Primary care physician

A patient having his blood pressure measured

A primary care physician is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. This term is primarily used in the United States, although this is a recent occurrence. In years past in the US and in the UK (and many other English-speaking countries), the equivalent term was/is “general practitioner”.

All physicians first complete medical school (MD, MBBS, or DO). To become primary care physicians, medical school graduates then undertake postgraduate training in primary care programs, such as family medicine (also called family practice or general practice in some countries), pediatrics or internal medicine. Some HMOs consider gynecologists as PCPs for the care of women, and have allowed certain subspecialists to assume PCP responsibilities for selected patient types, such as allergists caring for people with asthma and nephrologists acting as PCPs for patients on kidney dialysis.

Emergency physicians are sometimes counted as primary care physicians. Emergency physicians see many primary care cases, but in contrast to family physicians, pediatricians and internists, are trained and organized to focus on episodic care, acute intervention, stabilization, and discharge or transfer or referral to definitive care, with less of a focus on chronic conditions and limited provision for continuing care.

Scope of practice

A set of skills and scope of practice may define a primary care physician, generally including basic diagnosis and treatment of common illnesses and medical conditions.[1] Diagnostic techniques include interviewing the patient to collect information on the present symptoms, prior medical history and other health details, followed by a physical examination. Many PCPs are trained in basic medical testing, such as interpreting results of blood or other patient samples, electrocardiograms, or x-rays. More complex and time-intensive diagnostic procedures are usually obtained by referral to specialists, due to either special training with a technology, or increased experience and patient volume that renders a risky procedure safer for the patient.[2] After collecting data, the PCP arrives at a differential diagnosis and, with the participation of the patient, formulates a plan including (if appropriate) components of further testing, specialist referral, medication, therapy, diet or life-style changes, patient education, and follow up results of treatment. Primary care physicians also counsel and educate patients on safe health behaviors, self-care skills and treatment options, and provide screening tests and immunizations.

Role in the health care system

A primary care physician is usually the first medical practitioner contacted by a patient, due to factors such as ease of communication, accessible location, familiarity, and increasingly issues of cost and managed care requirements. In some countries, for example Norway, residents are registered as patients of a (local) doctor, and must contact that doctor for referral to any other. Also many health maintenance organizations position PCPs as "gatekeepers", who regulate access to more costly procedures or specialists. Ideally, the primary care physician acts on behalf of the patient to collaborate with referral specialists, coordinate the care given by varied organizations such as hospitals or rehabilitation clinics, act as a comprehensive repository for the patient's records, and provide long-term management of chronic conditions. Continuous care is particularly important for patients with medical conditions that encompass multiple organ systems and require prolonged treatment and monitoring, such as diabetes and hypertension.

Studies of the quality of care provided by primary care physicians

Studies that compare the knowledge base and quality of care provided by generalists versus specialists usually find that the specialists are more knowledgeable and provide better care.[3][4] However, these studies examine the quality of care in the domain of the specialists. In addition, these studies need to account for clustering of patients and physicians.[5]

Studies of the quality of preventive health care find the opposite results – primary care physicians perform best. An analysis of elderly patients found that patients seeing generalists, as compared to patients seeing specialists, were more likely to receive influenza vaccination.[6] In health promotion counseling, studies of self-reported behavior found that generalists were more likely than internal medicine specialists to counsel patients[7] and to screen for breast cancer.[8]

Exceptions may be diseases that are so common that primary care physicians develop their own expertise. A study of patients with acute low back pain found the primary care physicians provided equivalent quality of care, but at lower costs than orthopedic specialists.[9]

Factors associated with quality of care by primary care physicians:

Dissemination of information to generalists compared to specialists

The dissemination of information to generalists compared to specialists is complicated.[12] Two studies found specialists were more likely to adopt COX-2 drugs before the drugs were recalled by the FDA.[13][14] One of the studies went on to state "using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication".[14] Similarly, a separate study found that specialists were less discriminating in their choice of journal reading.[15]

Challenges for primary care

Declining numbers

In the United States, the number of medical students entering family practice training dropped by 50% between 1997 and 2005.[16] In 1998, half of internal medicine residents chose primary care, but by 2006, over 80% became specialists.[17] A survey Research by the University of Missouri-Columbia (UMC) and the U.S. Department of Health and Human Services predicts that by 2025 the United States will be short 35,000 to 44,000 adult care primary care physicians.[18]

Causes parallel the evolutionary changes occurring in the US medical system: payment based on quantity of services delivered, not quality; aging of the population increases the prevalence and complexity of chronic health conditions, most of which are handled in primary care settings; and increasing emphasis on life-style changes and preventative measures, often poorly covered by health insurance or not at all.[19] In 2004, the median income of specialists in the US was twice that of PCPs, and the gap is widening.[20] Discontent by practicing primary care internists is discouraging trainees from entering primary care; in a 2007 survey of 1,177 graduating US medical students, only 2% planned to enter a general internal medicine career, and lifestyle was emphasized over the higher subspecialty pay in their decision.[21] Primary care practices in the United States increasingly depend on foreign medical graduates to fill depleted ranks.[19]

Maldistribution

Developing countries face an even more critical disparity in primary care practitioners. The Pan American Health Organization reported in 2005 that "...the Americas region has made important progress in health, but significant challenges and disparities remain. Among the most important is the need to extend quality health care to all sectors of the population...Experience over the last 27 years shows that health systems that adhere to the principles of primary health care produce greater efficiency and better health outcomes in terms of both individual and public health..." [22] The World Health Organization (WHO) has identified worsening trends in access to PCPs and other primary care workers, both in the developed and the developing nations:[23]

Lagging quality of care measures

A survey of 6,000 primary care doctors in seven countries revealed disparities in several areas that affect quality of care.[24] Differences did not follow trends of the cost of care; primary care physicians in the United States lagged behind their counterparts in other countries, despite the fact that the US spends two to three times as much per capita. Arrangements for after-hours care were almost twice as common in the Netherlands, Germany and New Zealand as in Canada and the United States, where patients must rely on emergency facilities. Other major disparities include automated systems to remind patients about follow-up care, give patients test results or warn of harmful drug interactions. There were differences as well among primary care doctors, regarding financial incentives to improve the quality of care.

References

  1. ↑ Institute of Medicine (1996). Primary Care: America's Health in a New Era. National Academies Press. p. 27. Retrieved 2006-08-30.
  2. ↑ Institute of Medicine (2000). Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality. National Academies Press. Retrieved 2006-08-30.
  3. ↑ Majumdar S, Inui T, Gurwitz J, Gillman M, McLaughlin T, Soumerai S (2001). "Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction". J Gen Intern Med 16 (6): 351–9. doi:10.1046/j.1525-1497.2001.016006351.x. PMC 1495223. PMID 11422631.
  4. ↑ Fendrick A, Hirth R, Chernew M (1996). "Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease". Am J Gastroenterol 91 (8): 1544–8. PMID 8759658.
  5. ↑ "Summaries for patients. Comparing the quality of diabetes care by generalists and specialists". Ann Intern Med 136 (2): I42. 2002. doi:10.7326/0003-4819-136-2-200201150-00003. PMID 11928735.
  6. ↑ Rosenblatt R, Hart L, Baldwin L, Chan L, Schneeweiss R (1998). "The generalist role of specialty physicians: is there a hidden system of primary care?". JAMA 279 (17): 1364–70. doi:10.1001/jama.279.17.1364. PMID 9582044.
  7. ↑ Lewis C, Clancy C, Leake B, Schwartz J (1991). "The counseling practices of internists". Ann Intern Med 114 (1): 54–8. doi:10.7326/0003-4819-114-1-54. PMID 1983933.
  8. ↑ Turner B, Amsel Z, Lustbader E, Schwartz J, Balshem A, Grisso J (1992). "Breast cancer screening: effect of physician specialty, practice setting, year of medical school graduation, and sex". Am J Prev Med 8 (2): 78–85. PMID 1599724.
  9. ↑ Carey T, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker D (1995). "The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project". N Engl J Med 333 (14): 913–7. doi:10.1056/NEJM199510053331406. PMID 7666878.
  10. ↑ Kitahata M, Koepsell T, Deyo R, Maxwell C, Dodge W, Wagner E (1996). "Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival". N Engl J Med 334 (11): 701–6. doi:10.1056/NEJM199603143341106. PMID 8594430.
  11. ↑ Friedberg; et al. (2007). "Does Affiliation of Physician Groups with One Another Produce Higher Quality Primary Care?". Journal of General Internal Medicine 22 (10): 1385–1392. doi:10.1007/s11606-007-0234-0.
  12. ↑ Turner BJ, Laine C (2001). "Differences between generalists and specialists: knowledge, realism, or primum non nocere?". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 16 (6): 422–4. doi:10.1046/j.1525-1497.2001.016006422.x. PMC 1495225. PMID 11422641. PubMed Central
  13. ↑ Rawson N, Nourjah P, Grosser S, Graham D (2005). "Factors associated with celecoxib and rofecoxib utilization". Ann Pharmacother 39 (4): 597–602. doi:10.1345/aph.1E298. PMID 15755796.
  14. 1 2 De Smet BD, Fendrick AM, Stevenson JG, Bernstein SJ (2006). "Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists: the tortoise and the hare revisited". Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine 21 (7): 694–7. doi:10.1111/j.1525-1497.2006.00463.x. PMC 1924718. PMID 16808768.
  15. ↑ McKibbon KA, Haynes RB, McKinlay RJ, Lokker C (2007). "Which journals do primary care physicians and specialists access from an online service?". Journal of the Medical Library Association : JMLA 95 (3): 246–54. doi:10.3163/1536-5050.95.3.246. PMC 1924945. PMID 17641754.
  16. ↑ American Academy of Family Physicians, National Resident Matching Program data: Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates, 1994-2006 Retrieved 30 August 2006
  17. ↑ "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" (PDF) (Press release). The American College of Physicians. 2006-01-30. Retrieved 2006-08-30.
  18. ↑ Jack M. Colwill, James M. Cultice and Robin L. Kruse, JM; Cultice, JM; Kruse, RL (2008-04-29). "Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population?". Health Affairs 27 (3): w232–w241. doi:10.1377/hlthaff.27.3.w232. PMID 18445642.
  19. 1 2 Bodenheimer, Thomas (2006-08-31). "Primary care - Will It Survive?". The New England Journal of Medicine 355 (9): 861–864. doi:10.1056/NEJMp068155. PMID 16943396. Retrieved 2006-08-31.
  20. ↑ Medical Group Management Association Physician Compensation Survey, 1998 - 2005: Median Compensation for Selected Medical Specialties Retrieved 30 August 2006
  21. ↑ Karen E. Hauer, MD; Steven J. Durning, MD, KE; Durning, SJ; Kernan, WN; Fagan, MJ; Mintz, M; O'Sullivan, PS; Battistone, M; Defer, T; et al. (2008-09-10). "Factors Associated With Medical Students' Career Choices Regarding Internal Medicine". JAMA 300 (10): 1154–1164. doi:10.1001/jama.300.10.1154. PMID 18780844. Retrieved 2008-09-16.
  22. ↑ Pan American Health Organization (September 2005): Regional Declaration on the New Orientations of Primary Health Care Retrieved 30 August 2006
  23. ↑ World Health Organization: World Health Report-2006 Retrieved 30 August 2006
  24. ↑ Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Jordon Peugh, and Kinga Zapert, C; Osborn, R; Huynh, PT; Doty, M; Peugh, J; Zapert, K (1999-11-02). "On The Front Lines Of Care: Primary Care Doctors' Office Systems, Experiences, And Views In Seven Countries" (abstract). Health Affairs 25 (6): w555. doi:10.1377/hlthaff.25.w555. PMID 17102164. Retrieved 2006-11-06.
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