Primary care physician
Encyclopedia
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
/medical doctor
Doctor of Medicine
Doctor of Medicine is a doctoral degree for physicians. The degree is granted by medical schools...
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.
All physicians first complete medical school
Medical school
A medical school is a tertiary educational institution—or part of such an institution—that teaches medicine. Degree programs offered at medical schools often include Doctor of Osteopathic Medicine, Bachelor/Doctor of Medicine, Doctor of Philosophy, master's degree, or other post-secondary...
(MD
Doctor of Medicine
Doctor of Medicine is a doctoral degree for physicians. The degree is granted by medical schools...
, MBBS
Bachelor of Medicine and Surgery
Bachelor of Medicine, Bachelor of Surgery, or in Latin Medicinae Baccalaureus, Baccalaureus Chirurgiae , are the two first professional degrees awarded upon graduation from medical school in medicine and surgery by universities in various countries...
, or DO). To become primary care physicians, medical school graduates then undertake postgraduate training in primary care programs, such as family medicine
Family medicine
Family medicine is a medical specialty devoted to comprehensive health care for people of all ages. It is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages, sexes, diseases, and parts of the body...
(also called family practice or general practice in some countries), pediatrics
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
or internal medicine
Internal medicine
Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. They are especially skilled in the management of patients who have undifferentiated or multi-system disease processes...
. Some HMO
Health maintenance organization
A health maintenance organization is an organization that provides managed care for health insurance contracts in the United States as a liaison with health care providers...
s 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
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
and nephrologists acting as PCPs for patients on kidney
Kidney
The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...
dialysis
Dialysis
In medicine, dialysis is a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure...
.
Emergency physician
Emergency physician
An emergency physician is a physician who works at an emergency department to care for acutely ill patients. The emergency physician is a specialist in advanced cardiac life support , trauma care such as fractures and soft tissue injuries, and management of other life-threatening situations.In...
s are sometimes counted as primary care physicians. Emergency physicians see many primary care cases, but in contrast to family physicians, pediatricians and internists, 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. Diagnostic techniques include interviewing the patient to collect information on the present symptoms, prior medical historyMedical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
and other health details, followed by a physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
. Many PCPs are trained in basic medical test
Medical test
A diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease. For example:* to diagnose diseases, and preferably sub-classify it regarding, for example, severity and treatability...
ing, such as interpreting results of blood or other patient samples, electrocardiogram
Electrocardiogram
Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...
s, or x-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s. More complex and time-intensive diagnostic procedures are usually obtained by referral to specialists, due to either special training with a technology, or increased experience and patient volume that renders a risky procedure safer for the patient. After collecting data, the PCP arrives at a differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
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
Behavior change
Many health conditions are caused by risk behaviors, such as problem drinking, substance use, smoking, reckless driving, overeating, or unprotected sexual intercourse. The key question in health behavior research is how to predict and modify the adoption and maintenance of health behaviors....
, self-care skills and treatment options, and provide screening tests
Screening (medicine)
Screening, in medicine, is a strategy used in a population to detect a disease in individuals without signs or symptoms of that disease. Unlike what generally happens in medicine, screening tests are performed on persons without any clinical sign of disease....
and immunizations.
Role in the health care system
A primary care physician is usually the first medical practitioner contacted by a patient, due to factors such as ease of communication, accessible location, familiarity, and increasingly issues of cost and managed careManaged care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
requirements. In some countries, for example Norway
Norway
Norway , officially the Kingdom of Norway, is a Nordic unitary constitutional monarchy whose territory comprises the western portion of the Scandinavian Peninsula, Jan Mayen, and the Arctic archipelago of Svalbard and Bouvet Island. Norway has a total area of and a population of about 4.9 million...
, residents are registered as patients of a (local) doctor, and must contact that doctor for referral to any other. Also many health maintenance organizations position PCPs 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
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
.
Studies of the quality of care provided by primary care physicians
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. However, these studies examine the quality of care in the domain of the specialists. In addition, these studies need to account for clustering of patients and physicians.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. In health promotion counseling, a studies of self-reported behavior found that generalists were more likely than internal medicine specialists to counsel patients and to screen for breast cancer.
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.
Factors associated with quality of care by primary care doctors:
- The more experience the primary care physician has with a specific disease.
- Physician group affiliation with networks of multiple groups.
Dissemination of information to generalists compared to specialists
The dissemination of information to generalists compared to specialists is complicated. Two studies found specialists were more likely to adopt COX-2 drugs before the drugs were recalled by the FDA. 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". Similarly, a separate study found that specialists were less discriminating in their choice of journal reading.Declining numbers
Shortages of primary care physicians are an increasing problem in many developed countries. In the United States, the number of medical students entering family practice training dropped by 50% between 1997 and 2005. In 1998, half of internal medicine residentsResidency (medicine)
Residency is a stage of graduate medical training. A resident physician or resident is a person who has received a medical degree , Podiatric degree , Dental Degree and who practices...
chose primary care, but by 2006, over 80% became specialists. 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.
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. In 2004, the median income of specialists in the US was twice that of PCPs, and the gap is widening. 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. Primary care practices in the United States increasingly depend on foreign medical graduates to fill depleted ranks.
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..." The World Health OrganizationWorld Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(WHO) has identified worsening trends in access to PCPs and other primary care workers, both in the developed and the developing nations:
- "Worker numbers and quality are positively associated with immunization coverage, outreach of primary care, and infant, child and maternal survival"
- "The quality of doctors and the density of their distribution have been shown to correlate with positive outcomes in cardiovascular diseases"
- "In health systems, (primary care) workers function as gatekeepers and navigators for the effective, or wasteful, application of all other resources such as drugs, vaccines and supplies"
- "there are currently 57 countries with critical shortages equivalent to a global deficit of 2.4 million doctors, nurses and midwives"
- "In many countries, the skills of limited yet expensive professionals are not well matched to the local profile of health needs"
- "...all countries suffer from maldistribution characterized by urban concentration and rural deficits"
- "Richer countries face a future of low fertility and large populations of elderly people, which will cause a shift towards chronic and degenerative diseases with high care demands"
- "Growing gaps will exert even greater pressure on the outflow of health workers from poorer regions"