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On my mind, part II
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In last month’s column, I posed the question of the loss of the independent general pediatrician. One could also ask whether we have come to the end of physicians as primary care generalists. As much as I would like it to be, I realize that pediatrics does not drive medicine or medical care. However, many of the same changes and pressures I discussed last month also apply to primary care across the fields of pediatrics, internal medicine and family practice. Unfortunately, the debate over solutions will likely lack voices from those of us physicians who are practicing general pediatrics or primary care medicine in any form.
Medical home redefined
Primary care receives a lot of mention as our national debate on health care reform proceeds, but it would be naive to think that primary care is being conceptualized in any uniform way or that its lack of definition is not intentionally vague. Much of the current reform discussion, as has been true of much of recent efforts, relies on a strong primary care base. In pediatrics, we have spoken of a medical home for decades. Adult medicine has now adopted a similar terminology and it is being built into blueprints for care in many states.
Oddly enough, although so much reliance on primary care is being called for, the actual practice of the same is becoming more difficult. The pressure placed upon primary care has hit the independent practitioner the hardest. Left alone to negotiate with insurers and hospitals, navigate mandates from payers and even our own professional organizations, we often do not recognize the current landscape, let alone feel enabled to comment on the future.
Although calling for a reinvestment in primary care with increased access to and reliance on primary care services, they do not seem to realize that our education and training system is not producing primary care physicians, let alone rewarding the ones that do exist. Remember, these experts are also the ones who believe that electronic medical records are the solution to all of medicine’s current problems. If you think there needs to be a place for the pediatric generalist, then we will all need to speak out. I do believe that it is a fight that will need to be fought by practicing pediatricians, or primary care will be defined for us, and we will not recognize the outcome — and may not even be a part of it.
Calling all primary care physicians
That future is now. The Jan. 20 issue of The New England Journal of Medicine included two lead editorials on the future role of advanced practice nurses in primary care. Coming from Donna Shalala, the former Secretary of Health and Human Services, and other authors representing the Robert Wood Johnson Foundation, the Institute of Medicine, and leading schools of nursing and public health, the viewpoints presented are serious contributions to the debate over the future of primary care. Taken together, they call for an expansion of the role of the nurses’ scope of practice in primary care and a shift in the proportion of new nurses who hold a bachelor’s degree (now only one-third of new graduates). They claim that physicians’ additional training has not been shown to result in measurable differences, compared with nurse practitioners in the quality of basic primary care services, and that more complete utilization of advanced practice nurses could save billions of dollars a year in health care costs.
Interestingly, the lead editorial in the Feb. 10 edition of The New England Journal of Medicine is a plea from Stephen Smith, MD, a family practitioner and former associate dean of the Warren Alpert Medical School at Brown University. Smith said to fill the growing need for primary care in this country by increasing the percentage of graduates of US allopathic medical schools entering primary care fields (currently 16%-18%). Smith focuses on the newly created allopathic medical schools with a “recipe” for improving the status of primary care medicine. His observations on the causes of diminished graduation numbers, hurdles to change and prospects for the future of a patient-centered educational model being implemented are sound. I would add that as a medical student graduate of The Johns Hopkins School of Medicine and residency graduate of Children’s Hospital, Boston, neither known for their principle dedication to primary care, that increasing the percentages of students committed to primary care can occur across all our allopathic medical schools and residency training programs. Commitment to a patient-focused curriculum is not a bad basis for any medical school or residency.
Changes needed at academic level
Although changes at the medical school level are critical to the future of primary care, equally important are changes at academic medical centers. The disappearance of practicing pediatricians rounding in hospitals and participating in the education of residents, often supplanted by hospitalists, is an enormous barrier to energizing students and residents about the practice of general pediatrics. The reliance on advanced-practice nurses and physician assistants because of hospital financial constraints and the hour limits on residents is also a detriment to the future of primary care. In a double-edged fashion, medical students clearly see that their current and future level of training places them above the mere bedside; and establishes the basis for physician extenders to bill at the same level as primary care providers in both the inpatient and outpatient setting.
Guidance is needed
Finally, we need to redefine the practice of general pediatric practice. I hope we remain a resource (medical home) for the health maintenance, newborn and sick care, and anticipatory guidance of our patients and their families. I hope we can accommodate the additional demands of “traditional” chronic disease (eg, asthma, diabetes, cystic fibrosis); “newer” chronic disease (eg, obesity); behavioral and developmental conditions, many of which are chronic (eg, autism, attention-deficit/hyperactivity disorder); and the effect of genomic medicine on the future of general pediatrics. Furthermore, I hope we continue to be active and visible in the hospital and in our pediatric training programs. Otherwise, we will be left with a model of care in which physicians no longer provide direct primary care, medical schools and residency programs train subspecialists, and perhaps those of us who love general practice will accept apprentices.
I have never been fully comfortable with the idea of the medical home, primarily in the sense that, with simple emphasis, the term somehow implies that health outcomes will improve. My deeper concern is that its definition is now out of my control as a practicing pediatrician and is now open to being determined by others, and even now being used in adult medicine in a checklist manner to determine eligibility for increased billing charges. To truly deserve the designation, or more importantly the trust of our families, and the comfort of our convictions, we must constantly strive to redefine what it means to be an effective pediatrician. The pursuit of that daunting goal will always be exciting and worth the fight with whatever powers that be.
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board.
Disclosure: Dr. Gerson reports no relevant financial disclosures.
For more information:
- Fairman JA. N Engl J Med. 2011;364:193-196.
- Smith SR. N Engl J Med. 2011;364:496-497.