infection instead. I reassured her that no one was hiding a new diagnosis of cancer from her. We discussed that cancer screenings, like the pap smear, are more appropriately performed by a primary care provider and not in the emergency setting, and that the care she received in the ER was appropriate and intended to evaluate for and treat emergencies. She made an appointment to return to our clinic for a pap smear the following week. I saw the anger and anxiety in her face change, and she left our clinic a different woman than she had arrived.

I sat astonished at my desk after her exit. By all current billing standards, I had done nothing. I had spent no more than fifteen minutes with Alice and had done nothing more than explain in layman’s terms what had taken place in her recent ER visit, things that were surely explained in the ER but that she may have been too stressed or upset to understand. But this interaction — hard to define, even harder to bill for — had improved this woman’s understanding of her medical conditions and perhaps had avoided another ER visit. And, by the look on her face when she left, the interaction had probably improved her quality of life, too.

Because I saw Alice in a free clinic, I didn’t have to come up with a billing code to describe our interaction. But a clinic that needs reimbursement for time spent with patients would have been at a loss as to how to classify the visit. Yet members of the primary care team constantly provide some version of this “care,” this coordination of care, to our patients. We know, anecdotally, that these interactions improve quality of care, likely decrease unnecessary emergency room visits, and cut costs as a result. But without a billing code for this service, we have no record of the value of care provided. We need to work together to better capture the depth and utility of these interactions in an effort to promote the vitally important but too-often hidden work of primary care.

Michelle Nall is a nurse practitioner.

Image credit: Shutterstock.com

Prev

The demand for preparation: from the playing field to the OR

December 11, 2017 Kevin 1
…
Next

Insurance and the destruction of our health care system

December 11, 2017 Kevin 26
…

Tagged as: Primary Care

Post navigation

< Previous Post
The demand for preparation: from the playing field to the OR
Next Post >
Insurance and the destruction of our health care system

More by Michelle Nall, MPH, ANP-BC

  • a desk with keyboard and ipad with the kevinmd logo

    Defining the patient’s goals of care

    Michelle Nall, MPH, ANP-BC

Related Posts

  • Primary Care First: CMS develops a value-based primary care program for independent practices

    Robert Colton, MD
  • Primary care faces a very difficult winter

    Ken Terry
  • How the CPT system shortchanges primary care

    Richard Young, MD
  • Nurse practitioners will save primary care

    Leah Hellerstein, LCSW
  • Primary care today: There are several concerning trends

    Sue S. Bornstein, MD
  • Please make primary care as sexy as Grey’s Anatomy

    Elizabeth Métraux

More in Policy

  • Pediatricians grapple with guns in America, from Band-Aids to bullets

    Tasia Isbell, MD, MPH
  • Health care wins, losses, and lessons

    Robert Pearl, MD
  • Maximizing care amidst provider shortages: the power of measurement-based care

    Tom Zaubler, MD
  • Unveiling excessive medical billing and greed

    Amol Saxena, DPM, MPH
  • Chronic health issues and homelessness

    Michele Luckenbaugh
  • The impact of certificate of need laws on rural health care

    Jaimie Cavanaugh, JD and Daryl James
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Family support is pivotal in the treatment of schizophrenia

      Frank Chen, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
  • Recent Posts

    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Practicing medicine with conviction

      Arthur Lazarus, MD, MBA | Physician
    • The power of memory in shaping human identity

      Emily F. Peters and Sandeep Jauhar, MD, PhD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Transforming primary care for physician well-being [PODCAST]

      The Podcast by KevinMD | Podcast
    • COVID-19 unleashed an ongoing crisis of delirium in hospitals

      Christina Reppas-Rindlisbacher, MD, Nathan Stall, MD, and Paula Rochon, MD | Conditions

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Anti-TIGIT Plus Immunotherapy 'Promising' in NSCLC, Esophageal Cancer
  • Cancer Drug Shortages for Kids; Pharma Agrees to Price Talks; Catch-Up on Screening
  • FDA Adds Intestinal Blockage Reports to Ozempic Labeling
  • COVID Heart Injuries Traced Back to Infected Arterial Plaque, Inflammation
  • Obamacare Makes Surprise Cameo in Second GOP Debate

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • I’m tired of being a distracted doctor

      Shiv Rao, MD | Tech
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Family support is pivotal in the treatment of schizophrenia

      Frank Chen, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
  • Recent Posts

    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Practicing medicine with conviction

      Arthur Lazarus, MD, MBA | Physician
    • The power of memory in shaping human identity

      Emily F. Peters and Sandeep Jauhar, MD, PhD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Transforming primary care for physician well-being [PODCAST]

      The Podcast by KevinMD | Podcast
    • COVID-19 unleashed an ongoing crisis of delirium in hospitals

      Christina Reppas-Rindlisbacher, MD, Nathan Stall, MD, and Paula Rochon, MD | Conditions

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The hidden work of primary care
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...