Challenging the Conventional Wisdom of Primary Care Medicine

Recently, I heard someone say we have a severe shortage of primary care physicians in Arizona, in the context of noting 46% of our medical school class is to enter a primary care residency. The implication is that there are not enough students being directed to primary care.

Primary care physicians are certainly the faculty students have the most intimate relationships with on a daily basis and from whom they receive the majority of their mentoring.

However, students recognize that for many large areas of content, such as mus­culoskeletal medicine, the primary care physician is not the best person to provide information or teach physical examination skills. If students choose a primary care residency, about 30% of the patients they see will have musculoskeletal problems. Physicians will need to know how to develop a plan of management and start treatment before the patient is referred to an orthopedic surgeon. The problem is, a majority of physicians do not know and simply send the patient on without appropriate evaluation or the most basic treatment. The need for more primary care physicians is a myth and this concept increases the cost of healthcare when the primary care physician controls access to the patient. Patients will be served just as well if the initial visit was to a nurse practitioner or physician assistant and then triaged on to the appropriate specialist.

This use of primary care doctors as the access point has occurred over the last 20 years in sports medicine as well. The orthopedic surgeon has become a consultant and not the team doctor as it was in past years. Some of the most useful experiences I had were when I was able to sit down with coaches and athletes to discuss options and the relative value of choices, as well as indications for one treatment over another. This is no longer possible because there are 2 layers of insulation from those relationships produced by the presence of a trainer and a “team physician.”

This commentary is based on 37 years of observation of this evolution in the training room and the office treating musculoskeletal problems, which have had treatment delayed or misdiagnosed without the most basic of care rendered. A stress fracture with a deformity so large on the anterior tibia it was eroding the skin when finally I was asked to see the athlete for this “obvious” abscess. A quick check with an image intensifier and the stress fracture was identified after 3 months of prior “treatment.” A referral of a young woman with an inflamed knee, with no history of injury and no treatment or workup, has no signs of mechanical complaints or laxi­ty. When evaluated in my office, she has inflammatory arthritis with an elevated sedimentation rate, C-reactive protein, anti-cyclic citrullinated peptide, and positive rheumatoid factor. The patient said “I knew this wasn’t a torn menis­cus, but it was easier to see you than my primary care physician.” Would the patient have been better served to see a nurse practitioner in an urgent care setting started on an NSAID and icing with a referral to a rheumatologist as a better and more cost effective solution to the problem? 

These are everyday examples of the need for more informed first responder care of musculoskeletal problems, but is the solution more primary care phy­sicians, or a better triage and initial management approach which are not currently part of the primary care curric­ulum? I know primary care physicians are busy dealing with the epidemic of mental health problems, obesity and its complications, and complicated patients who have 2 pages of medications to be juggled, which is a common occurrence in our practice. So, I am not singling out these hard working physicians. I do ask for a more efficient approach to musculoskeletal problems and a better approach to triage of these patients, which will result in fewer complica­tions. I believe the increased numbers of providers should be in physician extenders in the short term and better education of primary care physicians in initial management of musculoskeletal problems in the long term. Orthopedic surgeons can take the lead in creating guidelines for management of common symptom sets and point treatment in a reasonable direction.

If primary care is to be the focal point of our national healthcare system, then there should be a discussion of how this initial care is rendered and what its goal should be. Right now, the initial care leads to other problems which complication the definitive care of the patient and cost the healthcare system more than it should. The current approach has evovled, as primary care physicians have become busier dealing with an increasingly larger number of patients on the Centers for Medicare and Medicaid Service rolls.

Perhaps there is an alternative to more primary care physicians to provide the basic care. The current system and its evolution to the full blown Affordable Health Care Act has significant waste in it which has not been addressed in any way by the President and Congress. This discussion calls attention to a portion of this waste, which is substanital and could be changed with nonphysician providers and better education of students and residents.

The conventional wisdom has been to provide more physicians, but in this instance, that may not be the correct approach. Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” The hole we have dug in this country is one which requires extraordinary thinking to fill. Hopefully in this case it will include a consideration of methods and personnel. 

Author's Disclosure Statement. The author reports no actual or potential conflict of interest in relation to this article.

Recently, I heard someone say we have a severe shortage of primary care physicians in Arizona, in the context of noting 46% of our medical school class is to enter a primary care residency. The implication is that there are not enough students being directed to primary care.

Primary care physicians are certainly the faculty students have the most intimate relationships with on a daily basis and from whom they receive the majority of their mentoring.

However, students recognize that for many large areas of content, such as mus­culoskeletal medicine, the primary care physician is not the best person to provide information or teach physical examination skills. If students choose a primary care residency, about 30% of the patients they see will have musculoskeletal problems. Physicians will need to know how to develop a plan of management and start treatment before the patient is referred to an orthopedic surgeon. The problem is, a majority of physicians do not know and simply send the patient on without appropriate evaluation or the most basic treatment. The need for more primary care physicians is a myth and this concept increases the cost of healthcare when the primary care physician controls access to the patient. Patients will be served just as well if the initial visit was to a nurse practitioner or physician assistant and then triaged on to the appropriate specialist.

This use of primary care doctors as the access point has occurred over the last 20 years in sports medicine as well. The orthopedic surgeon has become a consultant and not the team doctor as it was in past years. Some of the most useful experiences I had were when I was able to sit down with coaches and athletes to discuss options and the relative value of choices, as well as indications for one treatment over another. This is no longer possible because there are 2 layers of insulation from those relationships produced by the presence of a trainer and a “team physician.”

This commentary is based on 37 years of observation of this evolution in the training room and the office treating musculoskeletal problems, which have had treatment delayed or misdiagnosed without the most basic of care rendered. A stress fracture with a deformity so large on the anterior tibia it was eroding the skin when finally I was asked to see the athlete for this “obvious” abscess. A quick check with an image intensifier and the stress fracture was identified after 3 months of prior “treatment.” A referral of a young woman with an inflamed knee, with no history of injury and no treatment or workup, has no signs of mechanical complaints or laxi­ty. When evaluated in my office, she has inflammatory arthritis with an elevated sedimentation rate, C-reactive protein, anti-cyclic citrullinated peptide, and positive rheumatoid factor. The patient said “I knew this wasn’t a torn menis­cus, but it was easier to see you than my primary care physician.” Would the patient have been better served to see a nurse practitioner in an urgent care setting started on an NSAID and icing with a referral to a rheumatologist as a better and more cost effective solution to the problem? 

These are everyday examples of the need for more informed first responder care of musculoskeletal problems, but is the solution more primary care phy­sicians, or a better triage and initial management approach which are not currently part of the primary care curric­ulum? I know primary care physicians are busy dealing with the epidemic of mental health problems, obesity and its complications, and complicated patients who have 2 pages of medications to be juggled, which is a common occurrence in our practice. So, I am not singling out these hard working physicians. I do ask for a more efficient approach to musculoskeletal problems and a better approach to triage of these patients, which will result in fewer complica­tions. I believe the increased numbers of providers should be in physician extenders in the short term and better education of primary care physicians in initial management of musculoskeletal problems in the long term. Orthopedic surgeons can take the lead in creating guidelines for management of common symptom sets and point treatment in a reasonable direction.

If primary care is to be the focal point of our national healthcare system, then there should be a discussion of how this initial care is rendered and what its goal should be. Right now, the initial care leads to other problems which complication the definitive care of the patient and cost the healthcare system more than it should. The current approach has evovled, as primary care physicians have become busier dealing with an increasingly larger number of patients on the Centers for Medicare and Medicaid Service rolls.

Perhaps there is an alternative to more primary care physicians to provide the basic care. The current system and its evolution to the full blown Affordable Health Care Act has significant waste in it which has not been addressed in any way by the President and Congress. This discussion calls attention to a portion of this waste, which is substanital and could be changed with nonphysician providers and better education of students and residents.

The conventional wisdom has been to provide more physicians, but in this instance, that may not be the correct approach. Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” The hole we have dug in this country is one which requires extraordinary thinking to fill. Hopefully in this case it will include a consideration of methods and personnel. 

Author's Disclosure Statement. The author reports no actual or potential conflict of interest in relation to this article.

Recently, I heard someone say we have a severe shortage of primary care physicians in Arizona, in the context of noting 46% of our medical school class is to enter a primary care residency. The implication is that there are not enough students being directed to primary care.

Primary care physicians are certainly the faculty students have the most intimate relationships with on a daily basis and from whom they receive the majority of their mentoring.

However, students recognize that for many large areas of content, such as mus­culoskeletal medicine, the primary care physician is not the best person to provide information or teach physical examination skills. If students choose a primary care residency, about 30% of the patients they see will have musculoskeletal problems. Physicians will need to know how to develop a plan of management and start treatment before the patient is referred to an orthopedic surgeon. The problem is, a majority of physicians do not know and simply send the patient on without appropriate evaluation or the most basic treatment. The need for more primary care physicians is a myth and this concept increases the cost of healthcare when the primary care physician controls access to the patient. Patients will be served just as well if the initial visit was to a nurse practitioner or physician assistant and then triaged on to the appropriate specialist.

This use of primary care doctors as the access point has occurred over the last 20 years in sports medicine as well. The orthopedic surgeon has become a consultant and not the team doctor as it was in past years. Some of the most useful experiences I had were when I was able to sit down with coaches and athletes to discuss options and the relative value of choices, as well as indications for one treatment over another. This is no longer possible because there are 2 layers of insulation from those relationships produced by the presence of a trainer and a “team physician.”

This commentary is based on 37 years of observation of this evolution in the training room and the office treating musculoskeletal problems, which have had treatment delayed or misdiagnosed without the most basic of care rendered. A stress fracture with a deformity so large on the anterior tibia it was eroding the skin when finally I was asked to see the athlete for this “obvious” abscess. A quick check with an image intensifier and the stress fracture was identified after 3 months of prior “treatment.” A referral of a young woman with an inflamed knee, with no history of injury and no treatment or workup, has no signs of mechanical complaints or laxi­ty. When evaluated in my office, she has inflammatory arthritis with an elevated sedimentation rate, C-reactive protein, anti-cyclic citrullinated peptide, and positive rheumatoid factor. The patient said “I knew this wasn’t a torn menis­cus, but it was easier to see you than my primary care physician.” Would the patient have been better served to see a nurse practitioner in an urgent care setting started on an NSAID and icing with a referral to a rheumatologist as a better and more cost effective solution to the problem? 

These are everyday examples of the need for more informed first responder care of musculoskeletal problems, but is the solution more primary care phy­sicians, or a better triage and initial management approach which are not currently part of the primary care curric­ulum? I know primary care physicians are busy dealing with the epidemic of mental health problems, obesity and its complications, and complicated patients who have 2 pages of medications to be juggled, which is a common occurrence in our practice. So, I am not singling out these hard working physicians. I do ask for a more efficient approach to musculoskeletal problems and a better approach to triage of these patients, which will result in fewer complica­tions. I believe the increased numbers of providers should be in physician extenders in the short term and better education of primary care physicians in initial management of musculoskeletal problems in the long term. Orthopedic surgeons can take the lead in creating guidelines for management of common symptom sets and point treatment in a reasonable direction.

If primary care is to be the focal point of our national healthcare system, then there should be a discussion of how this initial care is rendered and what its goal should be. Right now, the initial care leads to other problems which complication the definitive care of the patient and cost the healthcare system more than it should. The current approach has evovled, as primary care physicians have become busier dealing with an increasingly larger number of patients on the Centers for Medicare and Medicaid Service rolls.

Perhaps there is an alternative to more primary care physicians to provide the basic care. The current system and its evolution to the full blown Affordable Health Care Act has significant waste in it which has not been addressed in any way by the President and Congress. This discussion calls attention to a portion of this waste, which is substanital and could be changed with nonphysician providers and better education of students and residents.

The conventional wisdom has been to provide more physicians, but in this instance, that may not be the correct approach. Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” The hole we have dug in this country is one which requires extraordinary thinking to fill. Hopefully in this case it will include a consideration of methods and personnel. 

Author's Disclosure Statement. The author reports no actual or potential conflict of interest in relation to this article.