The hidden work of primary care


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.

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