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Your Health: Your primary care physician

“Team up with the best primary-care doctor you can find.”

Medicine in the 21st century is highly compartmentalized. Most doctors are highly specialized: cardiologists, pulmonologists, surgeons, gynecologists, urologists, orthopedists, oncologists to name the most common. Hyper specialization is the trend. For example, not so long ago general surgeons performed breast surgery. Now there are specialists who restrict their surgical realm to breast surgery. These specialists have a narrow focus and they tend to treat a part of the body rather than the whole patient.

The primary care doctor or “PCP”, who gives you an annual checkup and who is the person you go to when you are sick, is different. The primary care doctor is a generalist. These physicians are trained in either Family Medicine or Internal Medicine. But for the most part they do the same thing: take care of their patients over a period of years. They are the only doctors in the system who really get to know their patients.

Besides their role as the doctor patients see first and who generally treat their patients, PCPs have two crucial roles in patient care. First, it is generally the primary care physician who decides which specialists her patients need to see. Many insurance plans actually require that the patient receive a referral from the primary care physician in order to see a specialist. Many situations require referrals to more than one specialist. After the specialist sees the patient a report is prepared and sent to the primary care doctor. Because the specialists take care of specific parts of the body or specific types of diseases, a single physician is necessary to be the quarterback of the team, to analyze all of the data and recommendations from the physicians, and then to guide the patient through the entire process. It is the job of the PCP to put the pieces of the puzzle together because the odds are none of the other doctors will even see all the pieces, much less solve the puzzle.

Unfortunately, if you need to be hospitalized your primary care doctor will more likely than not be kept out of the loop and will be unable to direct your treatment. It used to be that a hospitalized patient would most likely be seen by his PCP. Internists had hospital privileges and they made rounds to check on their patients. That doesn’t happen any longer. For the last ten years PCPs simply do not have the time to see patients in hospitals. Insurance reimbursement rates are so low that the doctors need to spend all their time in the office seeing patients. If they went to the hospital every day they would have trouble making ends meet. As a result, very few primary care physicians now have hospital privileges. Very often if a doctor wants a patient to be admitted to the hospital he will tell the patient to go the emergency room where he will be seen by a doctor who knows nothing about him.

The role of quarterback has been transferred to a group of doctors known as “hospitalists.” Hospitalists are internal medicine doctors who work either for the hospital or for a company that has a contract with a hospital. Hospitalists are called to the emergency room to admit patients, and they are supposed to oversee the care of the patient while in the hospital.

In theory the hospitalist should fill the role formerly occupied by the primary care doctor, i.e., coordinating care among specialists and being responsible for the overall wellbeing of the patient. In practice, however, the supposed continuity of care is absent. Hospitalists work in shifts. In some practices they work seven days on and seven days off. Unlike the PCP who once retained responsibility for his/her patient throughout the patient’s hospitalization, it is likely that such responsibility will remain with a single doctor.

We will discuss the ways to deal with this issue in a future entry.