In this era of medical specialists, we often lose sight of the value of a primary-care physician who can coordinate and assimilate efforts, who knows the patient, and who can function as “captain of the team.”
One of my neighbors recently experienced severe dizziness and unsteadiness. He is an elderly gentleman and was, of course, concerned. He went to the emergency department, where he received an expensive cardiac workup, including having a monitor placed on his chest to follow his heart rate and rhythm for 48 hours.
When that didn’t reveal any problems, he went to a neurologist, who ordered expensive testing of his inner ears. He then went to his primary-care physician, who had assembled all of the results, did a very careful history and physical examination, and was able to identify this multifactorial problem and come up with a simple treatment plan.
He probably should have gone to his primary-care physician first. But each of us feels entitled to receive what we believe to be the best medical care, which often translates to a bevy of specialists, none of whom looks at the whole patient.
During the early years of my training and practice, the primary-care physician was regarded as the “king.” He (and back then, most of them were men) was the most important person in the health-care team and well-respected. He was the person who called consultants, discussed the case, referred patients, and decided whether to accept and implement their suggestions. After all, he knew the patient well and coordinated current findings with past history, family history, and social circumstances.
As insurance reimbursement for primary care has been rapidly outrun by reimbursement for specialists, it is difficult to persuade the best and brightest to go into primary care. Today’s primary-care physicians are expected to see an unrealistic number of patients every day, and usually can’t spend enough time with each. So, some feel they must send patients to specialists, and the vicious cycle begins.
To change this, we need to change the reimbursement system. We need to reimburse primary-care doctors commensurate with their cognitive and problem-solving skills. We need to give them more time to interact with each patient and then think about the case and perhaps consult with colleagues. We need to return them to their position as “captain of the ship,” which most patients would prefer. If we increase their reimbursement, allow them to spend more time with patients, and give them the respect they deserve, perhaps once again we will attract the best and the brightest into primary care. I certainly hope so. This change will take time but is essential.
Paula L. Stillman MD, MA, is professor of medicine, director of the Steven H. Korman Center for Community Engagement at Jefferson Health System, and a member of the Inquirer’s Health Advisory Panel.