Why Primary Care Matters

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Am I the only one seeing the obvious?

There has been lots of talk about reforming healthcare in a way that is budget-neutral.  The president has touted the use of EMR and of preventive medicine to save money.  Many have rightly pointed out that both of these are unlikely to save money.  EMR will only really save money when it is inter-connected, allowing healthcare workers to have accurate data to make decisions.  Preventive care will actually probably result in more utilization in the short run, not less.  Ordering more mammograms, for example, will incur a cost by itself, but even more significant will be the number of ultrasounds and biopsies in response to abnormal tests.  The savings will hopefully come down the line when less women have advanced disease requiring hospitalization and chemotherapy.  Both of these suggestions have merit, but only over the long-term.

So then the question comes up: how do we save money in the short run?  Answer: primary care medicine.

Wait…didn\’t I just say that prevention would only save money down the road?  Yes, I did.  But primary care medicine is not all about prevention; most of my day is spent either treating acute illnesses or managing chronic problems.  In both of these instances (despite the surprisingly naive things reported elsewhere), I can save the system money quickly.  Here\’s how:

1.  Diseases do better when treated.

Treated diabetics do better than those who are not treated.  It\’s better to have a blood pressure of 110/70 than 190/100.  It\’s best to get to the doctor early if you have pneumonia.  All of these things are basic; they are medicine 101.  If we argue these things, we argue the whole basis of what doctors do.  We intervene to lengthen life and to maximize the quality of life.

This is not insignificant.  One hospitalization for uncontrolled diabetes, stroke, or heart attack will more than make up for any costs I incur as a PCP.  It doesn\’t take much good medicine to decrease cost to the system.

2.  Our goal is to keep people away from specialists and hospitals.

Specialists are essential for care – we need people who can treat cancer, deal with heart attacks, and do surgery.  Hospitals are great things too (stating the obvious).  But don\’t you want your doctor to make it so you don\’t need either of these?  I really hope I never need an oncologist or a cardiologist.  I really hope I never spend time in the ICU.  Working with someone to reduce this risk is absolutely desirable.

The problem is that the more work we give specialists, the more cost goes out of control.  Not only are the specialists themselves and the procedures they do expensive, they utilize hospitals much more.  That\’s not wrong; it\’s just not a good way to cut cost.  Staying healthy is a good way to keep from seeing doctors and using hospitals (again stating the obvious).

Primary care is the one field whose success would mean lower cost.  If I do my job really well, I see my patients infrequently (because they are healthy) and they don\’t need other care elsewhere.  That is, of course, unrealistic to expect for all of my patients, but it surely should be my aim with each of my patients.  I don\’t want them to be sick.

3.  Relationships mean better healthcare

When I am unfamiliar with a patient, I have to do much more to figure out what is going on.  I spend a lot of time asking questions about a person\’s past and trying to figure out their personality.  Docs are pretty good at this, but there is no question that I get to answers much quicker with someone who I have seen for many years.  Studies have borne this out: the better the relationship between doctor and patient, the better the quality of care.

The patient\’s comfort with the doctor may be even a bigger factor.  When a patient knows and trusts their doctor, they are much more likely to listen to what their doctor has to say.  If they know that I am not an over-prescriber of drugs or a high-utilizer of tests, they will trust me more when I do recommend them than they would a physician they had never met.

Again, better quality care is better than poorer quality care (see point 1) and will save money.  Would anyone question the idea that having a physician who knows you well, oversees all of your care, and helps you coordinate it is going to save money and prevent illness?

4.  PCP\’s (should) order less tests than specialists

I put the parenthetical \”should\” in the sentence because I do know PCP\’s who don\’t practice good medicine.  Either they own lab or x-ray equipment that they want to use, or they are stuck with the idea of being a \”gatekeeper\” – acting more as an envoy to specialists than as a clinician and diagnostician.  There are bad doctors in all areas (bad teachers, lawyers, and zoo keepers as well).  But good primary care will act differently than good specialty medicine when confronted with a problem.

For example: when a person presents to me with chest pain, I do an EKG less than 50% of the time (probably less than 20%).  Why?  People with asthma, bronchitis, chest wall pain, and anxiety can have chest pain as a symptom.  I am used to seeing the general public, which is a population with a minority of people having significant heart conditions.  A cardiologist, on the other hand, is used to seeing high-risk people.  To them an EKG is a routine test, as the overwhelming majority of their patients do have heart problems (duh).

The same holds true for neurosurgeons and MRI scans, neurologists and headaches, and pulmonologists and cough.  They are all used to seeing a sicker population and so will tend to look at the patient through that filter.

My job is to sift through the chest pain and send those patients with real heart problems to the cardiologist – keeping the rest for myself.  They don\’t want to see every chest pain I see.  So again, me doing my job well saves money quickly.

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The idea of prevention is often thought of in terms of screening tests (mammograms, colonoscopy, cholesterol testing).  This is a minor part of prevention in my life.  The most important prevention I do is to keep diseases quiet and keep illnesses from getting bad.  I do this 10 times more than I do classic \”preventive medicine.\”  And the turn-around on this with respect to cost is very fast.

Kevin Pho has done much to champion primary care, as have many others.  The discussion, however, sometimes misses its real benefit.  If we can somehow give PCP\’s motivation to use hospitals and specialists less (by doing good medicine), we will hit the mother-load of savings.  PCP\’s are in the unique position of being paid to keep people well.  We don\’t want disease.  We are happy when our patients don\’t need us.

That\’s our job.  And if somehow primary care would be really rewarded, the system would see a huge drop in cost.

17 thoughts on “Why Primary Care Matters”

  1. I agree with you. Completely.My primary care physician is a push over. It’s true… p-u-s-h over. I can tell him what’s wrong with me and what I need… and he listens. It sometimes bothers me, but in all actuality it’s sort of nice. I have looked around for a “good” PC physician but always seem to head back to the push over doctor.
    With medical background in my family I know when I have a sinus infection, ear infection, etc. so it’s convenient for me to say, “Yo. Doc. I need this”.
    I do think it’s dumb that my PCP didn’t see that I had 6 sinus infections in 2007 and try to get to the root of the problem…. which was allergies! I had to go to a “specialist” to get my allergies under control. Kind of dumb. And more money for me (and my insurance company).
    It would be nice to have a primary care physician that cares about me… That remembers my name or remembers that I walked on a broken ankle for 6 months before getting x-rays. But I don’t have that, and I honestly don’t know where to find that. My OBGYN is the closest thing I have to that, which I am very thankful for. Maybe you should do a post on “how to find a Primary Care Physician that CARES”.
    So until you pack your bags and move to West Texas, I’ll continue to “get by” with my Primary Care Push Over Doc.

  2. I agree with you. Completely.My primary care physician is a push over. It’s true… p-u-s-h over. I can tell him what’s wrong with me and what I need… and he listens. It sometimes bothers me, but in all actuality it’s sort of nice. I have looked around for a “good” PC physician but always seem to head back to the push over doctor.
    With medical background in my family I know when I have a sinus infection, ear infection, etc. so it’s convenient for me to say, “Yo. Doc. I need this”.
    I do think it’s dumb that my PCP didn’t see that I had 6 sinus infections in 2007 and try to get to the root of the problem…. which was allergies! I had to go to a “specialist” to get my allergies under control. Kind of dumb. And more money for me (and my insurance company).
    It would be nice to have a primary care physician that cares about me… That remembers my name or remembers that I walked on a broken ankle for 6 months before getting x-rays. But I don’t have that, and I honestly don’t know where to find that. My OBGYN is the closest thing I have to that, which I am very thankful for. Maybe you should do a post on “how to find a Primary Care Physician that CARES”.
    So until you pack your bags and move to West Texas, I’ll continue to “get by” with my Primary Care Push Over Doc.

  3. Interesting perspective, however, when a general practionser takes care of someone they are acting as the specialist for the medical condition they are treating. Except, they do have the perpective and training of a specialist. For most common conditions that is ok, however, for other conditions that may go unrecognized and become very costly in human sufferring and financial expense, it is not ok. There needs to be a balanced use of primary and specialty physicians.
    What is most important however, for whomever is rendering care and for whomever is receiving care that known guidelines for health be followed. Often times recommendations for appropriate care are not followed either by specialists or generalists with poor patient outcome and reulting suffering and expense.

    performance is measureable and I would like to see th data that substantiates or disproves this argument.

    For further discussion see recent posting on Healthgadfly.com

  4. Interesting perspective, however, when a general practionser takes care of someone they are acting as the specialist for the medical condition they are treating. Except, they do have the perpective and training of a specialist. For most common conditions that is ok, however, for other conditions that may go unrecognized and become very costly in human sufferring and financial expense, it is not ok. There needs to be a balanced use of primary and specialty physicians.
    What is most important however, for whomever is rendering care and for whomever is receiving care that known guidelines for health be followed. Often times recommendations for appropriate care are not followed either by specialists or generalists with poor patient outcome and reulting suffering and expense.

    performance is measureable and I would like to see th data that substantiates or disproves this argument.

    For further discussion see recent posting on Healthgadfly.com

  5. No, I am not acting as a specialist. The specialist’s job is to take care of the exceptional/difficult cases. My view on chest pain is actually more accurate than that of the specialist for the general population. The cardiologist is no more qualified to diagnose chest pain off of the street than me – in fact, they probably have done it less. They rarely get someone walking in with chest pain who has no previous cardiac history or has not been seen by a PCP or emergency physician. The same is true with neurosurgeons and sciatica. I see far more first-presentation sciatica than a neurosurgeon. The patients they see are usually already worked-up by a PCP and have an MRI ordered (in fact, most of them require that they have one before they are referred). In terms of diagnostic skills, PCP’s are generally more qualified than specialists.
    As far as research goes, here’s a good reference: http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.97v1.pdf – there are lots of studies that show the cost of care goes down with more PCP’s and the mortality rates drop.

  6. No, I am not acting as a specialist. The specialist’s job is to take care of the exceptional/difficult cases. My view on chest pain is actually more accurate than that of the specialist for the general population. The cardiologist is no more qualified to diagnose chest pain off of the street than me – in fact, they probably have done it less. They rarely get someone walking in with chest pain who has no previous cardiac history or has not been seen by a PCP or emergency physician. The same is true with neurosurgeons and sciatica. I see far more first-presentation sciatica than a neurosurgeon. The patients they see are usually already worked-up by a PCP and have an MRI ordered (in fact, most of them require that they have one before they are referred). In terms of diagnostic skills, PCP’s are generally more qualified than specialists.
    As far as research goes, here’s a good reference: http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.97v1.pdf – there are lots of studies that show the cost of care goes down with more PCP’s and the mortality rates drop.

  7. Love you Lindsey!! And Dr. Rob, I can help with the “Finding a Pediatrician Who Cares” if you ever want someone who works in peds to help out! 😉

  8. Love you Lindsey!! And Dr. Rob, I can help with the “Finding a Pediatrician Who Cares” if you ever want someone who works in peds to help out! 😉

  9. I love everything you say. I have one small quibble. Perhaps your could change this:
    Our goal is to keep people away from specialists and hospitals.

    To this:

    Our goal is to make sure people don’t need specialist and hospitals.

    It reflects better what you say on this point and keeps people from reading your bullet point and making the knee-jerk assumption that you want to prevent patients who need it from seeing specialists or going to the hospital.

    Another thing that your post has me thinking about. I love my kids’ pediatrician. He does many of the things you describe, and I trust him. But so do (seemingly) ten thousand other moms in Atlanta. So, I have a devil of a time getting my kids in to see him, and when I do, he’s in a terrible hurry. It’s very frustrating, and I’m beginning to wonder if he’s become too popular and that it’s time for me, however reluctantly, to find a pediatrician who has a little more time available to maintain that quality relationship you’re referring to.

  10. I love everything you say. I have one small quibble. Perhaps your could change this:
    Our goal is to keep people away from specialists and hospitals.

    To this:

    Our goal is to make sure people don’t need specialist and hospitals.

    It reflects better what you say on this point and keeps people from reading your bullet point and making the knee-jerk assumption that you want to prevent patients who need it from seeing specialists or going to the hospital.

    Another thing that your post has me thinking about. I love my kids’ pediatrician. He does many of the things you describe, and I trust him. But so do (seemingly) ten thousand other moms in Atlanta. So, I have a devil of a time getting my kids in to see him, and when I do, he’s in a terrible hurry. It’s very frustrating, and I’m beginning to wonder if he’s become too popular and that it’s time for me, however reluctantly, to find a pediatrician who has a little more time available to maintain that quality relationship you’re referring to.

  11. Agree with your change.
    The dilemma is that good docs tend to be busy. Good luck!

  12. Agree with your change.
    The dilemma is that good docs tend to be busy. Good luck!

  13. Dr. Rob,
    Because of my being one of your patients for 7 1/2 years, I am very thankful for the balance you have shown in helping me with my chronic condition. I appreciate the fact that you do listen to me and that you do what is necessary to try and solve the mysteries of some of my physical complaints. Your knowledge and caring spirit have helped me get the medical care I have needed or you have sent me to specialists to get the medical care that was needed. You are brilliant in my opinion, yet humble about what you know. I appreciate you!

    For those who read this reply, one of the things on my part that has helped Dr. Rob to have wisdom in taking care of my medical needs is that each time I have an appointment with Dr. Rob, I give him a list (usually typed) of my medical concerns for which I need his help. The list includes, not just my medical concerns, but the symptoms I am experiencing, the time frame that I have experienced the symptoms, as well as the severity of the symptoms (pain level –from 0-10 with 10 being the worst pain I have ever experienced; and the type of pain–sharp, dull, piercing, burning, etc.). These specific explanations of the symptoms helps Dr. Rob to come to a quicker diagnosis. Dr. Rob can read the list and then decide what symptoms need his attention the most. I have a copy of the list so that I can see what he covers and how he covers the symptoms. He looks forward to my list because he knows that I have tried to carefully think about what needs to be covered. The majority of the time, I don’t leave the examination room thinking that I have forgotten something.

    Dr. Rob works hard to listen and understand my symptoms. He treats my whole person, not just 2 or 3 symptoms. I have recommended Dr. Rob to quite a few of my friends. Some of them are now patients of Dr. Rob. Not one of my friends, who are his patients, have said any negative thing about Dr. Rob. All of them, including me, are very appreciate of Dr. Rob’s help and care. I thank God for using a friend of mine to recommend I see Dr. Rob 7 1/2 years ago when my other PCP moved out of town. I believe that one of the reasons that my condition has greatly improved is that God has used Dr. Rob to be a catalyst in my life; physically, mentally, and spiritually.

    Thank you, Dr. Rob!

  14. Dr. Rob,
    Because of my being one of your patients for 7 1/2 years, I am very thankful for the balance you have shown in helping me with my chronic condition. I appreciate the fact that you do listen to me and that you do what is necessary to try and solve the mysteries of some of my physical complaints. Your knowledge and caring spirit have helped me get the medical care I have needed or you have sent me to specialists to get the medical care that was needed. You are brilliant in my opinion, yet humble about what you know. I appreciate you!

    For those who read this reply, one of the things on my part that has helped Dr. Rob to have wisdom in taking care of my medical needs is that each time I have an appointment with Dr. Rob, I give him a list (usually typed) of my medical concerns for which I need his help. The list includes, not just my medical concerns, but the symptoms I am experiencing, the time frame that I have experienced the symptoms, as well as the severity of the symptoms (pain level –from 0-10 with 10 being the worst pain I have ever experienced; and the type of pain–sharp, dull, piercing, burning, etc.). These specific explanations of the symptoms helps Dr. Rob to come to a quicker diagnosis. Dr. Rob can read the list and then decide what symptoms need his attention the most. I have a copy of the list so that I can see what he covers and how he covers the symptoms. He looks forward to my list because he knows that I have tried to carefully think about what needs to be covered. The majority of the time, I don’t leave the examination room thinking that I have forgotten something.

    Dr. Rob works hard to listen and understand my symptoms. He treats my whole person, not just 2 or 3 symptoms. I have recommended Dr. Rob to quite a few of my friends. Some of them are now patients of Dr. Rob. Not one of my friends, who are his patients, have said any negative thing about Dr. Rob. All of them, including me, are very appreciate of Dr. Rob’s help and care. I thank God for using a friend of mine to recommend I see Dr. Rob 7 1/2 years ago when my other PCP moved out of town. I believe that one of the reasons that my condition has greatly improved is that God has used Dr. Rob to be a catalyst in my life; physically, mentally, and spiritually.

    Thank you, Dr. Rob!

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