Correspondence

The Scope of Practice in Primary Care

N Engl J Med 2000; 342:1453-1454May 11, 2000

Article

To the Editor:

I was dismayed by Dr. Grumbach's comment, in his editorial on primary care in the United States (Dec. 23 issue),1 that primary care physicians are “the type of physician everyone really needs, unless of course the person is actually ill, at which point a more qualified specialist should take over.”

I am a board-certified family physician. I am fully qualified to diagnose and treat the vast majority of my patients' medical problems. When a patient has an unusual or very severe clinical presentation, I do not hesitate to consult my colleagues, with whom I enjoy excellent relationships. My patients find great comfort in having me follow them when they are evaluated by physicians in other specialties, and their families find solace in knowing that I will be there if there is a need for admission to an intensive care unit or if decisions about terminal care or hospice care have to be made.

Dr. Grumbach expresses the very bias that we must overcome if primary care is to have the status it deserves in the U.S. medical system. The fact that there are different levels of medical practice means not that doctors practicing primary care are less qualified than other physicians but instead that different levels of expertise are needed within a system that attempts to provide personal yet also technologically advanced medical care.

Miguel Buxeda, M.D.
Family Medical Centre, Hialeah, FL 33014

1 References

1
Grumbach K. Primary care in the United States -- the best of times, the worst of times. N Engl J Med 1999;341:2008-2010
Full Text | Web of Science | Medline

To the Editor:

In response to the articles on the scope of practice in primary care by St. Peter et al. (Dec. 23 issue)1 and the accompanying editorial by Grumbach: I have been a primary care physician for more than 20 years, and I am not sure I know what that means in today's world. I do know what it means to be a cardiothoracic or transplantation surgeon. It means that you treat patients who cannot look up how to treat themselves on the Internet and also that you have enough time to feel that you have done your best. As a primary care internist and geriatrician, I have seen my ability to satisfy patients (and my ability to be satisfied with my work) diminish with the ambitious expectations of patients, families, insurers, employers, health plans, and hospitals. The direct marketing of medications to consumers has posed another challenge for physicians; patients often demand specific treatments that may or may not be reasonable. The interruptions in insurance coverage noted by Grumbach make it difficult to establish rapport and develop trusting relationships with patients. In addition, with the patient moving from clinician to clinician, there is no single repository of health care data for that person. For elderly patients with complex chronic illnesses, this situation is especially troublesome, because it interferes with the development of long-term planning for care at the end of life.

I am still grateful to have gone to medical school and to be a physician. I would do it again, and I would be pleased if one of my children chose this profession. However, we have tremendous challenges ahead of us with the aging of my cohort — the very spoiled, indulged, and entitled baby-boom generation. Many expensive treatments are being planned with advances in genetic engineering; meanwhile, there is very little interest in the problems of chronically ill elderly persons, whose numbers are increasing dramatically.

For patients and primary care doctors alike, discontinuity reigns supreme. My primary care colleagues and I have seen the time we need to counsel, listen, and build trust all but evaporate. Maybe under capitalism this is all we can expect. Frankly, I fear getting old and becoming chronically ill in the system we have today, which is a sad statement to make from within the medical profession.

Mary A. Shepard, M.D.
LB Healthcare Advisors, Bellingham, WA 98226-3164

1 References

1
St Peter RF, Reed MC, Kemper P, Blumenthal D. Changes in the scope of care provided by primary care physicians. N Engl J Med 1999;341:1980-1985
Full Text | Web of Science | Medline

To the Editor:

I read the article by St. Peter et al. on the scope of care provided by generalists in the hope that I could use the data in teaching family-practice residents. Unfortunately, I could glean little practical information, because the authors used the outdated but still common practice of combining family physicians with general practitioners in their data analysis.

Family medicine grew out of general practice, and at one point, this combination made sense. But the American Board of Family Practice has now been in existence for 30 years. Graduates of its three-year, accredited residency programs differ in distinct ways from current general practitioners. A general practitioner may have completed one or two years of training in any residency program (not necessarily a generalist program) before obtaining a medical license and beginning to practice. Older general practitioners who did not elect to be grandfathered into family medicine when that option was available have made no commitment to continuing medical education or to periodic recertification. They are a heterogeneous group. In regard to their formal training for primary care practice, general practitioners have no more in common with board-certified family physicians than they do with board-certified general internists or pediatricians. The authors have combined apples and oranges.

The large number of physicians in the combined group of family physicians and general practitioners (3112) suggests to me that the authors could have divided it into two separate groups and still had an adequate number in each for data analysis. The authors used the prevailing wisdom in creating groups for data analysis. But the prevailing wisdom is wrong and should be changed.

William A. Hensel, M.D.
Moses H. Cone Family Practice Residency Program, Greensboro, NC 27401

Author/Editor Response

The authors reply:

To the Editor: The thoughtful comments of Dr. Shepard echo the sentiments expressed by many of the physicians who participated in the Community Tracking Study Physician Survey. Unfortunately, it is difficult to capture and report such information in a quantitative survey.

Dr. Hensel raises the issue of possible differences between general practitioners and family practitioners that might have been masked by combining these two groups of physicians in our analyses. We agree that differences in training and experience between the two groups might be expected to lead to important differences in the scope-of-care outcomes we examined.

In our article, we reported data from 3112 general or family practitioners, treated as a combined group. In response to Dr. Hensel's comments, we subsequently repeated the analysis with these physicians divided into two separate groups (2678 family practitioners and 434 general practitioners). Using the same multivariate model described in the article, we did not find a statistically significant difference between general practitioners and family practitioners in the likelihood of reporting that the scope of care they are expected to provide to their patients without referral to specialists is greater than it should be. Furthermore, with this modification of the model, there were no important changes in the odds ratios for the other findings that we reported in the article.

However, it is important to note that although these data do not conclusively demonstrate a difference, Dr. Hensel's hypothesis is not wholly unsupported by the analysis. In the modified model, the odds ratio for general practitioners as compared with family practitioners (1.27; 95 percent confidence interval, 0.97 to 1.68) was similar to the odds ratios for general internists and general pediatricians as compared with family practitioners (general internists, 1.32; 95 percent confidence interval, 1.14 to 1.54; general pediatricians, 1.24; 95 percent confidence interval, 1.04 to 1.48), but the difference between general practitioners and family practitioners was not statistically significant. Given the relatively small number of general practitioners (434) in our sample, it is quite reasonable to conclude that significant differences might have been demonstrated if the sample had included more general practitioners.

In summary, general internists and general pediatricians are more likely than family practitioners to report that the scope of care they are expected to provide to their patients without referral to specialists is greater than it should be. The finding with respect to general practitioners as compared with family practitioners suggests, but is not conclusive evidence, that a similar difference may also exist between these two groups of physicians. We appreciate the opportunity to make this important point to readers of our article.

Robert F. St. Peter, M.D.
Kansas Health Institute, Topeka, KS 66612-1212

Marie C. Reed, M.H.S.
Peter Kemper, Ph.D.
Center for Studying Health System Change, Washington, DC 20024-2512

Author/Editor Response

In my editorial, I attempted to convey the tension between the importance of primary care and the market demands of commercially driven managed care and the culture of specialization. Although I believe that considerable work remains to be done to create the conditions under which primary care in the United States can flourish, I am not as pessimistic as Dr. Shepard appears to be about primary care and the prospects for “getting old and becoming chronically ill.”

Amid the stormy seas of the current U.S. health care system, there are some innovative approaches to the primary care of patients with chronic illness. For example, Dr. Ed Wagner and colleagues at Group Health Cooperative of Puget Sound have developed models of care for patients with diabetes, using a multidisciplinary team and a population-health approach to support primary care physicians.1 This approach demonstrates that primary care physicians can provide a broad scope of high-quality care when systems of practice are designed to support primary care coordination, not simply to draft physicians into rigid roles as gatekeepers, with less expensive care being the paramount indicator of success. Models such as those at Group Health Cooperative of Puget Sound require the leadership of clinicians and a system committed to long-term success in clinical outcomes, not simply a short-term return on stockholders' investments.

Like Dr. Buxeda, I am a board-certified family physician. I think his patients are fortunate to have as a primary care physician someone who so sincerely values continuity of care and an allegiance to his patients throughout their experiences with the health care system. The statement in my editorial to which he refers was intended to be satirical; it was not an endorsement of a dismissive view of primary care practitioners. I regret it if any readers mistook as an offensive buccal protuberance that which was merely tongue in cheek.

Kevin Grumbach, M.D.
University of California, San Francisco, San Francisco, CA 94143

1 References