Primary Care: Introduction
Niloufar Tehrani, MD
As a primary care physician, you evaluate a 2-year-old boy who is presenting to the office for the first time. The mother states he has always been small; he was born at term but weighed only 2,272 g (5 lb). She is a single mother, and he is her only child. He speaks only 5 words and is quite active. The physical examination is normal, but the boy’s height and weight are less than the fifth percentile. The mother reports her son is immunized, but she does not have his immunization records with her at this visit.
1. What are the 4 components of primary care?
2. What are the main characteristics of a medical home? What are the eligibility criteria for designating a practice as a medical home?
3. What is the difference between a consultation and a referral?
4. Why are laboratory tests done during a routine health maintenance visit?
Primary care is defined as the comprehensive health care a patient receives from the same health professional over a longitudinal period. The term was first used in the 1960s to designate the role of the primary care physician in response to the abundance of subspecialists and lack of generalists among practicing physicians. It is generally accepted that primary care physicians include pediatricians, family physicians, and internists. In 1966, The Graduate Education of Physicians: The Report of the Citizens Commission on Graduate Medical Education (the Millis Committee Report) to the American Medical Association recognized the importance of primary care and recommended a national commitment to educating primary care physicians. Primary care was further defined in 1974 by Charney and Alpert, who separated it into component parts: first contact, longitudinal care, family orientation, and integration of comprehensive care. To comprehend the depth of primary care, it is necessary to understand its component parts.
First contact occurs when a patient arrives for medical care at the office of a primary care physician. The visit includes an intake history, complete physical examination, screenings appropriate for age, and an assessment of problems with treatment, if indicated. Of great importance is the establishment of the physician-patient relationship. Physicians become the primary medical resource and counselors to these patients and their families and the first contacts when successive medical problems arise.
Longitudinal care, the second component of primary care, implies continuity of care over time. Physicians assume responsibility for issues concerning health and illness. In pediatrics, such care involves monitoring growth and development, following school progress, screening for commonly found disorders, conducting psychosocial assessments, promoting health, preventing illness with immunizations, and providing safety counseling programs.
Family orientation, the third component of primary care, is a recognition that the provision of adequate care is dependent on viewing patients in the context of their environment and family. In pediatrics, a child’s problems become the family’s, and the family’s problems become the child’s. This has become increasingly apparent with the recognition that the social determinants of health (eg, problems of poverty, drug use, obesity, teenage pregnancy, and gang involvement), directly affect a child’s health and quality of life (see Chapter 141). The psychosocial forces in a particular child’s life are intricately interwoven into that child’s health care, and the assessment of these forces is an essential component of the primary care of that child. Environmental exposures (eg, lead contamination of the water supply) have a direct effect on a child’s health, and the primary care physician must have knowledge of those environmental threats.
The fourth component of primary care, integration of comprehensive care, involves the use of health and educational resources in the community to supplement care as a means of addressing the increased complexity of pediatric medical problems. Primary care physicians integrate and coordinate these services in the best interest of patients. Working with social service agencies, home care providers, educational agencies, and government agencies, physicians can use multiple resources for the benefit of patients. Understanding the available community resources is an important part of a primary care physician’s education.
When patients select a primary care physician, they have identified a medical home. The medical home incorporates the physical, psychological, and social aspects of individual patients into comprehensive health care services, thus meeting the needs of the whole person. This concept of the medical home was first documented by the American Academy of Pediatrics (AAP) in 1967 in the book Standards of Child Health Care, which noted that a medical home should be a central source of all the child’s medical records. The idea of a medical home developed into a method of providing comprehensive primary care and was successfully implemented in the 1980s by Calvin Sia, MD, FAAP, in Hawaii. He is considered to be the “father” of the medical home. In policy statements published in 1992 and 2002 (the latter reaffirmed in 2008), the AAP defined the characteristics of a medical home to be “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” Geographic and financial accessibility are key elements in making that home work for patients. The most important aspect of a home, however, is that it be a place in which patients feel cared for.
Since its implementation in pediatrics in 2004, the medical home model was adopted by the American Academy of Family Physicians and the American College of Physicians. The definition of the medical home was expanded to include use of electronic information services, population-based management of chronic illness, and continuous quality improvement. The concept has been accepted as a form of high-quality health care. Cost and quality of benefits have been well documented. Recognizing these benefits, large corporations in collaboration with health professionals formed the Patient-Centered Primary Care Collaborative to promote the idea of designated medical homes. As part of that collaborative, the National Committee for Quality Assurance adopted eligibility criteria for a practice to define itself as a medical home. Requirements for the designation include the adoption of health information technology and decision-support systems, modification of clinical practice patterns, and ensuring continuity of care.
With the advent of health care reform in the United States, as part of the effort to control the rising cost of health care, the federal government has endorsed the concept of the medical home model. The Academic Pediatric Association has defined the family-centered medical home to delineate the dependency of the child to the family and community in the medical home model. This principle was highlighted in a consensus statement that was developed and jointly endorsed by the AAP, American College of Physicians, American Academy of Family Physicians, and the American Osteopathic Association.
Role of the Primary Care Pediatrician
As a primary care physician, the pediatrician has a role that has included not only the management of acute illness and injury but also the preventive aspects of well-child care with its focus on immunizations, tracking growth and development, and anticipatory guidance. Currently, there exists a renewed emphasis on the importance of the role of the pediatric primary care physician in assessing the psychosocial aspects of pediatric patients. Evaluation of social issues such as family dysfunction, developmental problems (including learning disabilities) and behavioral problems (including emotional disorders), termed the new morbidity by Robert Haggerty, MD, in the 1970s, has become a significant part of the role of the physician. In 1993, the AAP stated that pediatricians are obliged to have knowledge of physical and environmental factors and behaviors affecting health, normal variations of behavior and emotional development, risk factors and behaviors affecting physical health, and behavior problems. The focus of the pediatrician should be detection, evaluation, and management, with referrals if necessary. Newer morbidities secondary to the increasing complexity of our society were outlined in 2001 by the AAP. These include school problems, mood and anxiety disorders, adolescent suicide and homicide, firearms, school violence, drug and alcohol abuse, HIV, obesity, and the effects of the media on children. Other psychosocial factors, such as poverty, homelessness, single-parent families, divorce, working parents, and child care, necessitate that pediatricians work with social service agencies to deliver appropriate care to their patients. The role of the primary care physician is continually expanding in an effort to deliver comprehensive care to each patient in a medical home. This care is often rendered by physician-led teams that include other health professionals.
Considerable advancement has been made in medical knowledge and technology in the past several decades. Total knowledge of all fields is impossible for any individual physician. As a result, the role of the subspecialist physician has developed as an adjunct to that of the primary care physician. New fields of subspecialties, such as child abuse pediatrics, have arisen as a response to increased knowledge. The primary care physician should seek subspecialist consultation when the suspected or known disease process is unusual or complicated, in cases that require the use of specialized technology, and in situations in which the primary care physician has little experience with the disease. Generally, subspecialists evaluate patients and concentrate on the organ system or disease process in their area of expertise.
Use of a subspecialist is termed secondary care. The primary care physician can elicit the help of a subspecialist in the form of a consultation or a referral. When initiating a consultation, the primary care physician seeks advice from the consultant on workup or management of the patient. The consulting physician assesses the patient with a history and physical examination, focusing on the particular specialty. The consultant recommends possible additional laboratory tests and offers a diagnosis and treatment plan, after which the patient returns to the primary care physician for coordination of further care.
Electronic, abbreviated consultations can now be conducted using an e-consultation system. These consultations give the primary care physician a treatment plan, which may also include 1 or more visits to the subspecialist. For example, an 8-year-old girl with weight loss and persistent abdominal pain has an upper gastrointestinal radiograph series that reveals a duodenal ulcer. Her primary care physician requests a consultation from a pediatric gastroenterologist for an endoscopy to allow definitive diagnosis and up-to-date management guidelines. After the procedure, the girl returns to the primary care physician with recommendations for treatment and further care.
Primary care physicians can also generate a referral to a subspecialist, which differs from a consultation. A referral requests that the subspecialist assume complete care of the patient. This transfer of care may be to a tertiary care site where a subspecialist provides care and assumes responsibility for coordinating further patient care. For example, a 4-year-old boy with recurrent fever, hepatosplenomegaly, and blasts on peripheral blood smear is referred to a pediatric oncologist for diagnosis, treatment, and ongoing medical care.
When requesting advice from subspecialists, whether on a consultative or referral basis, the primary care physician should outline specific questions with a probable diagnosis to be addressed by the subspecialist. For example, a consultation requesting evaluation of a child with hematuria is inappropriate. The primary care physician should perform a basic diagnostic evaluation and suggest the most likely diagnosis, after which the child can be referred appropriately. For example, a child with a diagnosis of nephritis should be sent to a pediatric nephrologist, whereas a child with a diagnosis of Wilms tumor should be sent to a pediatric oncologist.
When primary care physicians and subspecialists function cooperatively and offer 3 levels of care (ie, primary, referral, consultative), patients receive the highest quality medical care. Generally, care provided by subspecialists is characterized as being more expensive and procedure driven. Subspecialists order more laboratory studies than primary care physicians, which further inflates the cost of medical care. Additionally, if a patient lacks longitudinal health care and sees multiple practitioners, often repeat laboratory studies are ordered. Compared with subspecialty care, primary care is believed to deliver more cost-effective medical care. The spiraling cost of medical care has resulted in continued nationwide emphasis on producing more primary care physicians. It should be remembered, however, that the subspecialist plays an essential supplementary role to the primary care physician when managing complicated diseases. A balance between generalists and subspecialists must be maintained in the education process.
For most conditions, the diagnosis is revealed by the history and physical examination in more than 95% of cases. Thus, good communication skills are a basic tenet of primary care. Patients frequently complain about unnecessary laboratory tests, which increase the cost of medical care, and the prescription of unnecessary medications. To lessen these problems, the primary care physician should be discriminating when ordering laboratory tests and prescribing medications, recognizing their value as well as their potential iatrogenic effects.
In primary care, laboratory tests are used to help confirm a condition suspected on the basis of the history or physical examination or diagnose a condition that may not be apparent after a thorough history and physical assessment. In pediatrics especially, the value of each test result should be weighed against the inconvenience, discomfort, and possible side effects in children. Tests in at-risk children can also be used as screening tools to prevent disease or identify a disease early so that treatment can begin and symptoms can be minimized. Laboratory studies can provide a host of other information, including data to establish a diagnosis, knowledge necessary to select therapy or monitor a disease, and information about the risk of future disease. Organ function, metabolic activity, and nutritional status also can be assessed, and evidence of neoplastic or infectious disease can be provided. Additionally, laboratory studies can be used to identify infectious and therapeutic agents or poisons.
Screening laboratory tests are used when the incidence of an unsuspected condition is sufficiently high in a general population to justify the expense of the test (see Chapter 13). Subclinical conditions, such as anemia, lead poisoning, and hypercholesterolemia, are part of some health maintenance assessments.
Physicians must remember that variability exists in test results and that laboratory error can occur. Laboratory results should always be viewed in the context of the patient. The sensitivity of a test, the ability of the test to detect low levels, and the specificity of a test for the substance being measured must also be considered by the physician when evaluating a test result.
Challenges for the Future
The role of the primary care physician in health care delivery has increased in importance. In 2010, the Patient Protection and Affordable Care Act was signed into law. This law emphasizes the importance of the medical home and promotes its implementation. Two of the basic tenets of primary care—accessibility and an ongoing relationship with the primary care physician, both of which are reported by patients to be very important—are recognized as essential components of the medical home. The challenge continues to ensure continuity in health care funding to preserve the continuity of the medical home. Payment reform promises to improve payment to primary care practices and rewards high performance. As proposed in health care reform, through accountable care organizations, primary care physicians would be the foundation of the organization whose mission is management of the continuum of care and cost as well as ensuring quality of care.
Access to same-day care, which is part of the obligation of the medical home and essential to pediatric patients, can be difficult in the busy schedule of primary care physicians. Practices must accommodate these visits. Community health centers can provide excellent medical homes for children in families with low income; however, these centers can have challenges with accessibility and adequate referral sources. Walk-in immediate medical care clinics and retail clinics have arisen, but episodic visits in a variety of settings do not deliver comprehensive care for the patient, and these short visits may not take into account the entirety of the patient’s medical history. This creates a challenge for the primary care physician and medical home to develop a system to integrate the information from these encounters into the comprehensive medical record.
With the advent of hospitalists providing inpatient care, primary care physicians may not be included in inpatient management, which can make it challenging for primary care physicians to retrieve important information about the care of their patients.
Medical care reform incorporates accountability, demonstration of quality of care, and standards of medical practice into the medical home model, which has resulted in an exponential increase in the oversight and bureaucracy of medical care. This business of medicine with redundant oversight of medical care has placed a tremendous burden of administrative activities on the primary care physician. Physicians face a significant challenge in providing care while answering to administrative structures. Additionally, although the use of electronic medical records decreases some of the challenges of information retrieval and communication among medical providers, it poses other challenges in a potential lack of pediatric functionality and loss of productivity.
The biggest challenge for pediatric primary care physicians has always been to ensure the future of health care funding to provide all children access to and availability of a medical home. The Patient Protection and Affordable Care Act aims to provide health coverage for nearly all children, but in a multipayer, market-driven health care system, significant challenges will remain. A multitude of programs exist to pay for children’s health care, and these programs vary by state. Families move among payers, which disrupts continuity of care. Universal health care for children is being advocated. Without a secure national plan for financing, children’s health care will continue to be variable, resulting in disparities in children’s health.
You ask the mother about her son’s former physician and obtain signed permission to get the prior medical records, including immunizations. You attempt a hearing assessment as the initial step in evaluating his speech delay, but the patient does not cooperate. You ask the mother about access to food and complete a referral to the Special Supplemental Nutrition Program for Women, Infants, and Children and provide her with information about the Supplemental Nutrition Assurance Program (ie, food stamps). You provide the patient with an age-appropriate book from Reach Out and Read and make a return appointment for 1 month hence to continue care and determine whether the patient needs any immunizations.