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09/04/2015

Are Primary Care Providers Providing Primary Care?

I
initially set out to write a post about lack of access to primary care
physicians, but the more I explored the topic, the more I realized that the
issue is not only that access to PCPs is limited, but that the medical model of
primary care itself has changed.

It
has been widely discussed among bioethicists and health care policy experts
that emergency departments are overcrowded, urgent care centers are rapidly
becoming
a substitute for the traditional primary care doctor
, and that the number
of new physicians specializing in primary care medicine has been declining
in
favor of other, higher-paying specialties
. 
Still, many insurance plans require regular visits with a PCP and only
cover specialty services if the referral is made by the patient’s primary
doctor.
  Specialists and urgent care
clinicians also insist that patients follow up with their PCP after treatment
and make sure that their records are forwarded.
 
Despite the push for establishing a “medical home” and centralizing care
around the primary care physician, demand for urgent care or emergency services
is still high, and getting into a practice or getting a timely appointment with
a primary care physician is difficult.

Lack
of access to primary care is often blamed on financial issues, especially lack
of insurance, but even well-insured patients are affected by the PCP
shortage.
  A patient may be able to
afford the PCP visit, but they either cannot find a practice accepting new
patients or, if they are already a patient, may have to wait several days to
get a sick visit appointment.
  For a
patient with strep throat or another easily diagnosable and treatable illness,
an extra 4-5 days is too long – the patient suffers longer, risks complications
or worsened illness, and must take more time off of work, which can have
significant consequences.

Faced
with this dilemma, why would a patient wait days for their primary care
appointment when they could go somewhere else to receive care the same
day?
  Are urgent care centers severing
the relationship between patients and their primary care physicians?
  And are patients really to blame for their
failure to find a medical home?
 

As
it turns out, it may not be that the use of urgent care centers is disrupting
the patient-physician relationship, but instead is a
welcome
change to the medical model of primary care
.  While primary care offices see patients for
annual physicals and monitoring of chronic conditions, it seems that if
patients have an acute illness, the expectation is not that they will get a
same-day sick visit with the PCP, but that they should go to an urgent care
center instead.
  Often this suggestion
comes from the office itself.

Patients
can be seen and treated quickly this way, but is this model of division of
labor good for patients?
  While patients
may still see their doctor annually, their visits to urgent care centers mean
that they are treated by a revolving door of clinicians, from doctors to
physician’s assistants to nurse practitioners.
 
A patient may have taken time and effort to find a primary care doctor,
taking into account experience, personality, medical approaches and practices,
and general comfort level with the provider.
 
In this model, however, the patient may see that doctor once per year,
while being treated several times per year by unknown practitioners that vary
in the way they practice medicine.
 

This
delegation of health care tasks raises a host of questions: Are these urgent
care clinicians able to consider a patient’s acute illnesses in the greater
context of their overall health?
  Who is
really the front line primary care provider for this patient?
  And are primary care physicians actually the
primary providers of health care for their patients, or are they increasingly
serving as a common dumping ground for patient medical records from other
providers?
  

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.

 

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