Primary Care: Expanding the Definition
In his entry Rebuilding the Past as the Future of Healthcare Services, Carey Kriz asks a good question about our primary care system. Before diving into the answers, we need to make sure the question is clear. The term primary care means many things to many people. It is at once being expanded by public policy and narrowed by medical advances.
In the Developed world as well as the Developing world, the notion of primary healthcare is being expanded by public policy and funding discussions that make it difficult to draw the line between public health, illness care and social services. Is the cost of long term nursing home care for a patient disabled by a spinal cord injury or dementia a healthcare cost or a housing cost? Is the cost of providing clean water to prevent disease a healthcare issue or a public works issue? The more expansive the definition the more ill suited high acuity care delivery appears suited to address the problem. That is not an indictment of hospitals; it is a problem of definition.
On the other hand, advances in medical technology and information technology are reducing the scope of things that were once called primary care. The ability to decide if a person is genetically at risk for a particular cancer or diabetes, for example, will mean that fewer people will need to go through routine screening because we can tell who is at risk. Similarly, we are now developing the ability to predict which patients will respond to which drugs using genetic markers such that primary care visits once used for trial and error treatments will be unnecessary. Finally, illnesses that we did not understand well and treated with broad based therapies, such as Type II Diabetes Mellitus, now have sophisticated drug regimens that are tailored to specific patients. It is becoming increasingly more difficult for primary care doctors to manage this level of specialization. The journey of HIV/AIDS illustrates this well. When it was first discovered, it was an exotic illness and treated by specialists. Then the epidemic came upon us, but there was little effective treatment so it became a disease of primary care. Once the antiretroviral drugs became available, the toxicity and complexity made treatment look like chemotherapy and it became a disease of specialty care. The more we know about diseases, the more we can target care and move it to higher or lower levels of specialization. In this paradigm, primary care is narrowed as knowledge increases.
Information technology has also narrowed the purview of primary care providers. Patients have the ability to access medical journals and the advice and experience of others in ways that were inconceivable just 15 years ago. Today a highly motivated patient with a disease can easily know more about that disease than their primary care doctor and sometimes even their specialist. Patients with symptoms have the resources to understand and even diagnose their conditions at home. Patients often find better information faster from their social network than from a healthcare professional.
This is why there is debate in the US as to whether or not we actually face a shortage of primary care physicians. If one assumes that economic growth and aging population increase demand for care as we know it – then we face a shortage. If one assumes that medical technology and information technology will reduce the kind of care provided by primary care doctors, then the specialty is on the wane.
As we go forward in this blog I hope to enlighten the debate by adding the necessary nuance to make good decisions. It is easy to talk about “the system” or “averages” but understanding the wide variation in the parts of the system is key to making things better without making them worse
Posted by Kaveh Safavi at 12:02AM PST
Debra Mar 31, 2009
It is clear to everyone that something in our healthcare process has to change drastically, and that technology will facilitate efficiency to the process and outcomes; however, there are many considerations to take into account. The entry posted on March 31, 2009, Primary Care: Expanding the Definition, the writer suggests that we ask the correct questions before having the answers, and I believe that would be a great step in the right direction.
I have been involved with healthcare for most of my career as a direct care provider, and in my experience, I have observed that change is especially difficult for the clinicians. It is understood that change is complicated. Yet these people are intelligent, so what causes such a negative reaction? One possibility is that the care providers often do not have a voice in decisions affecting patient care because business people and politicians are deciding. The decision makers do not see the entire problem if they only take a bird’s eye view. The problem has to be seen from all angles and distances. Another explanation may be that over time many have seen good solutions go bad for the patient (Patient-Focused Care Model in the 1990s). If you throw technology into the mix, well then you have to consider that a large percentage of the experienced practitioners today struggle with technology. Between advances in medicine, ever-changing regulations, and attempts to cut costs over the last two decades, physicians and nurses have become almost defensive to change.
In the article, "Rebuilding the Past as the Future of Healthcare Services," there are valid points except I feel it has not asked enough questions, gathered enough credible evidence, and seen enough views of the situation, especially regarding hospitals, to suggest realistic solutions. I agree that healthcare must start with the individual, and that medicine is about people, however in the current state unfortunately many people utilize these "new age industrial parks" for primary care services. From the rooftop view, we see our Emergency Departments are overcrowded, staff working short, and budgets cut. From the bedside view, we see sicker patients, increased patient loads, and a litigious society, all that will only worsen as the Baby Boomers age. Regardless of the view, health systems are overwhelmed.
Like everyone else with an interest in improving healthcare in America, I would like to be part of the solution. Although I have no profound instant answers, I would like to support the idea of discovering, or diagnosing if you will, the problems before assigning solutions. Additionally, as the discussions evolve, I urge the inclusion of care providers from multiple disciplines. Finally, I propose that we are careful as we set change in motion by planning well, assuring adequate resources, and educating all involved.