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The Disgraceful State of Primary Care

Glauser, Jonathan MD, MBA

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doi: 10.1097/

    The patient-centered medical home is an approach to providing comprehensive primary care for children and adults. This is touted as facilitating partnerships between individual patients and their personal physicians and, when appropriate, the patient's family. This is the brainchild of a consortium of organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. These worthy groups claim to represent approximately 330,000 physicians. Their principles include:

    • ▪ Each patient will have an ongoing relationship with a personal physician to provide first contact and continuous, comprehensive care.
    • ▪ The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
    • ▪ There will be a “whole-person orientation” for all stages of life: acute care, chronic care, preventive services, and end-of-life care.
    • ▪ Care will be integrated across all elements of the complex health care system.
    • ▪ Quality and safety are hallmarks of the medical home: evidence-based medicine, accountability, quality improvement, family participation, enhanced access, and open scheduling.

    I should mention that the concept is not new; it was introduced by the American Academy of Pediatrics in 1967. It's on all patient-centered medical home web pages. Obviously, these organizations will be pressing for funding to promote their ideas of primary care. They want money, money that might go to other elements of our flagging health care system.

    Say what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.

    I cannot be the only emergency physician who has treated patients referred by primary care doctors for such non-emergencies as:

    • ▪ Asymptomatic hypertension of 190/115 mm Hg picked up in the office or at health fairs. If you told me 25 years ago that some guy out on the town for the evening would be referred to the ED by an internist to manage high blood pressure, I would have thought you were crazy.
    • ▪ Asymptomatic hyperglycemia of 350-500 mg/dL in patients already managed by these doctors on oral agents.
    • ▪ An asymptomatic patient with an INR of 5.
    • ▪ An entire family of eight referred for screening for pertussis exposure, all asymptomatic.

    I can instruct the patient with the INR of 5 to avoid getting hit in the head by a baseball bat for the next few days, but so can the doctor who sent him to the ED. Give primary care doctors more money? Their patients usually have the common sense to know they do not have a medical emergency when these doctors refer them in to the ED.

    I have my own ideas about what primary care should accomplish, but foremost among them is to see patients in a timely way when they get sick as opposed to the dermatologist who schedules an appointment three weeks later, by which time the rash has disappeared. Or how about having the diagnostic and therapeutic skills to intervene in some way when the acutely ill patient does show up? Or caring for patients regardless of their ability to pay. After all, the people who sustain strokes, MIs, and aortic dissections because of untreated conditions of some sort (hypertension, diabetes, hyperlipidemia) are the ones most likely to benefit from preventive services.

    I have never encountered a plea for health care reform that did not extol the benefits of detection and treatment before some disastrous outcome ensues. In the long run, of course, preventive care does not save society money; we all get some terminal illness eventually. But it does enhance the quality of life we have if we can go though our days without aphasia, hemiparesis, or an ejection fraction of 20%. Where is it in the plan that everyone gets a doctor regardless of ability to pay? Clearly, the uninsured, the working poor, and the people currently without access to care would benefit most from such a program. What happens to the patient-centered medical home when the patient can't pay?

    Much of the degeneration of primary care in this country, in fairness, is not due to these doctors themselves. After all, their office visits have been booked solid for months. They get paid for seeing 25 patients (or 20 or 30) a day, so they and their office staff can knock off at 4:30 p.m. Any appointment they see on February 26 was booked in November. They never see anyone who is acutely sick so it wouldn't even make sense to add an appointment on as an emergency. When one of my kids was cut or injured when they were younger, my wife dutifully wanted to call our pediatrician. I couldn't figure out why she should make that call 15 years ago because our pediatrician didn't have suturing skills and the only time she ever repaired a facial laceration was during residency. I would have had to bring the suture materials into her office from the ED. On an even more basic level, why even call the pediatrician for a fever? Most fevers are benign, but the ones that are serious (sepsis, meningitis) have to be sent to the ED anyway for diagnosis and treatment.

    To an extent, the risk of throwing away precious dollars on any primary care initiative is our collective fault. How could we as physicians ever allow a doctor to call himself primary care when he can't manage simple chronic illness, cannot definitively treat acute illness or injury, often has no skills to save lives and no access to equipment if he had the skills, and does not even see patients at their own (the customers') convenience? Did I mention seeing people who simply need care, regardless of ability to pay?

    This new proposal appears to encompass keeping track of immunizations, health screening tests, and coordinating and consolidating one's medical information. This is undoubtedly a valuable task, but hardly one that requires a doctor's extensive training. If I were really cynical, which of course I am not, I could add that computerized medical records have made the bulk of a patient visit be spent with the provider pecking away at a keyboard to input information. There isn't much laying on of hands anymore. If I were really a suspicious person, which surely I am not, I would find the clinical skills of many primary care providers to differentiate splenomegaly from lymphoma or a direct from an indirect hernia suspect.

    I would posit that many of the failures of our health care system are exactly the failures of and by the primary care system. Patients are admitted to the hospital and all of their meaningful care is performed in the emergency department by specialists, hospitalists, and surgeons. Hopefully, the primary care doctor sequestered in his office learns later about the care provided because it is by no means a sure thing that he will visit his patient in the hospital.

    The sham of primary care is in some ways a metaphor for the failure of all doctors to act as doctors. When a huge fraction of Harvard's medical school class is going into dermatology (hardly a field that would be missed by the American public), when general surgeons want a patient admitted to general medicine to manage a potassium of 3.4, and when orthopedics consults medicine for a Tylenol order (I couldn't make this stuff up), we have a general syndrome of doctors failing to be doctors. Don't reward “primary care” organizations by funding them. Their unparalleled record of failure and complete dispensability does not merit even a second thought of throwing dollars their way.

    © 2008 Lippincott Williams & Wilkins, Inc.