The Myth of Primary Care

Throughout much of the past decade, primary care providers have been extolled as the salvation of our health care system. Even before the Clinton health care plan was unveiled, the secret to health care cost control was supposed to be primary care. Primary care providers (PCPs) were the ones in short supply, and would keep us solvent by rationing technology and access to specialists. Specialists were doomed.

We as emergency physicians were doing our utmost to be counted as PCPs. If this did not happen, our reimbursement as physicians would go down to nothing, post-graduate training positions in emergency medicine would not be funded, ED census nationwide would plummet, and our existence as a specialty would be jeopardized.

Why has this not happened? Several factors indicate that, far from being the solution to whatever crises ever existed within United States health care, the major problem in the country may be the primary care system. In fact, emergency medicine may be perceived as the only answer, although policymakers would never admit that this is so.

People vote with their feet. They come to emergency departments with non-emergency visits for myriad reasons, all related to the failure of the primary care system in this country. Few PCPs (certainly not enough) will provide charity care to the uninsured. We do. Of course, the law says we have to, but this is beside the point. EPs can still put their hand on the Bible, and recite the Hippocratic oath. Most PCPs keep inconvenient hours, convenient to the doctor but to no one else. Real people have jobs or kids who attend school. People do not want to seek care during their weekends. Emergency physicians all know that Mondays are the busiest day of the week in the ED for this reason, unless it is a Tuesday following a three-day holiday. Non-emergency care should not be provided at primary care practitioners' convenience and at the inconvenience of the rest of the world, but it is. Why should physicians who demand that patients miss work or school to seek health care have the effrontery to claim hero status?

This assumes that PCPs are accessible in a timely way at all. People who have back pain, a migraine, or viral illness may know that their disease is self-limited, yet they cannot get appointments within weeks. Often, by the time they are seen, they feel better. While people may not be dying from their malady, it certainly places an undue burden on emergency departments for the management of chronic illnesses, including pain management. Even for the insured, emergency departments may represent the quickest access to care.

I have known more than one administrator who has bemoaned the high cost of ED care for everyone else, but who goes to the emergency department himself at the drop of a hat because he doesn't know how to access episodic care. I have written about EMTALA in this publication; perhaps the day is not far off that we face fines for not seeing patients in a timely way - the dreaded delayed screening examination. Is a four-hour wait for treatment in an emergency department qualitatively worse than a four-week wait for some internist (or specialist) to see a patient for any problem in the world? Can any reader envision a family practitioner facing a $50,000 fine from HCFA for a delayed appointment? Perhaps we as a specialty should feel flattered about facing fines for failure to provide a timely screening examination. It seems to indicate that a number of bureaucrats and health care planners have given up entirely on everyone else in medicine, although it means beating up on emergency care and hospitals as the only available providers.

Of course, the public also must sense what we already know. When a patient is truly in need of care, there is precious little that many primary care providers can do in the office. If a child has a URI, any health care provider (doctor or not) can pull that patient through alive, hopefully without prescribing an antibiotic or phenylpropanolamine. A sick or toxic child more likely than not will be sent to a hospital emergency department. It is not an unreasonable wager that most office-based pediatricians have not performed a lumbar puncture for years, some perhaps not since residency, and I am not a betting man. A child with a forehead laceration should have his parents bypass their pediatrician's office and come directly to the hospital to eliminate the superfluous middleman PCP. I confess to being baffled at the tolerance of the British for a system in which a PCP is called in the middle of the night so that one can obtain permission to visit an accident ward for suspected appendicitis. Few Americans would abide this for an instant.

What about the preventive care that is supposed to be the salvation of us all to keep hospital admissions down? Immunizations are of tremendous value, as may be hypertension or hypercholesterolemia screening, maybe even osteoporosis monitoring. But all in all, I have been unimpressed with preventive care. Most Americans who have activity on their waking EEG don't need a doctor to tell them that it is not healthy to smoke or to be 200 pounds overweight. Heart disease and cancer are the big killers nowadays, especially for those of us who are not prone to being shot or crashing motorized vehicles.

The heart disease and lung cancer risk factors are pretty self-evident. When I review lists of lethal cancers that a middle-aged male like I might contract, I can eliminate the screening value of most of them. For example, lymphoma and pancreatic cancer are pretty much death sentences whether picked up early or late. The single common cancer that can be detected and treated early is colorectal carcinoma, and gastroenterologists screen for that one.

It is important for patients To have an advocate in the ED when it is unclear how long the wait will be and when most of the patients surrounding them are people their mothers told them to avoid

In all fairness, health care is complex and expensive. Patients with multiple medical problems need health care providers to juggle all of their tests, to keep track of diagnostic work-ups, and to handle overall care, especially because specialists show no inclination to want to treat or to keep track of anything outside their field. We don't always appreciate the importance for patients of having an advocate in the ED when it is unclear how long the wait for treatment will be and when most of the patients surrounding them are people their mothers told them to avoid.

PCPs are valuable advocates, and represent their liaison to the health care system long-term. Yet any EP knows primary care as it exists today is not the answer. Too often, calls to a PCP result in a request to consult neurology or call cardiology and get back to me with what they say. Calls such as these may keep patients' primary care doctors informed and keep administrators happy that their clientele (these doctors) get their calls. But too often, these PCPs have little to add regarding their own patients' care, and waste our valuable time because they do not help us make a treatment decision or disposition. Emergency medicine is an imperfect solution to health care access, but it still appears to be better than waiting for any policymaker's version of primary care to do the job.