Having covered various topics such as the growth of Wal-Mart and retail pharmacy walk-in clinics and the proliferation of hospitalists of various stripes (intensivist, surgicalist, preceduralist), I have personally come to the conclusion that the days of the primary care physician (PCP) are numbered and that this group of physicians needs to redefine themselves and upgrade their skills. This same idea has occurred to Scott Shreeve (see: Gatekeepers vs. Quarterbacks: Primary Care Gets Back in the Game). Below is an excerpt from his recent blog note with boldfaces emphasis mine:
...I have become very interested in redefining health care financing to align incentives in order to obtain better health care outcomes. I believe that primary care needs to be paid in a way that recognizes the value that it creates for improving population health (just as I believe that teachers should be paid for the value they create for society). Notice that I did not say physicians – as I am of the persuasion that primary care physicians are being undone by their own lack of demonstrating value and moving appropriately up the health care delivery value chain. Primary care physicians ARE GOING TO GET REPLACED (appropriately so!) for all the simple stuff that is covered by retail clinics. Anything that can be reduced to a guideline, a template, or treatment algorithm should absolutely be given to someone else in the health care delivery chain. PCP’s should not fight this, they should embrace this, in order to move toward delivery of higher value oversight, complexity, and clinical conundrums where they can uniquely put those years of training and experience to work.
Here's an excerpt from the Wikipedia description of a PCP:
Many health maintenance organizations position PCPs as "gatekeepers", who regulate access to more costly procedures or specialists. Ideally, the primary care physician acts on behalf of the patient to collaborate with referral specialists, coordinate the care given by varied organizations such as hospitals or rehabilitation clinics, act as a comprehensive repository for the patients records, and provide long-term management of chronic conditions.
I can't state this case any better than Scott. I believe that most of the common ailments seen in an office practice can and should be addressed by physician's assistants and nurse clinicians, the latter being defined as a registered nurse who has received special training and can perform many of the duties of a physician. To reiterate Scott's point above, this will include the following: [any task] that can be reduced to a guideline, a template, or treatment algorithm. The job description of PCPs should be to solve what Scott refers to as complexity and clinical conundrums. I will take this to mean that PCPs should manage the critical first steps in the diagnosis of complex disease prior to referring patients to medical specialists. The care of complex chronic diseases should also be the responsibility of the PCP.
Veteran readers of this blog may recall that I have been promoting the idea that pathologists, lab medicine specialists, and radiologists should merge into a new specialty of diagnostic medicine. It seems to me that a PCP, acting as a quarterback and not a gatekeeper to use Scott's phrase, would be an ideal partner for such a diagnostic team. Patients would be referred to the most appropriate specialist after a complete diagnostic workup has been completed and with a firm diagnosis in hand. In the case of patients with malignant neoplasms who are referred to oncologists, for example, the most appropriate therapy could be immediately begun.
Scott recently delivered a lecture at Lab InfoTech Summit 2008 (see: Health 2.0? Coming to a Lab Near You!) that you may want to review.
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