The art and science of practicing medicine and health care in general in the primary care setting of our traditional "doctor's office" has sustained some body blows over the past few years. Will the cumulative effect be fatal? I finished my graduate program in primary care advanced nursing in 1990. We were told that into the 21 st century, the need would quadruple for the medical generalist also known as the primary care provider. Primary care residencies for physicians in Family Practice, Internal Medicine and Pediatrics were at that time entering a renaissance in an age of super specialization. Even in the daunting maze of "big medicine" while working and studying at the University of Pennsylvania, I felt at home and with kindred spirits among these doctors, physician assistants and nurse practitioners who met the challenge of caring for the whole patient with all the foibles characteristic of a human being. Providing primary care demands the increasingly dizzying task of keeping abreast of the rapid developments in pharmacology, physiology, psychology, and technology. Add to this understanding the impact of alternative therapies and dietary supplements. There are skills necessary to being effective and able to remain on the front line of health care. Today fewer and fewer medical students upon graduating are entering primary care residencies and fewer and fewer medical educators are there to teach the ones that do. Dr Allan Goroll, author of one of the most widely used textbooks in primary care, said,” When students come to medical school, being somebody's doctor is really what they want to do. Somehow, by the time they leave, we've changed their minds; they'd rather do just about anything but that."(1) Why has this happened? In the late 1960's and early 1970's, a few studies in epidemiology showed that specialty doctors who were trained to care for the sickest of the sick were unprepared to care for healthy people and keep them that way. Once in practice most of their patients were far from needing hospitalization and wanted to stay that way. Over the next three decades evidence showed that primary care providers delivered overall care that was better than specialists. By the mid 1990's about half of all doctors graduated from allopathic medical schools entered one of the above mentioned primary care residencies. This was further fueled by a report issued by the Institute of Medicine, which credited the generalist in primary care for improving quality, efficiency and expanding access to appropriate non specialty as well as specialty care. This report went on to state that this kind of care "...forms an important bridge between personal health care and public health, to the advantage of both."(2) This report cited results from many studies that showed people who had an ongoing relationship with a primary care provider spent less time in the hospital, in Emergency Rooms, and had fewer procedures and tests all the while reporting to be happier with their care. But, alas, these things that made primary care so attractive are just what lead to its downfall. In an attempt to harness this primary care "expertise", to expand care and limit cost, the insurance industry, legislators and other government officials and even many health care providers themselves, doctors as well as nurses, failed to recognize that the fundamental linchpin on which primary care functions is the trust and bond between the patient and the primary care provider. The most significant blow came when forces mostly from within the insurance industry flattered and wooed generalists to be the "gatekeepers " for the health care system thus bestowing rightfully deserved respect on the otherwise second-class citizen in a culture of the valued specialist. But a decade before, it was shown that although a gatekeeper system did reduce costs in the short run, they tended to rebound after a period of time and physicians were uncomfortable with the role of denying care. And for good reason as the tools needed to make judgments as to the most clinically effective AND cost-effective interventions in individual cases are even to date non existent and the perception that their doctor was no longer acting solely in their best interest caused worry about and in some instances flight from primary care practices.(1) This worry and flight was not only on the part of the patients but the providers of the care themselves. Another blow is the worsening disparity in reimbursement for services. The inequities in the system are systemic in that medical insurance was developed and evolved to cover hugely expensive surgeries and intensive medicine practiced within costly organizations. It was not designed to compensate for figuring out if a surgery was necessary in the first place let alone keeping someone well and not in need of surgery at all. Reimbursement to primary care providers has not even kept up with inflation. Many of us do not get pay raises for cost of living even as we work harder to see more patients to generate more revenue while also continuing to spend the time needed to keep the bond and trust in the patient/provider relationship. Squeezing more patients in to keep the practice afloat may be another blow, all-be-it self-inflicted, that sinks the primary care ship. This makes it almost impossible to develop the relationships that are the chief reward for both physician and patient. It ultimately makes getting appointments more difficult and at appointments patients are meeting with providers that frequently seem harried and distracted. Frequently both participants in the encounter are dissatisfied. There is a desire for something different. Change is needed. The Institute of Medicine's Committee on the Quality of Health Care in America stated in a 2001 article entitled Crossing the Quality Chasm: Health Care for the 21 st Century, "[We are] confident that Americans can have a health care system of the quality they need, want and deserve. But the system as it now stands cannot do the job; trying harder will not work. Changing systems of care will."(2) I am confident that we can do this and do it in a way that promotes the bonds between people, the source of true health. REFERENCES (1) Sanders, L. The End of Primary Care. The New York Times Magazine;2004:6:52-5. (2) Committee on the Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: Health Care for the 21 st Century. 2001.
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