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In today's modern world, where does primary care fit in?

Especially at large academic medical centers like ours, the focus across the institution tends to be on secondary, tertiary, and quaternary care. This is the stuff that makes headlines; this is the stuff that attracts philanthropy; this is the stuff that marketing departments lock onto and love to generate stories about.

But even a large hospital that focuses on high-end care, on advanced imaging, providing specialized surgeries, and offering the latest experimental protocols and the most cutting-edge medicine, the patients have to come from somewhere -- and they have to go somewhere when they're done.

While large academic medical centers and hospital systems pour millions and billions into making sure they have the latest and the greatest, that they can attract and keep the best specialists, and that they are always at the forefront of medicine, the vast majority of patients funnel "up" from primary care. And once they've had treatment from these specialists, sub-specialists, and sub-sub-specialists, they will eventually need to go back into the hands of primary care providers. We regular old run-of-the-mill physicians -- the pediatricians, psychiatrists, OB/GYN's, and general internists -- are ones that are going to do the vast majority of management both before, often during, and especially after a patient has had an experience with these "higher" levels of care.

The process of referring someone up the line, of us generalists deciding that this is too much for us to handle, that we need help, that we've gone beyond our comfort zone, is a critical part of healthcare, and should not be taken lightly. But for the vast majority of conditions for most people, pretty much everything can and should be handled by us.

Personally, I think it's a waste when I see patients seeing a cardiologist for their high cholesterol or their hypertension, an endocrinologist for their diabetes or their hypothyroidism, or a gastroenterologist for their reflux or fatty liver disease. There are so many examples of conditions for which patients have found their way to the "best of the best", the famous specialist, the person who their friend told them they absolutely had to see. And the patients never want to let go of these amazing doctors. However, it's often a waste of a specialist's time for them to be refilling someone's statin, or their thyroid replacement, or their insulin, or their blood pressure medicines.

Maybe these specialists never want to let these patients go. Sure, those are easy visits, and the specialists probably welcome seeing a couple of really simple and stable patients appear on their schedules. But if we could return these folks to primary care, where we can manage the vast majority of things (with a commensurate level of support to take really great care of these patients), then we'd free up these specialists to handle the really tough cases, the ones where we call for help.

Instead, we have created a world in which a waitlist to get into folks has gotten so long that we primary care doctors are spending far too much time trying to argue patients into an appointment with somebody, or telling them their best bet is to go to another institution. If we got these specialists and subspecialists to "fire" these relatively healthy and stabilized patients, if they gave them back to us, and we had a brilliant system of team support to really manage these folks well -- like the specialists often do -- then we'd free them up to take on the more complex and challenging patients that are just not in our wheelhouse.

Some people think that a long wait to get in to see a specialist must mean that they must be the best. But in an ideal world, access to them should be as timely as the urgency of the care they will provide will be.

So if an academic medical center is really interested in fully developing its secondary, tertiary, and quaternary care, it only makes sense for it to fully develop its primary care bedrock, to flesh out an incredibly solid and diverse foundation of folks who are out there making sure patients' preventive care is done, spotting things when they go wrong, managing acute and chronic illnesses, calling for help and referring where appropriate, and then taking patients back once they're finished getting the specialized care they may need.

Listen, some of my best friends are incredibly specialized doctors who only handle one illness, one complex kind of case, or one specific type of surgery. And God bless them; we'd all be lost without them. But if we invest in a system where we in primary care can handle most of it, the bulk of it, if we can keep the healthcare monster from being top-heavy, and spread out that core community of primary care and make it as solid as we can, then we're all more likely to succeed.

Now that would be something that philanthropy could really get behind.

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