This Is Primary Care

The following editorial was written by University of Minnesota Family Medicine and Community Health faculty Shailey Prasad, MD, MPH. It appeared in our fall 2013 newsletter, the Family Medicine Connection, and was originally shared on the Primary Care Progress blog. 

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Shailey Prasad, MD, MPH

Inspired by a campaign that identified the work of public health, faculty Shailey Prasad MD, MPH, hopes the work of primary care will one day be identifiable in our communities, outside clinic walls.  

By Shailey Prasad, MD, MPH 

I recently saw a sticker on a bus shelter. It was an arrow about 10 inches long and 6 inches wide. It seemed to be pointing to the bus map. “This Is Public Health,” it said. The sticker, part of a larger campaign, gave me pause. Sure, a bus stop is public health because it’s a marker of mass transportation; it symbolizes improved access and decreased pollution from individual cars. Looking around, I saw a lot of places that would be appropriate for that sticker.

Later, I had the opportunity to talk with a few students who had participated in the campaign. They were thrilled with the neat places they had labeled, such as a bike path, a farmers market, and a park. And they were particularly happy that the exercise had led them to a clearer understanding of public health—that it is pervasive and promotes healthy choices.

Labeling Primary Care

Given a sticker that reads, “This Is Primary Care,” I wonder where I would put it. How would I define primary care? For a long time, primary care doctors were derisively called “just generalists.” Our discipline was the fallback for medical students who couldn’t get into another specialty. We were also the least understood discipline since we address such a wide range of health issues.

I’ve read essays from pre-medical students who wanted to go into medicine in order to understand and serve the human condition. Idealism is a strong component of the drive to go into medicine. And then, as we’ve all heard someone say before, “medical school beats it out of them.” One way or another, career choices are skewed away from primary care during medical school.

Primary care has a marketing problem. We need “This Is Primary Care” labels to stick in diverse places around our towns.

Primary care has the unique ability to keep one foot in clinical medicine and one in public health. But we lean toward the clinical side and need to explore the wide world of public health. Restrictive payment models combined with the enormity of public health work and our lack of familiarity with it have kept us in the clinical realm. We need to counterbalance the pull and top heaviness of “sickness care” with a move to public-health-focused “wellness care.” It would be more productive and complete the holistic approach that most of us crave.  

Merging Primary Care and Public Health

 

I’m not alone in my thinking. The Institute of Medicine has challenged our field to better integrate primary care and public health in the context of improving population health. Merging the here-and-now of clinical medicine with the long-term horizon of public health brings with it challenges and opportunities. But it is in this particular niche area that we can thrive. Keeping individuals in mind, aiming for community-wide impact, and shaping the future of larger swathes of society should be the goals of the primary care physician of the future.

Merging public health and primary care would close the loop on issues identified in clinics with input from homes and communities. It would put into context environmental factors that worsen a child’s asthma and would link community groups who would then be partners in developing means to address those factors. Well-child visits would include college preparation activities. Activities that start with the immediacy of a clinical encounter would lead to activities that make a broader community impact. For example, a clinical encounter dealing with domestic abuse would lead to building or strengthening shelters for battered women. It would add out-of-clinic population management activities to our current in-clinic encounters, such as creating walking groups for people with peripheral vascular disease.

Besides improving population health, I believe this approach would help address physician burnout. Could a move to a more holistic approach to care and wellness decrease the existential angst of dealing with emotionally draining clinical scenarios one at a time?

Moving from the Clinic to the Community 

 

The Affordable Care Act calls for more preventive services and requires not-for-profit hospitals to develop community assessment and create community assistance funds, bringing opportunities to change our current care delivery models. We need to embrace these opportunities to move out of traditional clinical settings, go into the communities that we serve, and understand and function in the manner that communities want. The newer models of care, such as patient-centered medical homes and accountable care organizations, provide us with a rubric for population management. Moving out of traditional settings and into the community will empower us to better use our skills.

And as we do this, migrating from the current restrictions within the four walls of the clinic to the communities that we work in, we will be able to place labels all over our communities that read, “This Is Primary Care.”