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Future of primary care: Part 2
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Come writers and critics
Who prophesize with your pen
And keep your eyes wide
The chance won’t come again
And don’t speak too soon
For the wheel’s still in spin
And there’s no tellin’ who
That it’s namin’
For the loser now
Will be later to win
For the times they are
a-changin’.
– The Times They Are a-Changin, Bob Dylan, 1964
I don’t know who you think you are
I don’t know what you’re doing here
I don’t know what’s going on here
I don’t know how it’s supposed to be
I, I don’t have the vaguest notion
Whose it is or what it’s all for
I don’t know, I’m not cryin’
Laughin’ mostly as you can see’.
– What’s Happening?!?!, The Byrds (David Crosby), 1966
OK. I am not as confused as David Crosby’s lyrics might suggest (but I do believe that laughter is important). However, the times are not straightforward. Change is a constant in medicine, although recently it seems as if the pace resembles a differential equation more than a reflection of constant acceleration.
In part one of this two-part series, I wrote to the recent heightened interest in primary care as health care, as we know it is reformed. While much heralded, primary care appears more like the mirage of an oasis in the desert, fought over by the most disadvantaged while the powerful remain out of the intense sun shifting the irrigation pipes. However, if you think that as general pediatricians we are currently losing in this time of change, try channeling Bob Dylan.
The unknown future
What will primary care look like and who will be performing the provision of that care? The latter is the question that will drive the most critical transformations that affect those currently practicing general medicine. Recent judgments by societal bodies (AARP), professional organizations (Institute of Medicine), and even by many legislatures advocate a vision in which physicians will not provide primary care, at least not solely, and many among these thought leaders feel physicians should not perform these duties at all.
William T. Gerson
Integral to this discussion is the societal worth granted to practitioners of primary care. It is not a physician-only club. Primary care is now open to naturopaths, chiropractors and nurse practitioners. It is not only society at-large that considers primary care in such a way. Many of the specialty physicians and even some of the generalists that I know truly believe that there is no reason and certainly no model that should base well care on 1:1 patient-to-physician care. “Not for well people,” they explain. It is perhaps hard to disagree with until you try to define wellness and truly test its assignation in an office setting and not a public health forum.
An office model of care with primary care nurse practitioners in association with a pediatric consultant is an often mentioned design solution. What is lost in this conception and in those of similar ilk is what I do and what many of you do who currently practice general pediatrics — follow patients and their families day in and day out over decades. The importance of longitudinal care in the pediatric population is always underestimated in these calculations, but for those of us who love what we do, it is crucial to its success. The juxtaposing of consultant and primary care duties seems to me an odd match — not necessarily a poor model of care but the pediatrician role within it is surely not what is currently practiced and enjoyed by most general pediatricians.
Missing commitment to care
Does my ideal primary care general pediatrician more resemble an emperor with no clothes than a prescription for a reformed health care system? Unquestionably, particularly if one accepts the argument that physicians in primary care make no sense. As self-employed physicians become less prevalent, integrated health systems will no longer pay physicians for this role and by definition it will pass from a physician specialty. An efficient model of care will be championed in which electronic health record (EHR) corporations will dictate the language and texture of care and academic pediatrics will invest in investigations of best practice in the multiple daily “handoffs of patients” that will define primary care as it has already on the inpatient front. Primary care will be a mirage, not the central focus of well-being and access to more specialized care, but a front for the power of commercial medicine. All of which obviously ignores the basic tenet upon which primary care medicine is based — a commitment to 24-hour, 365-days-of-the-year care.
But don’t believe the prophecies. Medical students are still choosing primary care. Perhaps a reflection on the changing demographics of medical school classes, but even more likely because of changes to medical school education in which students and residents are exposed to primary care practitioners who love their chosen field. And here is the root cause for optimism. Do not discount the power and infectious quality of the enjoyment and caring that we live and can model in primary care pediatrics. We do not need to understand the complexities of health care reform — the alphabet soup of ACO, ICD and EHR — with or without an unclothed emperor, we need to remain true to our best practice model and positive in its strengths.
Primary care pediatrics should not be a competition and we certainly can pair, and have, with our nursing colleagues. However, we need to be vigilant and engaged in a process that will allow general pediatrics to continue to be both the premier model of care and the lead advocate for a society that puts children first.
It is an exciting quest. Hang on for the ride.
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Disclosure: Gerson reports no relevant financial disclosures.