It seems like much of primary care in the U.S. has been stuck in a delivery approach that is falling apart at the seams. Over and over I read that primary-care doctors are overwhelmed with the volume of patients they have to serve and that there is a shortage of primary-care doctors — a calamity in the making. Yet I see three changes in the current healthcare marketplace that are not consistent with this view.
1. There is a polarization of primary-care delivery.
The differentiation comes from recognition that a lot of the services that primary-care doctors have provided in the past could be handled well by lower-level providers. The result is the integration of mid-level providers like physician assistants (PAs) and nurse practitioners (NPs) into the system who can provide care in routine visit situations, freeing up the doctor for more complex cases or extending the capacity of many practices.
2. There is urgent care.
Walk-in clinics have open appointments, more convenient hours, and understand the needs of busy people who are looking for basic medical care. For providers, that can be a desirable position. They offer a job with less demand on personal time and little to no after-hours coverage. By design, urgent care clinics are not to be used for handling complex issues. They are for the day-to-day medical needs that people may have, in the past, gone to the family physician or possibly their internist to address. If the need is too great for the urgent care clinic, the patient is referred back to his internist/family physician or a specialist.
3. There is concierge care.
This style of medicine is for people who need and want more time with a highly trained and engaged physician who has known that patient over a long period of time. It combines all of the conveniences of urgent care with the best attributes of old-fashioned primary care.
Is there anything wrong with these changes? Not really. It is a reflection of the service needs and wants of the public; it is consumer/patient driven. For many people who are relatively healthy, going to see the NP or PA at an office, or going to an urgent care center is just fine. For those who are managing more complicated issues, a more integrated approach is appropriate.
The main problem is when what is perceived to be a small problem a patient is facing is actually a large one. In a hierarchical structure, where you start at the lowest level and are directed upward to the appropriate level of care, there is tremendous responsibility at the entry point. There are cases where the NP, PA, or even a physician just did not diagnose the problem accurately, the way a more experienced physician, with a history with the patient, would be able to diagnose. (As our healthcare system evolves, we will want to make sure that no matter where a patient gets care, there are systems in place to ensure those with more serious needs are seen by the appropriate physician.)
The important issue to note is that while we do have fewer primary-care doctors, we don't have a shortage of people able to provide care.
The marketplace is fluid and is gradually adapting to the changing needs of medical consumers and physicians. For those patients who feel they need to be under the close supervision of a physician who knows them personally and understands their whole health history, they have the choice to join a concierge medical program where that level of attention and support will offer them peace of mind and high-level service.