No Replacement for Primary Care

“The primary care shortage may be averted if non-physicians
are allowed to deliver primary care.”

This phrase has been repeated so often that some people may be starting to believe it.

empty doctor

Washington think tanks, policy makers, and special interest groups have increasingly popularized the idea that much of primary care is easily replaced. Instead of improving reimbursement or reducing hassles, just replace PCPs with other types of providers.
Here is the logic:
“After all, most sore throats, diarrhea, and coughs can be treated by a nurse.”

NewsFlash: Most of those illnesses will get better on their own anyway.
This is not the barometer by which to measure the value of primary care physicians.
In the examples used, it’s not that a non-physician could have done just as well,
because the patients with those illnesses were getting well anyway.
It is the ability to use those opportunities to look beyond the minor illnesses,
to identify other risks, and to establish a foundation for total healthcare.
It is when an illness seems minor, but is not. That is primary care.
The treatment of minor illness is not difficult. Typically it requires no treatment.
                                 Minor illness is… dare I say it… minor.

One of the classic jokes in medicine also happens to be a truth:
“The patient got here just in time…
another day and the illness might have cured itself.”

The trick is in knowing what is minor.
And the magic is in seeing beyond the complaints.

Ask an obstetrician. Often a delivery is just “catch the baby”. At those times, the only hard part is “don’t drop it”. Most deliveries are just guiding chaos. Birthing a baby has happened for millennia without physicians. Like coughs and fevers, the majority turn out fine.  But there’s a reason why an obstetrician studies so hard for so many years. To be prepared for the one delivery that doesn’t go right. And for the ability to anticipate when that problem might occur. That is primary care.

The sweat, sacrifice, and years of attention to detail in medical education have no substitute. The demands are high, the training is long,
and not everyone can do it.

Primary care physicians have met the requirements and are uniquely qualified.

Primary care physicians see patients everyday with chest pain. Most are not cardiac.
Everyday a cough is treated. Most are not cancer. Fevers, rashes, belly pains, and bumps on the head. Sore throats and diarrhea. How does one know which is minor?

And then there’s sadness, worry, fear, divorce and desperation.
Loss of job, loss of family, loss of faith. Patients share these pains.
Are any of these ever minor? That is primary care.

Primary care physicians treat all of these everyday.
Now pay attention to this part…
It’s by having seen that patient for their “minor illness” that allows primary care physicians to provide better care when it’s serious. It’s the early diagnosis, the evolving symptom pattern, sometimes even the “gut” feeling of an experienced primary care physician that comes from years of training and the demands of our educational requirements…
that makes the difference in care.

Pharmacists, chiropractors, and nurses are important members of the healthcare team.
The non-physician members of our team are needed, respected, and cherished.
But not one of them is a replacement.
Only a primary care physician is a Primary Care Physician.

Guy L. Culpepper, MD

2 thoughts on “No Replacement for Primary Care

  1. Pingback: Thank You, Doctor . . . « Becoming not Became

  2. If managed care had not worked so hard to put Primary Care Physicians in an ICD-9 box over the past decade, more people would not need the reminder of your posting. But the challenge is in overcoming the self-fulfilling prophesy of their actions. The more PCP’s are constrained, the easier it is to justify alternatives. It is another example of managed care “doubling down” on failed cost containment strategies instead of improving health.

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