Primary care physician: Difference between revisions

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The number of physicians entering primary care in the United States is dropping, probably in part due to making less income for the amount on time spend with patients.<ref name="NYTImes match day">{{cite web |url=http://www.nytimes.com/2008/03/19/fashion/19beauty.html |title=For Top Medical Students, an Attractive Field |accessdate=2008-03-31 |author=Singer, N |authorlink= |coauthors= |date=3/19/2008 |format= |work= |publisher=New York Times |pages= |language= |archiveurl= |archivedate= |quote=}}</ref>
The number of physicians entering primary care in the United States is dropping, probably in part due to making less income for the amount on time spend with patients.<ref name="NYTImes match day">{{cite web |url=http://www.nytimes.com/2008/03/19/fashion/19beauty.html |title=For Top Medical Students, an Attractive Field |accessdate=2008-03-31 |author=Singer, N |authorlink= |coauthors= |date=3/19/2008 |format= |work= |publisher=New York Times |pages= |language= |archiveurl= |archivedate= |quote=}}</ref>


In addition, non-physicians may replace much of the work of primary care physicians.<ref name="pmid25023250">{{cite journal| author=Shaw RJ, McDuffie JR, Hendrix CC, Edie A, Lindsey-Davis L, Nagi A et al.| title=Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis. | journal=Ann Intern Med | year= 2014 | volume= 161 | issue= 2 | pages= 113-21 | pmid=25023250 | doi=10.7326/M13-2567 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25023250  }} </ref><ref name="pmid22966102">{{cite journal| author=Altschuler J, Margolius D, Bodenheimer T, Grumbach K| title=Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. | journal=Ann Fam Med | year= 2012 | volume= 10 | issue= 5 | pages= 396-400 | pmid=22966102 | doi=10.1370/afm.1400 | pmc=PMC3438206 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22966102  }} </ref>
In addition, non-physicians may replace much of the work of primary care physicians.<ref name="pmid25023250">{{cite journal| author=Shaw RJ, McDuffie JR, Hendrix CC, Edie A, Lindsey-Davis L, Nagi A et al.| title=Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis. | journal=Ann Intern Med | year= 2014 | volume= 161 | issue= 2 | pages= 113-21 | pmid=25023250 | doi=10.7326/M13-2567 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25023250  }} </ref><ref name="pmid22966102">{{cite journal| author=Altschuler J, Margolius D, Bodenheimer T, Grumbach K| title=Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. | journal=Ann Fam Med | year= 2012 | volume= 10 | issue= 5 | pages= 396-400 | pmid=22966102 | doi=10.1370/afm.1400 | pmc=PMC3438206 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22966102  }} </ref> This disruption has been predicted by Clayton Christensen in his book, The Innovator’s Prescription: A Disruptive Solution for Healthcare<ref>Christensen, Clayton (2009) [http://www.slideshare.net/lucienengelen/clayton-christensen-innovative-prescription The Innovator’s Prescription: How disruptive innovation can transform health care (slide set)]. See slide 8.</ref>  


Alternative financial compensation models have been proposed.<ref>Baron, R. J., & Cassel, C. K. (2008). 21st-Century Primary Care: New Physician Roles Need New Payment Models. JAMA, 299(13), 1595-1597. {{doi|10.1001/jama.299.13.1595}}.</ref> These models include the medical home<ref name="titleACP: Medical Homes & Patient-Centered Care">{{cite web |url=http://www.acponline.org/advocacy/where_we_stand/medical_home/ |title=ACP: Medical Homes & Patient-Centered Care |accessdate=2008-04-02 |author=Anonymous |authorlink= |coauthors= |date=2008 |format= |work= |publisher=American College of Physicians |pages= |language= |archiveurl= |archivedate= |quote=}}</ref>, ambulatory intensive caring unit, and retainer model of compensation has been proposed to solve this problem (also called concierge  medicine).<ref name="medscape The Retainer Model or Single Payer">{{cite web |url=http://www.medscape.com/viewarticle/571133 |title=The Retainer Model or Single Payer -- What Will Save Primary Care? |accessdate=2008-03-31 |author=Centor RM, Vega CP |authorlink= |coauthors= |date=03/20/2008 |format= |work= |publisher=Medscape |pages= |language= |archiveurl= |archivedate= |quote=}}</ref>
Alternative financial compensation models have been proposed.<ref>Baron, R. J., & Cassel, C. K. (2008). 21st-Century Primary Care: New Physician Roles Need New Payment Models. JAMA, 299(13), 1595-1597. {{doi|10.1001/jama.299.13.1595}}.</ref> These models include the medical home<ref name="titleACP: Medical Homes & Patient-Centered Care">{{cite web |url=http://www.acponline.org/advocacy/where_we_stand/medical_home/ |title=ACP: Medical Homes & Patient-Centered Care |accessdate=2008-04-02 |author=Anonymous |authorlink= |coauthors= |date=2008 |format= |work= |publisher=American College of Physicians |pages= |language= |archiveurl= |archivedate= |quote=}}</ref>, ambulatory intensive caring unit, and retainer model of compensation has been proposed to solve this problem (also called concierge  medicine).<ref name="medscape The Retainer Model or Single Payer">{{cite web |url=http://www.medscape.com/viewarticle/571133 |title=The Retainer Model or Single Payer -- What Will Save Primary Care? |accessdate=2008-03-31 |author=Centor RM, Vega CP |authorlink= |coauthors= |date=03/20/2008 |format= |work= |publisher=Medscape |pages= |language= |archiveurl= |archivedate= |quote=}}</ref>

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A primary care physician is the doctor who is predominantly responsible for a patient's health. One of the tasks of the primary care physician is coordinating the many facets of a patient's health care and chronic diseases.[1]. Generalists physicians are more tolerant of being responsible for breadth of knowledge than are subspecialists.[2]

Most common reasons to see a primary care physician

Most common reasons for an office visit:[3]

  • Cough
  • Knee symptoms
  • Stomach and abdominal pain,
  • Symptoms referable to throat
  • Back symptoms
  • Earache, or ear infection
  • Skin rash
  • Shoulder symptoms
  • Vision dysfunctions

Most common reasons for a visit to the Emergency department:[4]

  • Stomach and abdominal pain
  • Chest pain and related symptoms
  • Fever
  • Headache, pain in head
  • Back symptoms
  • Shortness of breath
  • Cough
  • Pain, site not referable to a specific body system
  • Vomiting
  • Symptoms referable to throat

(include earache for visits by patients under 15 years old)

Studies of the quality of care provided by primary care physicians

Availability of primary care physicians in the physician workforce is associated with favorable clinical outcomes[5] and less regional variation in medical procedures.[6]

Studies that compare the knowledge base and quality of care provided by generalists versus specialists usually find that the specialists are more knowledgeable and provide better care. [7][8][9] However, these studies examine the quality of care in the domain of the specialists. In addition, these studies need to account for clustering of patients and physicians. [10]

Studies of the quality of preventive health care find the opposite results - primary care physicians perform best. An analysis of elderly patients found that patients seeing generalists, as compared to patients seeing specialists, were more likely to receive influenza vaccination. [11] In health promotion counseling, a study of self-reported behavior found that generalists were more likely than internal medicine specialists to counsel patients [12] and to screen for breast cancer. [13] Likewise, generalists are more accurate in selecting patients for screening for cervical cancer.[14]

Exceptions may be diseases that are so common that primary care physicians develop their own expertise:

  • A study of patients with acute low back pain found the primary care physicians provided equivalent quality of care, but at lower costs that orthopedic specialists. [15] Another study found that orthopedics surgeons may be less aware of current knowledge than primary care physicians.[16]
  • Regarding the treatment of pain in general, two studies found specialists were more likely to adopt cyclooxygenase 2 inhibitor drugs before the drug rofecoxib was withdrawn by its manufacturers because of its unanticipated adverse effects [17][18]. One of the studies went on to state:
"using COX-2s as a model for physician adoption of new therapeutic agents, specialists were more likely to use these new medications for patients likely to benefit but were also significantly more likely to use them for patients without a clear indication".[18]

The highest quality care may occur with primary care physicians and specialists collaborate.[21][22]

Factors associated with quality of care by primary care physicians include:

  • The more experience the primary care physician has with a specific disease. [23]
  • Physician group affiliation with networks of multiple groups.[24]

Markers of high quality in primary care

Use of electronic health records.[25][26]

Team-based, or collaborative care.[27]

Longer visit length.[28] However, over time, the number of items discussed during each visit has risen more than the length of a visit.[29]

Frequency of visits when medical problems are not controlled.[30]

Physicians with higher text scores in training may deliver better health care.[31]

Job satisfaction

A qualitative survey of internal medicine doctors in the United States found three sources of satisfaction from medical practice:[32]

  1. realizing a fundamental change in perspective via an experience with a patient
  2. making a difference made in someone's life
  3. connecting with patients

Part-time practice is associated with increased satisfaction.[33]

Difficulties

The increasing number of items to discuss during a patient visit is a problem[29] in spite of the increasing length of visits[28]. There is insufficient time to address:

Longer visits are associated with greater quality.[28]

Primary care physicians may be more likely to leave practice than specialists.[36]

Conflict of interest

Primary care physicians practicing in fee-for-service plans may be more susceptible to conflict of interest in their ordering of medical services.[37]

Collapse of primary care in the United States

The number of physicians entering primary care in the United States is dropping, probably in part due to making less income for the amount on time spend with patients.[38]

In addition, non-physicians may replace much of the work of primary care physicians.[39][40] This disruption has been predicted by Clayton Christensen in his book, The Innovator’s Prescription: A Disruptive Solution for Healthcare[41]

Alternative financial compensation models have been proposed.[42] These models include the medical home[43], ambulatory intensive caring unit, and retainer model of compensation has been proposed to solve this problem (also called concierge medicine).[44]

References

  1. ↑ Bodenheimer, T. (2008). Coordinating care -- a perilous journey through the health care system, N Engl J Med, 358(10), 1064-1071. DOI:10.1056/NEJMhpr0706165
  2. ↑ DeWitt DE, Curtis JR, Burke W (1998). "What influences career choices among graduates of a primary care training program?". J Gen Intern Med 13 (4): 257-61. PMID 9565389. PMC PMC1496946. [e]
  3. ↑ Centers for Disease Control and Prevention. NCHS Reports Using Ambulatory Health Care Data Table 9
  4. ↑ Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables
  5. ↑ Chiang-Hua Chang et al. Original Contribution Primary Care Physician Workforce and Medicare Beneficiaries' Health Outcomes. JAMA. 2011;305(20):2096-2104. DOI:10.1001/jama.2011.665
  6. ↑ Chassin MR, Brook RH, Park RE, Keesey J, Fink A, Kosecoff J et al. (1986). "Variations in the use of medical and surgical services by the Medicare population.". N Engl J Med 314 (5): 285-90. DOI:10.1056/NEJM198601303140505. PMID 3510394. Research Blogging.
  7. ↑ Majumdar S, Inui T, Gurwitz J, Gillman M, McLaughlin T, Soumerai S (2001). "Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction". J Gen Intern Med 16 (6): 351-9. PMID 11422631.
  8. ↑ Fendrick A, Hirth R, Chernew M (1996). "Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease". Am J Gastroenterol 91 (8): 1544-8. PMID 8759658.
  9. ↑ George S, et al. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technol Assess. 2008 May;12(23):1-58. PMID 18505669
  10. ↑ (2002) "Summaries for patients. Comparing the quality of diabetes care by generalists and specialists". Ann Intern Med 136 (2): I42. PMID 11928735.
  11. ↑ Rosenblatt R, Hart L, Baldwin L, Chan L, Schneeweiss R (1998). "The generalist role of specialty physicians: is there a hidden system of primary care?". JAMA 279 (17): 1364-70. PMID 9582044.
  12. ↑ Lewis C, Clancy C, Leake B, Schwartz J (1991). "The counseling practices of internists". Ann Intern Med 114 (1): 54-8. PMID 1983933.
  13. ↑ Turner B, Amsel Z, Lustbader E, Schwartz J, Balshem A, Grisso J. "Breast cancer screening: effect of physician specialty, practice setting, year of medical school graduation, and sex". Am J Prev Med 8 (2): 78-85. PMID 1599724.
  14. ↑ 14.0 14.1 Yabroff KR, Saraiya M, Meissner HI, Haggstrom DA, Wideroff L, Yuan G et al. (2009). "Specialty differences in primary care physician reports of papanicolaou test screening practices: a national survey, 2006 to 2007.". Ann Intern Med 151 (9): 602-11. DOI:10.1059/0003-4819-151-9-200911030-00005. PMID 19884621. Research Blogging.
  15. ↑ Carey T, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker D (1995). "The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project". N Engl J Med 333 (14): 913-7. PMID 7666878.
  16. ↑ Finestone AS, Raveh A, Mirovsky Y, Lahad A, Milgrom C (2009). "Orthopaedists' and family practitioners' knowledge of simple low back pain management.". Spine (Phila Pa 1976) 34 (15): 1600-3. DOI:10.1097/BRS.0b013e3181a96622. PMID 19564770. Research Blogging.
  17. ↑ Rawson N et al. (2005). "Factors associated with celecoxib and rofecoxib utilization". Ann Pharmacother 39: 597-602. PMID 15755796.
  18. ↑ 18.0 18.1 De Smet BD et al. (2006). "Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists: the tortoise and the hare revisited". J Gen Intern Med 21: 694-7. DOI:10.1111/j.1525-1497.2006.00463.x. PMID 16808768. Research Blogging.
  19. ↑ Saraiya M, Berkowitz Z, Yabroff KR, Wideroff L, Kobrin S, Benard V (2010). "Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs Papanicolaou testing alone: what screening intervals are physicians recommending?". Arch Intern Med 170 (11): 977-85. DOI:10.1001/archinternmed.2010.134. PMID 20548011. Research Blogging.
  20. ↑ Haynes RB, Cotoi C, Holland J, Walters L, Wilczynski N, Jedraszewski D et al. (2006). "Second-order peer review of the medical literature for clinical practitioners.". JAMA 295 (15): 1801-8. DOI:10.1001/jama.295.15.1801. PMID 16622142. Research Blogging.
  21. ↑ Lee DS, Stukel TA, Austin PC, Alter DA, Schull MJ, You JJ et al. (2010). "Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department.". Circulation 122 (18): 1806-14. DOI:10.1161/CIRCULATIONAHA.110.940262. PMID 20956211. Research Blogging.
  22. ↑ Kanwal F, Schnitzler MS, Bacon BR, Hoang T, Buchanan PM, Asch SM (2010). "Quality of care in patients with chronic hepatitis C virus infection: a cohort study.". Ann Intern Med 153 (4): 231-9. DOI:10.1059/0003-4819-153-4-201008170-00005. PMID 20713791. Research Blogging.
  23. ↑ Kitahata M, Koepsell T, Deyo R, Maxwell C, Dodge W, Wagner E (1996). "Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival". N Engl J Med 334 (11): 701-6. PMID 8594430.
  24. ↑ Friedberg et al., “Does Affiliation of Physician Groups with One Another Produce Higher Quality Primary Care?,” Journal of General Internal Medicine 22, no. 10 (October 21, 2007): 1385-1392, http://dx.doi.org/10.1007/s11606-007-0234-0 (accessed September 28, 2007).
  25. ↑ Cebul RD, Love TE, Jain AK, Hebert CJ (2011). "Electronic health records and quality of diabetes care.". N Engl J Med 365 (9): 825-33. DOI:10.1056/NEJMsa1102519. PMID 21879900. Research Blogging.
  26. ↑ Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL et al. (2011). "The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial.". Arch Intern Med 171 (5): 460-6. DOI:10.1001/archinternmed.2010.540. PMID 21403043. Research Blogging.
  27. ↑ Callahan CM, Boustani MA, Unverzagt FW, Austrom MG, Damush TM, Perkins AJ et al. (2006). "Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial.". JAMA 295 (18): 2148-57. DOI:10.1001/jama.295.18.2148. PMID 16684985. Research Blogging.
  28. ↑ 28.0 28.1 28.2 Chen LM, Farwell WR, Jha AK (2009). "Primary care visit duration and quality: does good care take longer?". Arch Intern Med 169 (20): 1866-72. DOI:10.1001/archinternmed.2009.341. PMID 19901138. Research Blogging. Cite error: Invalid <ref> tag; name "pmid19901138" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid19901138" defined multiple times with different content
  29. ↑ 29.0 29.1 Abbo ED, Zhang Q, Zelder M, Huang ES (2008). "The increasing number of clinical items addressed during the time of adult primary care visits.". J Gen Intern Med 23 (12): 2058-65. DOI:10.1007/s11606-008-0805-8. PMID 18830762. PMC PMC2596516. Research Blogging. Cite error: Invalid <ref> tag; name "pmid18830762" defined multiple times with different content
  30. ↑ Friedberg MW, Coltin KL, Pearson SD, Kleinman KP, Zheng J, Singer JA et al. (2007). "Does affiliation of physician groups with one another produce higher quality primary care?". J Gen Intern Med 22 (10): 1385-92. DOI:10.1007/s11606-007-0234-0. PMID 17594130. PMC PMC2305845. Research Blogging.
  31. ↑ Tamblyn R, Abrahamowicz M, Brailovsky C, Grand'Maison P, Lescop J, Norcini J et al. (1998). "Association between licensing examination scores and resource use and quality of care in primary care practice.". JAMA 280 (11): 989-96. PMID 9749481. [e]
  32. ↑ Horowitz C, Suchman A, Branch W, Frankel R (2003). "What do doctors find meaningful about their work?". Ann Intern Med 138 (9): 772-5. PMID 12729445.
  33. ↑ Mechaber HF, Levine RB, Manwell LB, et al (2008). "Part-time physicians...prevalent, connected, and satisfied". J Gen Intern Med 23 (3): 300-3. DOI:10.1007/s11606-008-0514-3. PMID 18214623. Research Blogging.
  34. ↑ Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL (2005). "Is there time for management of patients with chronic diseases in primary care?". Ann Fam Med 3 (3): 209-14. DOI:10.1370/afm.310. PMID 15928223. PMC PMC1466884. Research Blogging. Review in: J Fam Pract. 1998 May;46(5):377-89
  35. ↑ Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL (2003). "Primary care: is there enough time for prevention?". Am J Public Health 93 (4): 635-41. PMID 12660210. PMC PMC1447803. Review in: J Fam Pract. 1984 May;18(5):723-7 Review in: J Fam Pract. 1996 Oct;43(4):361-9 Review in: J Fam Pract. 1998 May;46(5):397-402 Review in: J Fam Pract. 1998 May;46(5):419-24
  36. ↑ Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK (2006). "Who is maintaining certification in internal medicine--and why? A national survey 10 years after initial certification.". Ann Intern Med 144 (1): 29-36. PMID 16389252.
  37. ↑ Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A et al. (2000). "Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians.". Cochrane Database Syst Rev (3): CD002215. DOI:10.1002/14651858.CD002215. PMID 10908531. Research Blogging.
  38. ↑ Singer, N (3/19/2008). For Top Medical Students, an Attractive Field. New York Times. Retrieved on 2008-03-31.
  39. ↑ Shaw RJ, McDuffie JR, Hendrix CC, Edie A, Lindsey-Davis L, Nagi A et al. (2014). "Effects of nurse-managed protocols in the outpatient management of adults with chronic conditions: a systematic review and meta-analysis.". Ann Intern Med 161 (2): 113-21. DOI:10.7326/M13-2567. PMID 25023250. Research Blogging.
  40. ↑ Altschuler J, Margolius D, Bodenheimer T, Grumbach K (2012). "Estimating a reasonable patient panel size for primary care physicians with team-based task delegation.". Ann Fam Med 10 (5): 396-400. DOI:10.1370/afm.1400. PMID 22966102. PMC PMC3438206. Research Blogging.
  41. ↑ Christensen, Clayton (2009) The Innovator’s Prescription: How disruptive innovation can transform health care (slide set). See slide 8.
  42. ↑ Baron, R. J., & Cassel, C. K. (2008). 21st-Century Primary Care: New Physician Roles Need New Payment Models. JAMA, 299(13), 1595-1597. DOI:10.1001/jama.299.13.1595.
  43. ↑ Anonymous (2008). ACP: Medical Homes & Patient-Centered Care. American College of Physicians. Retrieved on 2008-04-02.
  44. ↑ Centor RM, Vega CP (03/20/2008). The Retainer Model or Single Payer -- What Will Save Primary Care?. Medscape. Retrieved on 2008-03-31.

See also

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