Blog | Thursday, June 6, 2013

Primary care and the NEJM


The New England Journal of Medicine has an article, a perspective and an editorial on primary care and the mismatch between physicians and nurse practitioners perceptions of each other's skills. The perspective an editorial follow the increasingly familiar trope that advanced nurse practitioners are needed to solve our lack of physician primary care.

But nowhere in these pieces did I see the key point. Primary care is not one thing. Primary care is not "simple care." Primary care (like Dante's hell--no implied analogy) has many levels. Primary care as a term is really a Rorschach test. As an internist, when I consider primary care, I think of complexity: patient complexity, disease complexity and balancing multiple problems. I suspect when policy wonks consider primary care they think of simple stuff: blood pressure control, adjusting hypoglycemic drugs to achieve a "desired" Hgb A1c, sore throats, urinary tract infections, and smoking cessation.

Primary care physicians are our first line of diagnosticians, thus they need the experience and depth of knowledge to consider diagnoses, or at least know when the diagnostic possibilities need referral. Primary care physicians must juggle multiple problems, especially in our older patients. They must know when to follow guidelines and as important, when guidelines really should not apply.

We will continue to have uncomfortable and unproductive debates on this issue until we settle issue #1: What is primary care?

As I write above, primary care is not one thing, and thus the conversation will never achieve a dialogue until we agree on the definition(s) of our topic.

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.