A Reader and Author Respond to "Does Primary Care Matter?"

Joe Polaschek; Emily Friedman


December 29, 2008

To the Editor:

Emily Friedman raises an issue that should be developed further.[1]

Perhaps we might reconsider what has become of the family doctor concept of the past and what can be done to restore the role and value of this jewel of the healthcare delivery system. From a managed care perspective, the focus seems to be on the "specialist" physician and the apparent valuation (judging monetarily) of their services over those of the primary care physician.

We are hearing more about evidence-based medicine (EBM)[2,3,4] in the literature and from managed care plans. Although I am not a medical professional, I have observed and participated in the changing practice of medicine as a health system developer and manager for over 35 years and as an educated patient much longer. From a practical standpoint, I have no qualms with EBM. I simply believe there are some extremely well-trained and practiced medical professionals who fail to fully consider an important element of healthcare -- the patients, and their quality of life.

As an example, my personal PCP [primary care physician] is an osteopathic family physician, trained in treating the whole person and seeking causes, not just treatment of symptoms. While being evaluated for a particular condition recently, our discussions broadened, and he subsequently found a rather significant problem that had been missed by numerous "specialists."

I think EBM has become a type of buzz phrase, perhaps understood more as "treating a number" vs "treating a patient," which could translate into focusing on numbers alone or disease-oriented outcomes rather than on "patient-oriented evidence that matters (POEM).[5,6]"

Many physicians would do well to observe and listen more attentively to their patients and, to coin a phrase, use "experience-based intuition" as well, the loss of which may have become an adverse byproduct of managed healthcare systems.

There has been increasing discussion in general on the topic of combining the several versions of primary care physicians into one "super" primary care specialty, as was done at the Lake Erie College of Osteopathic Medicine [Erie, Pennsylvania].[7] From personal observation, I would favor a basic osteopathic training course with the addition of certain modalities of care that would perhaps begin to extend the role of the primary physician back to what we were used to not so very long ago.

This would require a review and modification of medical school and family practice residency curricula, perhaps reducing a 4-year term to 3 years,[7] and influencing the payers to recognize this "back to the future" approach as a benefit to them. The case might be made that an expanded specialty primary care focus applying "POEM" may return healthcare system cost savings by reducing unnecessary testing; extensive, unproductive medication usage; and other "specialist" referrals. Another benefit may be the return of interest by medical school students to this specialty.

This may be a daunting task, but at the very least, further investigation and dialogue on the subject may be warranted. From this dialogue, perhaps a viable action plan could be developed.

Joe Polaschek

  1. Friedman E. Does primary care matter? Medscape J Med. 2008;10:209. Available at: Accessed December 16, 2008.

  2. Eddy DM. Practice policies: where do they come from? JAMA. 1990;263:1265, 1269, 1272 passim.

  3. Eddy DM. Evidence-based medicine: a unified approach. Health Aff (Project Hope). 2005;24:9-17.

  4. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268:2420-2425. Abstract

  5. Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract. 1994;39:489-499. Abstract

  6. Slawson DC, Shaughnessy AF. Obtaining useful information from expert based sources. BMJ. 1997;314:947-949. Abstract

  7. Bell HS, Ferretti SM, Ortoski RA. A three-year accelerated medical school curriculum designed to encourage and facilitate primary care careers. Acad Med. 2007;82:895-899. Abstract

Author's Response:

To the Editor:

Mr. Polaschek makes several worthy points in his analysis. I will respond to 3 of them. First, the payment system that rewards specialists (in some cases, overrewards them) encourages fragmentation of care and overuse of tests and technology, and discourages holistic primary care as a dinosaur that requires major overhaul, including -- as Mr. Polaschek suggests -- rewards for physicians who "treat the whole patient" and coordinate care. Past successful lobbying by specialist groups has produced a situation in which few new physicians can afford to choose primary care, and that must change.

Second, evidence-based medicine is not necessarily overspecialization; it is simply the notion that if care is provided -- whether diagnostic, therapeutic, or palliative -- there should be evidence that it works. Much of what is provided by physicians is not, in fact, effective and can sometimes be detrimental. The difficulty in overcoming these practices is evident in the fact that although antibiotics are not effective against viral infections, millions of prescriptions for their use against such infections are still written every year, with physicians offering excuses, such as "otherwise the patient will find another doctor" or "it's for placebo effect." The result of this and other overuse of antibiotics is a growing group of pathogens that are resistant to them. If evidence-based medicine can produce more scientific, more conservative, and less harmful medicine, I'm all for it, and I do not believe that it interferes with the practice of good primary care, but rather enhances it. There is always room for "experience-based intuition" -- a nice concept.

Third and finally, I offer no opinion about the quality of osteopathic vs allopathic medicine when it comes to primary care. I do agree with Mr. Polaschek that medical education also needs an overhaul, whether that leads to a 3-year curriculum for primary care or not. However, the multiple vested interests that control medical education could make that a very hard sell; we would have more luck reducing inappropriate antibiotic prescriptions! Nonetheless, if the physicians of tomorrow are going to be successful in an environment that emphasizes science, coordinated care, prevention, and patient safety, current curricula and standards in education must be rethought in a profound way.

The answer, I suspect, is 3-fold: Create financial incentives that produce what is best for patients, society, and the professions; encourage physicians themselves to become change agents and realign priorities and power within the profession; and empower patients to be their own advocates and challenge the status quo.

Emily Friedman
Independent Health Policy and Ethics Analyst
Chicago, Illinois
Adjunct Assistant Professor
Boston University School of Medicine
Boston, Massachusetts

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