Until the 1980s, few people understood the term “primary care.”
Proposed in the 1960s, it sought to clarify the importance and role of generalist medicine in
an advancing era of technologically driven, specialty care
.
“Primary Care: America’s Health in a New Era,”
the Institute of Medicine (IOM),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 the family and the community.”
In other word someone who gets paid the least amount to do the most work
The IOM emphasized the diversity and breadth inherent in the definition
of this term, stressing that primary care included “the care provided by certain
clinicians,” “a set of activities,” “a level of care or setting,” “a set of attributes”
for care, and “a strategy for organizing the health care system.”23 In using this
expansive definition, the field of primary care now attempts to compete alongside
specialty medicine.
But the overt marketing of generalist care through national definitions was not needed three decades ago.
Until the 1980s, defining what primary care consisted of was irrelevant.
patients knew only one type of physician
well, and that was their generalist doctor who was called the family physician
today’s primary care /Providers can range from an internist who can possibly treat a number of conditions where patietn would be shunted to various specialists by today’s other primary care /Providers such as family practitioners,family nurse practitioners and physician assistants.
in the 80s advances in surgery, cardiology,orthopedics, and radiologystarted a revolution in medical care leading to increased patient expectations,
changed payment systems and care delivery
the physician
Before this happened individuals and their families went to their family doctor exclusively
"when they felt a doctor’s visit was necessary. This physician was not someone
trained in one specific medical field whose job involved singular treatment of a
specific patient problem. Instead, it was someone whose everyday work
involved practicing across many different clinical areas of expertise and attending
to a full range of patient complaints and conditions."
They knew patients over long stretches of time, held their trust to make health care decisions for them, and handled a large, diverse scope of work.
In a time before urgent care centers, retail medical clinics, and direct patient contact with specialists like orthopedists,
} The family physician was one-stop shopping for individuals and their illnesses.
These doctors often worked alone or in very small groups, owned their practices, were
well known in the local community, and served as the central hub for connecting
select patients with different specialists on the rarer occasions when clinical
cases grew too complex."
theywere located in a neighborhood house or apartment suite, perhaps in a small office building, and
staffed with a physician or two, a supporting nurse, and perhaps one or two
clerical staff. Records, notes, and billing were all done by paper;
all patient information remained within the confines of the practice, under the direct control of
the physician. ( there was no HIPPA, yet no one saw thousands of patients medical records hacked and exposed by computer hackers ) It was paternalistic in both the best and worst ways, with the
generalist physician telling the patient what to do, and expecting complete compliance with his orders. ( there was no WebMD syndrome pr zocdoc)
The scope of work for generalist doctors during this time was full and varied. Generalists oversaw the care of their patients in the hospital from admission to discharge, performed after-hours call duties to address patient emergencies that required several or more nights per week of interruptions and
decreased sleep, visited patients when they went to hospital emergency rooms,
and performed different procedures on patients in their offices.
In every sense,patients were the clinical property of the generalist, loaned out to other specialists
in the hospital when that generalist felt additional episodic care was needed, but returned to the generalist once that care was over.
Specialists knew this, and relied on the generalist to refer patients to them
. This relationship gave the generalist power and encouraged specialists to interact and get to
know the generalists in their community.
Patients could see one physician and feel like that physician knew their full range of medical needs.
General medicine was dominated by middle- and upper-middle-class white men who worked long hours and on weekends, cared about being successful businessmen as well as physicians,
and saw their families less as a result
. In return for this commitment to building a profitable business and meeting patient demand, generalist doctors got paid in accordance with what their usual and customary rates were for the time
and services they and their local primary care colleagues provided.
There were only one or two insurance companies with whom to deal, and these companies
rarely questioned physician decisions.
A forty-five-minute patient visit could be billed and reimbursed in ways decided by the generalist, and payment moved in tandem with the idiosyncratic practice patterns of the local generalist
community.
Office visits between doctor and patient lasted as long as the doctor preferred.
There was no time limit for a patient visit.
Doctors were reimbursed for longer time spent with the patient, regardless of the diagnosis or services rendered,as long as other physicians in the community billed similarly.
There was no set number of patients to see in a given day to generate adequate practice
reimbursement, because the volume of individual visits was not the deciding
factor in how much a doctor could get compensated.
Adequate reimbursement came from whatever the physician felt was billable
that day to meet his own definition of quality care and make ends meet.
If ten forty-five-minute visits did the trick, then there was nothing wrong with
conducting longer visits where time was spent talking with the patient and the
social interaction was extensive. Waiting rooms were rarely filled, the physician
often ducked out during the day to go to the hospital or an outside meeting,
and the typical practice functioned in a more leisurely manner.
The workday sped up or slowed down at the sole discretion of generalist doctors:
what they felt like doing, the types of patients with whom they wanted to spend
more time, and how much money they wanted to make.
To assure adequate work variety, generalist physicians moved around during
their workday, going to the hospital each morning and evening to see
patients, participating on hospital committees, interacting with specialists in
the community at hospital events and medical association meetings, and making
emergency house calls. (really !)
This work supplemented an office-based schedule that involved performing procedures such as splinting, casting, and stitching,
basic acute care, and some chronic disease care.
Generalist doctors could engage in this wide array of duties because payers
and patients alike assumed that they were trained and experienced enough to
handle many clinical situations.
A quality movement and technological revolution that would justify having specialized doctors assume direct care over parts of their work had not yet begun.
No one looked over the doctor’s shoulder.
Patients went to generalists for everything, were managed by generalists through their serious illnesses, and insurers paid generalists adequately for attending to whatever patient needs the doctors deemed reasonable. ( there was no need for a large number of medical managers,People did not waste time stuck in voice mail maze to get preauthorizations.)
This didnot mean patients received the highest-quality, most cost-effective care from
the generalist.
It meant only that generalists were perceived as the appropriate caregivers for a wide scope of clinical problems.
Of course, care for all conditions was simpler back then.
For example, diabetic care consisted not of the tens of pages of care guidelines now followed
but of three basic procedures: regular blood glucose checks, proper management of insulin therapy, andspending
The contributing roles of patient
education and self-management, proper diet, physical activity, as well as
proper physician management of other conditions such as heart disease and
high blood pressure were not yet well understood and not part of the generalist’s
approach to managing diabetes. Usually less than a handful of available
drug options were available for every clinical situation, ranging from respiratory
and sinus infections to controlling lipids and cholesterol, thus making the
choices of what to prescribe easier. Fewer patients had multiple chronic diseases
that interacted with one another to create highly complex care situations.
If a generalist faced an uncertain diagnosis in a patient, he or she could admit
that patient to the local hospital without questioning from insurance companies.
Specialists would help identify the problem, treat it if necessary, and then
return that patient to the management of the generalist.
The more glamorous current-day physician view reflected on television
provides no room for the typical office-based primary care physician of today,
yet it is shows such as ER and Grey’s Anatomy that medical students watch religiously
to learn about the work of their profession.
The PCP is no longer perceived as the “all knowing” physician within medicine, no longer sees patients in the hospital or does procedures, performs less and less complex acute care,
deals with sicker, less compliant patients, faces packed waiting rooms, and remains in the office the entire work day, socially isolated from hospital and specialist colleagues, in order to bill enough visits for adequate pay.
We now perceive that the best and brightest physicians are found in the
hospital, moving around effortlessly and engaging in a never-ending routine of intellectual foreplay while doing narrowly defined clinical work rather than expansive primary care.
It is in the television-constructed hospital where complex life-and-death decisions are made matter of factly, where diseases meet their match through the application of other-worldly intelligence and cutting edge technology, and where patients are not so much human beings as containment
vessels for interesting and hard-to-identify pathologies.
The reality is the rendering of general medicine to secondary status among insurers, medical specialties, medical students and patients.
Society has shunned primary care and primary care physicians.The result has been a shrinking primary care workforce, the transfer of traditional primary care work from generalists to specialists, the rise of alternative forms of primary care, and a new business model of primary care delivery
that deemphasizes both the spirit and substance of primary care .
funnily these changes have occurred while the country’s demand for general medicine doctor grows,
creating a perfect storm for crisis in our health care system.
Much of this material is rehashed from
The Transformation of Primary Care by
many medical
students and residents increasingly believe about primary care, whether it is
indeed true or not, that in any form the work involved is more chaotic and less
intellectually stimulating than almost any other specialty, and can never match
the better salaries and lifestyles afforded by specialties such as dermatology,
radiology, or ophthalmology. And even when the work is perceived as interesting
by would-be physicians, many of them flinch at the breadth of knowledge
needed to become a competent primary care doctor, opting instead to become
masters of narrow specialty areas.
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