Primary care or else

The Senate and House are inching closer to extending health insurance to millions of Americans. Access to insurance, however, does not necessarily mean access to healthcare. What is also needed is a sufficient supply of primary-care doctors. As an internal-medicine physician who works in multiple clinical settings, I repeatedly witness the consequences of patients not having that access.

When I was working in an emergency room a few months ago, for example, a middle-aged man with hypertension came in with a paralyzing stroke. Regular monitoring and treatment of his high blood pressure could have prevented this debilitating event. But he did not have a primary-care doctor. The next week, I had to tell a patient he had colon cancer. He had felt fine but came to our hospital after noticing blood in his stool. It was too late. His cancer had spread. A small-business owner facing advanced pancreatic cancer, a young woman succumbing to cervical cancer, a father suffering from liver disease -- these are people I have come across who had previous encounters with the healthcare system, whether an ER visit or a surgical procedure. Some even had insurance. What each lacked was regular, uninterrupted access to a primary-care doctor.

Primary-care doctors are an important part of our healthcare system because they screen for preventable diseases in the hope of detecting them early. However, prevention is only part of a broader role. Primary-care doctors are responsible for a patient’s overall health. They are a patient’s advocate, an ally in a system that is becoming increasingly complicated, overbearing and even dehumanizing.

The value of primary care is particularly evident in the intensive-care unit. Patients there, often sedated or unconscious, are connected to many monitors and machines. The most basic of body functions, such as breathing, eating and urinating, require invasive tubes. Patients who are delirious and attempt to pull out their tubes are often tied down by restraints. Specialists, nurses, therapists and other staff shuttle in and out of the room. Not surprisingly, patients and families are often left confused, frightened and even unsure of whom to trust or what to believe. Yet they are expected to make critical decisions such as whether to withdraw life support.

Patients with primary-care doctors, however, have often had the opportunity to be educated about end-of-life care and can document their preferences in advance. Such planning prevents the emotional turmoil that I witness so often in intensive-care units. It also ensures that patients receive care consistent with their values and can prevent unnecessary and expensive ICU admissions.

Whether in the ICU or other healthcare settings, I have seen why primary care is crucial. Unfortunately, I have also seen that our system discourages physicians from practicing primary care. Training is concentrated in urban, academic medical centers instead of the community-based practices where most Americans receive care. Medical residents and students have more experience managing severe sepsis or advanced liver failure than in evaluating shoulder pain or a common rash. This exposure makes them more inclined to specialize.

Some are drawn by the prestige of specializing. A recent graduate was once told that she was “too smart for primary care,” a remark that reflects an implicit expectation that the most successful students will specialize. Furthermore, specialists earn twice as much money as most primary-care doctors, a fact that weighs heavily on the minds of graduates with $150,000 in medical school debt.

Fifty years ago, half of American doctors were primary-care physicians. Today, that figure has dropped to a third. The American Academy of Family Physicians predicts a national shortage of 40,000 primary-care doctors in 10 years.

The proposed healthcare reform bills do little to reverse this trend. They may insure millions more Americans, but without accounting for the primary-care doctors who will be needed to care for them. As Massachusetts’ reform experience has suggested, this will increase waiting times. Frustrated patients will resort to emergency rooms, driving up costs without receiving the benefits of primary care.

To prevent this scenario, Congress must prioritize funding for primary care in the final bill. It should expand training opportunities and offer loan-repayment options to draw more graduates into primary care. We also need a fundamental shift away from a compensation system that rewards procedures over primary care.

Such measures may cost billions of dollars, but they will also ensure that Americans have access to healthcare and not just health insurance