Blog | Monday, May 7, 2012

Too many definitions for primary care and this is the problem!


Back when I was a young pup, primary care had one clear definition. Those were the exciting days for the primary care movement. Internal medicine had just discovered primary care and programs sprouted up around the country to train internists to provide such care.

In 1994 the Institute of Medicine provided this definition: Primary care is 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 family and community.

Earlier these thoughts dominated: A set of attributes, as in the 1978 IOM definition--care that is accessible, comprehensive, coordinated, continuous, and accountable--or as defined by Starfield (1992)--care that is characterized by first contact, accessibility, longitudinality and comprehensiveness;

So we who trained in the '70s and '80s thought of primary care as this challenging, comprehensive job caring for complex patients. We took great pride in the job. Primary care internists were proud, well trained and happy to accept the challenge.

So what happened? Today many internists reject the label of primary care. Too many policy wonks and politicians say primary care but mean something totally different.

Dictionary.com provides this definition: medical care by a physician, or other health-care professional, who is the patient's first contact with the health-care system and who may recommend a specialist if necessary.

Note the lack of comprehensive, coordinated, continuous and accountable in this definition.

The American Heritage Dictionary is, in my mind, even worse: The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.

Herein lays the problem. Primary care no longer has a clear meaning. When internal medicine organizations talk about primary care, they have in mind the original conceptualization. But when legislators and policy wonks hear primary care, they think simple care.

Now we have nurse practitioners who claim the primary care mantle. Internists generally reject this idea. Of course we are thinking of complexity, comprehensiveness and diagnostic challenges, while others hear primary care and think sore throats, urinary tract infections and adjusting blood pressure medicines.

For these reasons, I believe we internists should stop fighting about what is primary care and who can do it. Rather we must redefine who we are. We must tell everyone that we are internists. We can provide comprehensive, coordinated, continuous, accountable care. Many internists will still care for you in the outpatient and inpatient settings. And we are trained to do so.

Since the term has suffered semantic drift, so has our beloved profession suffered. We cannot turn back the dumbing down of this formerly beloved term. To continue talking about primary care only hurts our profession. We must take pride in internal medicine, for we have always been the doctors' doctors.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.