Primary care physician

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A patient having his blood pressure measured BloodPressure2.jpg
A patient having his blood pressure measured

A primary care physician (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The term is primarily used in the United States. In the past, the equivalent term was 'general practitioner' in the US; however in the United Kingdom and other countries the term general practitioner is still used. With the advent of nurses as PCPs, the term PCP has also been expanded to denote primary care providers.

Contents

A core element in general practice is continuity that bridges episodes of various illnesses. Greater continuity with a general practitioner has been shown to reduce the need for out-of-hours services and acute hospital admittance. Furthermore, continuity by a general practitioner reduces mortality. [1]

All physicians first complete medical school (MD, MBBS, or DO). To become primary care physicians, medical school graduates then undertake a postgraduate training in primary care programs, such as family medicine (also called family practice or general practice in some countries), pediatrics or internal medicine. Some HMOs consider gynecologists as PCPs for the care of women and have allowed certain subspecialists to assume PCP responsibilities for selected patient types, such as allergists caring for people with asthma and nephrologists acting as PCPs for patients on kidney dialysis.

Emergency physicians are sometimes counted as primary care physicians. Emergency physicians see many primary care cases, but in contrast to family physicians, pediatricians and internists, they are trained and organized to focus on episodic care, acute intervention, stabilization, and discharge or transfer or referral to definitive care, with less of a focus on chronic conditions and limited provision for continuing care.

Scope of practice

A set of skills and scope of practice may define a primary care physician, generally including basic diagnosis and treatment of common illnesses and medical conditions. [2] Diagnostic techniques include interviewing the patient to collect information on the present symptoms, prior medical history and other health details, followed by a physical examination. Many PCPs are trained in basic medical testing, such as interpreting results of blood or other patient samples, electrocardiograms, or x-rays. More complex and time-intensive diagnostic procedures are usually obtained by referral to specialists, with special training with a technology or increased experience and patient volume that make a risky procedure safer for the patient. [3] After collecting data, the PCP arrives at a differential diagnosis and, with the participation of the patient, formulates a plan including (if appropriate) components of further testing, specialist referral, medication, therapy, diet or life-style changes, patient education, and follow up results of treatment.

Primary care physicians also counsel and educate patients on safe health behaviors, self-care skills and treatment options, and provide screening tests and immunizations.

A recent United States survey, found that 45 percent of primary care doctors were contractually obligated to not inform patients when they moved on to another practice. This is a problem in rural areas, which may forbid doctors from setting up new or competing practices in areas where physicians are scarce. [4]

Role in health care system

A primary care physician is usually the first medical practitioner contacted by a patient because of factors such as ease of communication, accessible location, familiarity, and increasingly issues of cost and managed care requirements. In many countries residents are registered as patients of a (local) family doctor and must contact that doctor for referral to any other physician. They act as "gatekeepers", who regulate access to more costly procedures or specialists. Ideally, the primary care physician acts on behalf of the patient to collaborate with referral specialists, coordinate the care given by varied organizations such as hospitals or rehabilitation clinics, act as a comprehensive repository for the patient's records, and provide long-term management of chronic conditions. Continuous care is particularly important for patients with medical conditions that encompass multiple organ systems and require prolonged treatment and monitoring, such as diabetes and hypertension.

Quality of care

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. [5] [6] However, the studies examine the quality of care in the domain of the specialists. In addition, they need to account for clustering of patients and physicians. [7]

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. [8] In health promotion counseling, studies of self-reported behavior found that generalists were more likely than internal medicine specialists to counsel patients [9] and to screen for breast cancer. [10]

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 than orthopedic specialists. [11]

Factors associated with quality of care by primary care physicians:

Dissemination of information

The dissemination of information to generalists compared to specialists is complicated. [14] Two studies found specialists were more likely to adopt COX-2 drugs before the drugs were recalled by the FDA. [15] [16] 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". [16] Similarly, a separate study found that specialists were less discriminating in their choice of journal reading. [17]

Challenges

Declining numbers

In the United States, the number of medical students entering family practice training dropped by 50% between 1997 and 2005. [18] In 1998, half of internal medicine residents chose primary care, but by 2006, over 80% became specialists. [19] A survey Research by the University of Missouri-Columbia (UMC) and the U.S. Department of Health and Human Services predicts that by 2025 the United States will be short 35,000 to 44,000 adult care primary care physicians. [20]

Causes parallel the evolutionary changes occurring in the US medical system: payment based on quantity of services delivered, not quality; aging of the population increases the prevalence and complexity of chronic health conditions, most of which are handled in primary care settings; and increasing emphasis on life-style changes and preventative measures, often poorly covered by health insurance or not at all. [21] In 2004, the median income of specialists in the US was twice that of PCPs, and the gap is widening. [22] Discontent by practicing primary care internists is discouraging trainees from entering primary care; in a 2007 survey of 1,177 graduating US medical students, only 2% planned to enter a general internal medicine career, and lifestyle was emphasized over the higher subspecialty pay in their decision. [23] Primary care practices in the United States increasingly depend on foreign medical graduates to fill depleted ranks. [21]

Maldistribution

Developing countries face an even more critical disparity in primary care practitioners. The Pan American Health Organization reported in 2005 that "the Americas region has made important progress in health, but significant challenges and disparities remain. Among the most important is the need to extend quality health care to all sectors of the population.... Experience over the last 27 years shows that health systems that adhere to the principles of primary health care produce greater efficiency and better health outcomes in terms of both individual and public health." [24] The World Health Organization (WHO) has identified worsening trends in access to PCPs and other primary care workers, both in the developed and the developing nations: [25]

Lagging quality of care measures

A survey of 6,000 primary care doctors in seven countries revealed disparities in several areas that affect quality of care. [26] Differences did not follow trends of the cost of care; primary care physicians in the United States lagged behind their counterparts in other countries, despite the fact that the US spends two to three times as much per capita. Arrangements for after-hours care were almost twice as common in the Netherlands, Germany and New Zealand as in Canada and the United States, where patients must rely on emergency facilities. Other major disparities include automated systems to remind patients about follow-up care, give patients test results or warn of harmful drug interactions. There were differences as well among primary care doctors, regarding financial incentives to improve the quality of care.

Related Research Articles

<span class="mw-page-title-main">Physician</span> Professional who practices medicine

A physician, medical practitioner, medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the study, diagnosis, prognosis and treatment of disease, injury, and other physical and mental impairments. Physicians may focus their practice on certain disease categories, types of patients, and methods of treatment—known as specialities—or they may assume responsibility for the provision of continuing and comprehensive medical care to individuals, families, and communities—known as general practice. Medical practice properly requires both a detailed knowledge of the academic disciplines, such as anatomy and physiology, underlying diseases and their treatment—the science of medicine—and also a decent competence in its applied practice—the art or craft of medicine.

<span class="mw-page-title-main">Emergency medicine</span> Medical specialty concerned with care for patients who require immediate medical attention

Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians specialize in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency medical physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.

In the medical profession, a general practitioner (GP) or family physician is a physician who treats acute and chronic illnesses and provides preventive care and health education to patients of all ages. GPs' duties are not confined to specific fields of medicine, and they have particular skills in treating people with multiple health issues. They are trained to treat patients to levels of complexity that vary between countries. The term "primary care physician" is more usually used in the US. In Asian countries like India, this term has been replaced mainly by Medical Officers, Registered Medical Practitioner etc.

Osteopathic medicine is a branch of the medical profession in the United States that promotes the practice of science-based medicine, often referred to in this context as allopathic medicine, with a set of philosophy and principles set by its earlier form, osteopathy. Osteopathic physicians (DOs) are graduates of American osteopathic medical colleges and are licensed to practice the full scope of medicine and surgery in all 50 US states; they have historically applied for medical licensure in 87 countries outside of the United States, 85 of which provided them with the full scope of medical and surgical practice. The field is distinct from osteopathic practices offered in nations outside of the U.S., whose practitioners are generally not considered part of core medical staff nor of medicine itself, but rather are alternative medicine practitioners. The other major branch of medicine in the United States is referred to by practitioners of osteopathic medicine as allopathic medicine.

Internal medicine, also known as general internal medicine in Commonwealth nations, is a medical specialty for medical doctors focused on the prevention, diagnosis, and treatment of internal diseases. Medical practitioners of internal medicine are referred to as internists, or physicians in Commonwealth nations. Internists possess specialized skills in managing patients with undifferentiated or multi-system disease processes. They provide care to both hospitalized (inpatient) and ambulatory (outpatient) patients and often contribute significantly to teaching and research. Internists are qualified physicians who have undergone postgraduate training in internal medicine, and should not be confused with "interns”, a term commonly used for a medical doctor who has obtained a medical degree but does not yet have a license to practice medicine unsupervised.

<span class="mw-page-title-main">Primary care</span> Day-to-day health care given by a health care provider

Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need. Patients commonly receive primary care from professionals such as a primary care physician, a physician assistant, a physical therapist, or a nurse practitioner. In some localities, such a professional may be a registered nurse, a pharmacist, a clinical officer, or an Ayurvedic or other traditional medicine professional. Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.

<span class="mw-page-title-main">Physical examination</span> Process by which a medical professional investigates the body of a patient for signs of disease

In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a diagnosis and devise the treatment plan. These data then become part of the medical record.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

Hospital medicine is a medical specialty that exists in some countries as a branch of family medicine or internal medicine, dealing with the care of acutely ill hospitalized patients. Physicians whose primary professional focus is caring for hospitalized patients only while they are in the hospital are called hospitalists. Originating in the United States, this type of medical practice has extended into Australia and Canada. The vast majority of physicians who refer to themselves as hospitalists focus their practice upon hospitalized patients. Hospitalists are not necessarily required to have separate board certification in hospital medicine.

<span class="mw-page-title-main">Family medicine</span> Medical specialty

Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary care physician, is named a family physician. It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country. The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community". The issues of values underlying this practice are usually known as primary care ethics.

<span class="mw-page-title-main">Nurse practitioner</span> Mid-level medical provider

A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner. NPs are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe medications and treatment plans. NP training covers basic disease prevention, coordination of care, and health promotion. One study found that although reasons for referrals to specialists are similar for both physicians and NPs, the quality of documentation in the referrals may be lower for NPs.

A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include those branches of medicine that deal exclusively with children (paediatrics), cancer (oncology), laboratory medicine (pathology), or primary care. After completing medical school or other basic training, physicians or surgeons and other clinicians usually further their medical education in a specific specialty of medicine by completing a multiple-year residency to become a specialist.

Defensive medicine, also called defensive medical decision making, refers to the practice of recommending a diagnostic test or medical treatment that is not necessarily the best option for the patient, but mainly serves to protect the physician against the patient as potential plaintiff. Defensive medicine is a reaction to the rising costs of malpractice insurance premiums and patients’ biases on suing for missed or delayed diagnosis or treatment but not for being overdiagnosed.

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

The doctor–patient relationship is a central part of health care and the practice of medicine. A doctor–patient relationship is formed when a doctor attends to a patient's medical needs and is usually through consent. This relationship is built on trust, respect, communication, and a common understanding of both the doctor and patients' sides. The trust aspect of this relationship goes is mutual: the doctor trusts the patient to reveal any information that may be relevant to the case, and in turn, the patient trusts the doctor to respect their privacy and not disclose this information to outside parties.

The medical home, also known as the patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health outcomes. It is described in the "Joint Principles" as "an approach to providing comprehensive primary care for children, youth and adults."

Maintenance of Certification (MOC) is a recently implemented and controversial process of physician certification maintenance through one of the 24 approved medical specialty boards of the American Board of Medical Specialties (ABMS) and the 18 approved medical specialty boards of the American Osteopathic Association (AOA). The MOC process is controversial within the medical community, with proponents claiming that it is a voluntary program that improves physician knowledge and demonstrates a commitment to lifelong learning. Critics claim that MOC is an expensive, burdensome, involuntary and clinically irrelevant process that has been created primarily as a money-making scheme for the ABMS and the AOA.

<span class="mw-page-title-main">Physician supply</span>

Physician supply refers to the number of trained physicians working in a health care system or active in the labor market. The supply depends primarily on the number of graduates of medical schools in a country or jurisdiction but also on the number continuing to practice medicine as a career path and remaining in their country of origin. The number of physicians needed in a given context depends on several different factors, including the demographics and epidemiology of the local population, the numbers and types of other health care practitioners working in the system, and the policies and goals in place of the health care system. If more physicians are trained than needed, supply exceeds demand. If too few physicians are trained and retained, some people may have difficulty accessing health care services. A physician shortage is a situation in which there are not enough physicians to treat all patients in need of medical care. That can be observed at the level of a given health care facility, a province/state, a country, or worldwide.

Post-Hospitalist Medicine is the discipline concerned with the medical care of patients residing in Post-Acute, Long-Term Care, Rehabilitation and Assisted Living Facilities. The Physicians whose primary professional focus is the post-hospital medical care of these patients are called Post-Hospitalists.

References

  1. ↑ Sandvik, Hogne; Hetlevik, Øystein; Blinkenberg, Jesper; Hunskaar, Steinar (2022). "Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: A registry-based observational study in Norway". British Journal of General Practice. 72 (715): e84–e90. doi:10.3399/BJGP.2021.0340. PMC   8510690 . PMID   34607797.
  2. ↑ Institute of Medicine (1996). Primary Care: America's Health in a New Era. National Academies Press. p. 27. Archived from the original on 2006-12-17. Retrieved 2006-08-30.
  3. ↑ Institute of Medicine (2000). Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality. National Academies Press. Retrieved 2006-08-30.[ permanent dead link ]
  4. ↑ Andrews, Michelle (2019-03-15). "Did Your Doctor Disappear Without a Word? A Noncompete Clause Could Be the Reason". The New York Times . Retrieved 2019-03-18.
  5. ↑ 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. doi:10.1046/j.1525-1497.2001.016006351.x. PMC   1495223 . PMID   11422631.
  6. ↑ 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.
  7. ↑ "Summaries for patients. Comparing the quality of diabetes care by generalists and specialists". Ann Intern Med. 136 (2): I-42. 2002. doi: 10.7326/0003-4819-136-2-200201150-00003 . PMID   11928735.
  8. ↑ 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. doi: 10.1001/jama.279.17.1364 . PMID   9582044.
  9. ↑ Lewis C, Clancy C, Leake B, Schwartz J (1991). "The counseling practices of internists". Ann Intern Med. 114 (1): 54–8. doi:10.7326/0003-4819-114-1-54. PMID   1983933.
  10. ↑ Turner B, Amsel Z, Lustbader E, Schwartz J, Balshem A, Grisso J (1992). "Breast cancer screening: effect of physician specialty, practice setting, year of medical school graduation, and sex". Am J Prev Med. 8 (2): 78–85. doi:10.1016/S0749-3797(18)30838-9. PMID   1599724.
  11. ↑ 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. doi: 10.1056/NEJM199510053331406 . PMID   7666878.
  12. ↑ 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. doi: 10.1056/NEJM199603143341106 . PMID   8594430.
  13. ↑ Friedberg; et al. (2007). "Does Affiliation of Physician Groups with One Another Produce Higher Quality Primary Care?". Journal of General Internal Medicine. 22 (10): 1385–1392. doi:10.1007/s11606-007-0234-0. PMC   2305845 . PMID   17594130.
  14. ↑ Turner BJ, Laine C (2001). "Differences between generalists and specialists: knowledge, realism, or primum non nocere?". Journal of General Internal Medicine. 16 (6): 422–4. doi:10.1046/j.1525-1497.2001.016006422.x. PMC   1495225 . PMID   11422641. PubMed Central
  15. ↑ Rawson N, Nourjah P, Grosser S, Graham D (2005). "Factors associated with celecoxib and rofecoxib utilization". Ann Pharmacother. 39 (4): 597–602. doi:10.1345/aph.1E298. PMID   15755796. S2CID   25826363.
  16. 1 2 De Smet BD, Fendrick AM, Stevenson JG, Bernstein SJ (2006). "Over and under-utilization of cyclooxygenase-2 selective inhibitors by primary care physicians and specialists: the tortoise and the hare revisited". Journal of General Internal Medicine. 21 (7): 694–7. doi:10.1111/j.1525-1497.2006.00463.x. PMC   1924718 . PMID   16808768.
  17. ↑ McKibbon KA, Haynes RB, McKinlay RJ, Lokker C (2007). "Which journals do primary care physicians and specialists access from an online service?". Journal of the Medical Library Association. 95 (3): 246–54. doi:10.3163/1536-5050.95.3.246. PMC   1924945 . PMID   17641754.
  18. ↑ American Academy of Family Physicians, National Resident Matching Program data: Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates, 1994-2006 Retrieved 30 August 2006
  19. ↑ "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" (PDF) (Press release). The American College of Physicians. 2006-01-30. Archived from the original (PDF) on 2011-09-27. Retrieved 2006-08-30.
  20. ↑ Jack M. Colwill, James M. Cultice and Robin L. Kruse, JM; Cultice, JM; Kruse, RL (2008-04-29). "Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population?". Health Affairs. 27 (3): w232–w241. doi:10.1377/hlthaff.27.3.w232. PMID   18445642.
  21. 1 2 Bodenheimer, Thomas (2006-08-31). "Primary care - Will It Survive?". The New England Journal of Medicine. 355 (9): 861–864. doi:10.1056/NEJMp068155. PMID   16943396.
  22. ↑ Medical Group Management Association Physician Compensation Survey, 1998 - 2005: Median Compensation for Selected Medical Specialties Retrieved 30 August 2006
  23. ↑ Hauer, KE; Durning, SJ; Kernan, WN; Fagan, MJ; Mintz, M; O'Sullivan, PS; Battistone, M; Defer, T; et al. (2008-09-10). "Factors Associated With Medical Students' Career Choices Regarding Internal Medicine". JAMA. 300 (10): 1154–1164. doi:10.1001/jama.300.10.1154. PMID   18780844.
  24. ↑ Pan American Health Organization (September 2005): Regional Declaration on the New Orientations of Primary Health Care Retrieved 30 August 2006
  25. ↑ World Health Organization: World Health Report-2006 Retrieved 30 August 2006
  26. ↑ Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Jordon Peugh, and Kinga Zapert, C; Osborn, R; Huynh, PT; Doty, M; Peugh, J; Zapert, K (1999-11-02). "On The Front Lines Of Care: Primary Care Doctors' Office Systems, Experiences, And Views In Seven Countries" (abstract). Health Affairs. 25 (6): w555-71. doi:10.1377/hlthaff.25.w555. PMID   17102164 . Retrieved 2006-11-06.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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