Primary care is for chumps

So, I see via Megan (OK, so I don't actually know her or anything, but we both have blogs. That makes us colleagues, right? Right?!) that there is some discussion about primary care. Or rather, the shortage thereof.

First was this op-ed, by Dr. Jonathan Glauser, an emergency medicine physician somewhere. He considers primary care medicine a failure. I do not know Dr. Glauser, but I am not impressed by the nuanced workings of his mind. Let's read a bit, shall we?

I cannot be the only emergency physician who has treated patients referred by primary care doctors for such non-emergencies as:

▪ Asymptomatic hypertension of 190/115 mm Hg picked up in the office or at health fairs. If you told me 25 years ago that some guy out on the town for the evening would be referred to the ED by an internist to manage high blood pressure, I would have thought you were crazy.

▪ Asymptomatic hyperglycemia of 350-500 mg/dL in patients already managed by these doctors on oral agents.

▪ An asymptomatic patient with an INR of 5.

▪ An entire family of eight referred for screening for pertussis exposure, all asymptomatic.

Um, no. You're probably not the only ED physician who has had experiences like those. There are, sadly, bad primary care physicians out there. Likewise, there are some really terrible, stupid ED physicians out there. Shall I share some poor decisions I have seen ED physicians make? No, because it proves no point to share unflattering anecdotes. I won't draw broad conclusions about your field from my experience if you won't draw similar conclusions about mine, 'kay? 'Kay. (This is why we don't call anecdotes "evidence.")

Then he gives us this gem:

I have never encountered a plea for health care reform that did not extol the benefits of detection and treatment before some disastrous outcome ensues. In the long run, of course, preventive care does not save society money; we all get some terminal illness eventually

I don't want to overstate things, but this may possibly be the most addle-brained thing I have ever read. There is a difference between saving money and preventing death forever. If preventive care can keep you from keeling over with a massive coronary at 47, and you live another 30 years because your cholesterol levels and blood pressure are kept normal, then you have contributed income to society for an additional couple of decades, and your spouse doesn't have to rely on the state to help support your kids on half the money. Preventive care includes such wonders as vaccinations, which I can't imagine anyone would argue haven't saved society money. (Or perhaps we'd all like to have another crack at polio?) Preventive care of asthma dramatically improves both quality of life and productivity. Honestly, this piece is so poorly written I am amazed it was published.

Ezra Klein also has some things to say. He comes out in favor of nurse practitioners as a solution to the crisis in primary care. While I think this is a good solution in part, I think that it underestimates the difference in physician and NP training. I completed three years of an incredibly intense training residency, and had to pass a very stringent board certification exam. Having helped teach a good friend of mine who is in training for his NP, there is simply no comparison between his training and mine. This is not to say that NPs do not do excellent work; I am lucky to work with two who are superb. But doctors and NPs are not interchangeable.

I will say that primary care is no walk in the park. We have to spend lots of precious time documenting scrupulously in order to get paid, using a system so arbitrary it hurts. (One example -- you don't get any "credit" for documenting if there are normal bowel sounds [a very important finding, in some cases] but you get one point for simply touching the abdomen, and another for documenting if the liver is normal sized. One step, two points.) We have to fight with insurance companies to get paid for services rendered. Add in the joy of waking in the night for admissions, dealing with frustrated parents, explaining for the millionth time that vaccines don't cause autism, and it's not hard to see why people opt for radiology.


  1. I want to hear about the terrible ED physicians!

    And personally, I'll pay someone NOT to touch my stomach. Ticklish!

  2. OK, one story. Once, at one of the many, many hospitals at which I have worked in the past nine years, I saw a physician get into a power struggle with a patient in his late teens/early twenties over allowing a genital exam. The patient was refusing, and the physician was threatening to have him restrained so the exam could be performed. Keep in mind, the presenting complaint had nothing to do with the genitals, and there was nothing in the clinical scenario to indicate a need for such an exam. But, you see, the patient had refused a complete exam, and at the point when I left (going off shift) he was threatening to call security for restraint.

    This was before I was the maven of adolescent medicine you know and love (whoops! A clue!), and I am now blessedly in such a position that I could prevent lunacy of this kind. Oh, and yes, the physician in question was on the ED staff.

  3. Wow. OK. That's a pretty terrible ED physician.