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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