Why primary care is like air traffic control

Recently I had an interesting conversation with a few young doctors regarding the new health care reform that had been passed in the United States. One future specialist asked me why primary care doctors should receive more money than they have in the past.

And this is an important question that I think sheds light on the suboptimal state of our current health care system. It is important to specialists because there is only one pie – if primary care doctors start taking bigger cuts, specialists will have to take smaller pieces of income home. But more importantly, this question is compelling because, really, what do primary care doctors do that make them deserve more money than what they are already earning?

I think the general notion is that primary care doctors manage various medical issues that are not complicated enough to be passed on to specialists. And so my specialist friend asked, why can’t primary care doctors be replaced by allied health care professionals (nurse practitioners or physician assistants), if they are only managing basic medical issues? And if so, why do we need to pay primary care doctors more money if we can just hire non-doctors to do the same job?

I think that our job in primary care cannot be replaced any more than in other fields like surgery or anesthesiology. In every field of medicine, there are simple patients that can be taken care of by allied health care workers, even in specialized fields, and then there are more complicated patients that need to be cared for by physicians with a deeper understanding of medicine. For example, in the field of anesthesiology, nurse anesthesiologists can perform many tasks that MD anesthesiologists can, but they serve as a clone of that physician so that he/she can anesthetize a few patients at one time. In the field of obstetrics and gynecology, midwives play a very important role in non-complicated deliveries, while leaving trained obstetricians to care for complicated pregnancies.

I would like to argue that in the field of primary care we specialize in coordinating care for the patient as a whole person – a manager for your health care – which is one of the hardest jobs in this complicated health care maze. Many do not view this as a real or worthy specialization, but more and more people start to realize that this is a complex field of specialization that requires a competent physician with a thorough understanding of all other medical fields.

A good analogy is to think of primary care doctors as air traffic control. Specialists only see the problems within their field, just like a pilot in a single plane. They are important, but it’s impossible to expect them to take in the big picture of the whole airport with hundreds other diseases in it, all interacting with one another. Primary care doctors step back and integrate all the information to make sure that all treatments work together synergistically and that the airport as a whole functions optimally.

And this is why health care reform is focusing more and more on attracting talents to primary care. Since we are health care managers, we make the decisions on when patients need tests or a trip to the specialists. Without good primary care physicians, costs go up without increased outcomes, and specialists cannot get good referrals without a good gatekeeper. For a young healthy person, their care can usually be coordinated by allied health professionals, but for an 80-year-old patient with multiple comorbidities, that job gets complicated and it needs to be handled by a good primary care physician.

I have high hopes for primary care, and even though I did not choose this field for the money (because there is not much), I do hope that we get higher reimbursements in the future, so that we can attract good talents that will turn our failing system around and keep our nation healthy.

angienadia is an internal medicine physician who blogs at Primary Dx.

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