Tuesday, July 28, 2009

On the front lines of medicine

You've probably heard in the news lately that the role of primary care physicians (or primary care clinicians, which includes advanced nurse practitioners who can treat patients independently in many states) will be emphasized more in the health care system of the future. In the 1990s, the heyday of health maintenance organizations (HMOs), these physicians often functioned as "gatekeepers," among other things, determining if it was necessary for a patient to see a specialist for his or her medical problem. Some physicians had employment contracts that actually paid them more money to prevent patients from accessing specialty care - an uncomfortable (if not unethical) role that led to a popular backlash against, and eventual decline of HMOs as a means for controlling skyrocketing health care costs.


The Institute of Medicine has defined primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." That's quite a mouthful! But who counts as a primary care physician, and why are these particular doctors so important?


Family physicians provide comprehensive primary care to patients of all ages; about 1 in 3 family doctors routinely delivers babies. General internists provide primary care for non-pregnant adults, and pediatricians provide care to infants and children through late adolescence (variously defined as 18 or 21 years of age). To complicate matters, many generally healthy female patients rely on their obstetrician-gynecologist (OB-GYN) for primary care, and a few patients with complex medical conditions, such as insulin-dependent diabetes and acquired immune deficiency syndrome (AIDS) may obtain primary care from specialists, such as endocrinologists and infectious disease physicians.


Collectively, primary care physicians are the "docs in the trenches," laboring on the front lines of medicine to diagnose and treat most common acute and chronic health conditions. But for a number of reasons (which I'll get to in a later posting), fewer medical students are deciding to pursue careers in primary care each year, and that's a big problem - not only for the cost of health care, but the quality of health care too. Stay tuned for why this is.

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