Academic journal article Policy Review

Primary Care's Dim Prognosis

Academic journal article Policy Review

Primary Care's Dim Prognosis

Article excerpt

GIVEN THE CHORUS of approval for primary care emanating from every party to the health reform debate, one might suppose that the future for primary physicians is bright. Yet this is far from certain. And when one looks to history and recognizes that primary care medicine has failed virtually every conceivable market test in recent years, its prognosis is--to use doctor jargon--"guarded" at best.

Start by asking: Do primary care careers appeal to today's American medical students? Not so much. Barely 2 percent of them opt for careers in internal medicine and a mere 7 percent go into family practice. These numbers are down by 80 percent over just the past few years, and the trend will lead to shortages and the importation of foreign-trained physicians to cover the deficit. The problems of low pay and long hours that are blamed for the present predicament are likely to be exacerbated by new arrivals who typically are willing to work harder for less pay. A patient may find his new primary physicians difficult to understand, but he will nevertheless be grateful for their availability.

The generation of internal medicine specialists that was trained after World War II fundamentally reshaped American medicine. Three additional years of residency training beyond internship made them diagnosticians and consultants to both patients and other physicians. As they spread across the land, they brought modern medicine, once the province of large metropolitan areas, to small towns. This created the fertile soil in which a host of specialists and subspecialists would eventually thrive.

But general practitioners, sensing both a loss of status and not wanting to be left behind professionally, began renaming themselves family practitioners and extending their own residency training after medical school to equal that of the internists. Naturally, this blurred the difference between the two groups of doctors and added to the difficulty of defining what is meant by "primary care." The entry of nurse practitioners only added to the confusion. Could they really replace physicians? And could they do so at lower cost?

This, then, is the dilemma. Nobody has difficulty imagining what an obstetrician or an orthopedic surgeon does. But what does "primary care practitioner" really mean? The truth is that defining primary care and its scope has proved vexingly difficult. Does it include delivering babies or setting simple fractures? What about emergency room and in-hospital care? And is primary care really as easy as many specialists--and patients--believe it to be?

These uncertainties contribute to the sinking status of primary care medicine. In truth, much of primary care is indeed simple and straightforward. The initial care of a routine flu or backache isn't complicated and most of the time it doesn't matter who provides the care. The tricky part comes in identifying which factors make a certain case different from the last one. Because the outcome will, most of the time, be predictable, it can be difficult for an individual primary physician to prove his worth. There is nothing in primary care as clear as, say, mortality rates after coronary bypass surgery, which is the quality standard by which cardiac surgeons are measured.

Hospitals have resolved this quandary in how much training is needed for each individual task by deconstructing the job of nurses. So-called technical partners, after as little as one week's training, now may take patients' vital signs--blood pressure, pulse, temperature, and respiratory rate--that were once taken by registered nurses. This is usually harmless. But former janitors, tray carriers, and aides aren't the equivalent of RNS when it comes to identifying the tell-tale signs of a turn for the worse. Nor can they always resist the temptation to answer patients' medical questions that are instigated by the white coats that the technical partners wear. Using these partners saves money--something that is easy to measure--but at a cost that is hard to measure. …

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