The Miracle of Primary Care
June 22, 2020
I published the following blog in January 2012 writing under the pseudonym of the Frugal Family Doctor. I repost it today because so little has changed.
For research purposes, primary healthcare has been described using four characteristics. It is a healthcare resource that people first contact for many different health concerns. People continue to consult with primary care providers in sustained relationships over time. Primary caregivers provide a wide variety of services that are abbreviated as “comprehensive.” Primary medical providers coordinate care if external services or specialized help is deemed necessary. Thus primary care is remembered by the 4 C’s of first contact, continuity, comprehensiveness and coordination.
Using the above definition of primary care medicine Barbara Starfield, a recently deceased pediatrician researcher, spent many years reading, studying, collecting and analyzing health outcomes data. She then compared health indicator outcomes with the degree of primary care services available to and used by various populations. She discovered that increased primary care correlates consistently with improved health, prolonged lifespan, and reduced cost of care. She and colleagues published a robust review of this high quality research done by her and many others in the Milbank Quarterly in 2005. Studies were multiple and included many diverse and copious data sets. Studies involved variable population sizes and settings. Multinational and interstate populations of all age groups were analyzed and compared. Specific disease states as well as generally healthy people were scrutinized. A vast variety of health outcome measures were studied. Data was adjusted for health impacting confounders such as poverty and smoking. In the final analysis, the data was congruous. More primary healthcare provision means improved health and reduced healthcare costs. An example study compared non-urban counties based on number of primary care physicians practicing in the counties. Counties with a greater number of primary care physicians experienced a 2% lower all cause mortality, 4% lower heart disease mortality, and 3 % lower cancer mortality.
For most of the studies, primary care providers in the US were assumed to be family physicians, general internists and general pediatricians. But no matter which medical specialty met the 4 C’s criteria, this type of healthcare provision produces better health at lower healthcare costs. There have been debates about which US physician specialties actually do provide primary care, but Starfield’s review also looked at some pretenders and found them lacking. The broader the services provided, the better the health outcomes at lower cost. Kevin Grumbach, a family medicine researcher from San Francisco, dubbed this the “miracle of primary care” (STFM plenary address 2007). Indeed this data is compelling and primary care should be deemed miraculous.
The number of graduating medical students in the US seeking primary care specialties declined dramatically between 1997 and 2007 before, during and after Starfield’s studies were published. All primary care specialties suffered. General pediatricians and general internists have always represented a relatively small percentage of total primary care physicians workforce. Their numbers decline even further as many in these specialties practice primary care for a short time and then return to residencies for sub-specialty training. Family physicians are by far the largest portion of primary care doctors in the US, but they are often overlooked by healthcare pundits and super-specialized medical centers. Many experts in those settings exclude family medicine from their vision.
Despite the miraculous potential, the US healthcare system is producing fewer primary care doctors. Medical school administrations are dominated by specialists who recruit and train doctors who emulate them (specialists). Payments for healthcare are capitalized by specialists with many earning 10 times the annual incomes of family physicians despite similar or even longer work hours. Family doctors are not dramatic. They are not so wealthy and few are famous. But family doctors improve health of people, families, communities and populations and accomplish it at relatively lower costs. Shouldn’t our health systems recognize this bargain?