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VOL. 6 • NO. 4
© December 2011
THE CHOICE OF PRIMARY CARE PROVIDER IS NOT EASY, BUT NECESSARY TO MANAGE OVERALL HEALTH CARE
Primary care covers a wide spectrum of ages. Pediatricians treat children from birth to the teens. Geriatricians treat the elderly with multiple complex conditions.
Of all the health care choices, none is as essential as choosing a primary care provider (PCP). Not only is it difficult to find a PCP that is accepting new patients, what to look for in a doctor can be equally daunting. Personal preferences prevail. Gender and age can be a factor. People might have a higher comfort with a doctor of the same sex. Some might prefer a younger doctor more likely to be up-to-date with newer treatments while others may relish the attention of a more experienced doctor. Hospital affiliation, location and access are also important. Even race or ethnicity often plays a role. People are sometimes more comfortable with someone who looks like them. Unfortunately, a perception exists that doctors trained in another country just don’t measure up in terms of quality. Yet, foreign-trained medical doctors are subjected to the same rigorous standards as American-trained doctors. They undergo residency training in American hospitals and take the same national three-part licensing exams and specialty tests. And they’re helping to fill the void of PCPs created in part by the increased demand. A study published in 2010 in Health Affairs concluded that the medical school attended — international or U.S. — did not affect mortality rates for patients hospitalized for congestive heart failure or heart attack. Rather, board certification and the number of years since graduation had the most impact. Board certification is a measure of quality that certifies a physician’s expertise in a medical specialty. Further complicating a choice in PCP is that there’s more than one type. An internist is a doctor of adult medicine, while a pediatrician tends to the needs of children. Geriatricians confine
their care to the elderly. Family practitioners, on the other hand, provide comprehensive medical and surgical care for the individual and family regardless of age. In some organizations the gynecologist is considered the PCP for females. Non-physician providers, such as nurse practitioners and physician assistants, round out the PCP players. For the most part, medical care and the choice of PCP revolve around age, starting with pediatrics and ending with geriatrics. The good news is that people are living longer. According to a recent report from the Massachusetts Department of Public Health, those born in the Commonwealth in 2008 are expected to live an average of 80 years. But the longevity comes with a price. That’s when a geriatrician, a primary care physician for the elderly, steps in. Geriatricians are trained in internal medicine or family practice, but then specialize in the care of the elderly. The age of patients treated by a geriatrician varies from patient to patient, said Dr. Daniel J. Oates, a geriatrician at Boston Medical Center. The typical age is at least 65, but there is no set age at which a person “graduates” from an internist or family practitioner to a geriatrician. More telling is the health status of the person. “I often treat people with geriatric syndromes,” Oates explained. “These are people with multiple problems that require coordination of care.” The list of problems he sees is long — falls, arthritis, pain, cardiovascular disease, poor vision. Special attention is made to functional independence and activities of daily living — concerns not typical in the younger population. People with memory problems are increasing in number and those with depression require coordinated efforts, not only with other providers but with the family as well. Getting medications right takes a bit of work. Those with complex and multiple medical problems take multiple drugs. It’s easy enough to juggle one or two medications, but, according to the Centers for Disease Control and Prevention, the average 75-year-old takes five prescription drugs. One of the most common reasons an elderly person lands in an emergency room are side effects of medication mishaps. Oates does not view working with the elderly as a challenge. “I see it as an opportunity,” he explained. “It allows me to have a major impact PCP, continued to page 4
HONESTY AT HEART OF GOOD MEDICAL PARTNERSHIP Dr. Julien Dedier, a doctor of internal medicine at Boston Medical Center, readily admits that much has changed in medicine over the years, especially among primary care physicians (PCPs). And that’s a good thing, according to Dedier. While PCPs are still busy diagnosing and treating a litany of illnesses, gone are the days when paternalism ruled the medical approach. Health care is now more of a partnership. “I’m part of a team,” he said. “They have to know that I am working on their behalf. My job is to know my patient and my patient’s overall health well enough to establish trust and confidence.” For Dedier, that means being aware of more than just his patients’ height, weight and blood pressure levels. “I need to know the total picture,” he explained. PCPs like Dedier are in high demand these days. According to the 2008 National Ambulatory Medical Care Survey, more than 60 percent of the 956 million physician office visits that year were for primary care. That’s not unusual. Primary care — considered the portal of entry to the health care system — encompasses the greatest number of patients and provides the widest array of services. People flock to their doctors for colds, aches and pains, immunizations, screening tests and medication. Coughs that don’t abate, rashes that persevere, even broken bones all wind up in a doctor’s office or clinic.
PCPs have their hands full. They diagnose everything from high blood pressure to diabetes to cardiovascular diseases and make referrals to other providers. In a sense, PCPs are CEOs, having the overall responsibility of managing their patients’ total care. But the biggest job, at least according to Dedier, is to listen and pay attention. The PCP needs to know, for instance, why a person shuns flu shots or refuses to take medication for an illness when he or she feels fine. “I have to understand where my patient is coming from and take each concern seriously,” he said. Dedier demands one thing in return from his patients. “Honesty,” he said. “I want patients to feel comfortable telling me what they have or haven’t done. My role is to help them improve their health.” But he has to know the truth. “If I prescribe a medicine and a patient swears up and down that they have taken it when they have not, it causes a problem,” he explained. The patient’s response could cause him to alter the dose or try another medication when either move is not necessary or worse, could be harmful. Though PCPs are essential to the health care system they are in diminishing supply. The 2011 Physician Workforce Study by the Massachusetts Medical Society determined that the shortage of family practitioners and internists in the Commonwealth is severe and critical. The waiting times for an
Dr. Julien J. Dedier, an internist at Boston Medical Center, says that teamwork and trust are essential for a successful doctor/patient relationship. (Photo courtesy of Boston Medical Center)
appointment range from 36 to 48 days. And it’s only expected to get worse. Medical students are not choosing primary care as their area of clinical interest, as noted in a recent study published in the Archives of Dedier, continued to page 4