by Richard Baron, MD, MACP
Dr. Baron practices general internal medicine at Greenhouse Internists, P.C., a 7 physician practice located in the Philadelphia area.Â Dr. Baron's practice has been a pioneer in the comprehensive adoption of electronic health records in the small practice environment and Greenhouse Internists is participating in a Patient Centered Medical Home pilot in Southeastern Pennsylvania.
Primary care doctors as general contractors
When you face a complex project like a home renovation, the electrician knows how to do the electric stuff, but do you count on them to make the whole job right?
You might hire a "general contractor" to help oversee all the various components of the problem. And in health care, this is a role played by a primary care doctor.
Patients in the US health care system confront a dizzying array of specialists with more and more technology and treatment options available. Sorting through the options when you are sick - or even when you are well - can be a daunting task.
Primary care docs know you and the medical options
And more often than not, the information you want isn't "what's the 'best' approach" (for anyone), but "what's the 'best' approach for me. Getting the answer to that question requires that you be working with someone who knows you and knows the options and can help you choose among them without strong economic incentives that might influence their behavior.
And that is the heart of what we do in primary care: we create longitudinal relationships with people we get to know, we stay on top of medical advances, and we help our patients figure out what is best for them.
Many of my patients confronting difficult medical decisions think it is a "knowledge problem" to be solved - they think they want to see the person who "knows the most" about the disease. But what most of them need is someone who "knows the most" about them - their preferences, their values, what is important to them. And, of course, more and more patients today have multiple medical problems, not just one.
Dealing with them one at a time, by specialists who focus on that problem rather than the big picture, forces you to be your own general contractor in health. Patients in that situation are left to coordinate their own care - or that of an aging relative - and to navigate through conflicting advice from specialists who have expertise in only one part of the problem. Paul Grundy, a health care leader from IBM, calls specialists "partialists", while he calls primary care doctors "comprehensivists".
Why is it so hard to find a primary care doc?
We all have an interest in stronger primary care. But the challenge we face in American health care is that we have so chronically underfunded primary care capacity that very few doctors want to go into it, and those who are in it are often looking to get out.
It isn't just the income differential between primary care doctors and their specialist colleagues, which is clearly an important consideration for medical students graduating with a lot of debt. Even more important, it's the lack of capacity to do their job and meet their patients' needs. If you can't find good primary care in your community, it's because the system has systematically starved primary care to support high tech, high margin health services.
When patients and health care purchasers demand better primary care, I predict doctors will rush to get into this field. Fact is, it's why most of us went to medical school in the first place.