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 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, which is that it is pervasive and promotes healthy choices.
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 towards 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 the 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.
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 battered women shelters. 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 the vast 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?
The Affordable Care Act’s requirement that not-for-profit hospitals develop community assessment and create community assistance funds and the law’s provisions for more preventive services bring opportunities to change our current care delivery models. We need to embrace this opportunity to move out of traditional clinical settings, go into the communities that we serve and understand and function in the manner that communities want us to. 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. It is this opportunity of working in communities, using biopsychosocial paradigms, emphasizing wellness care with sickness care that will make future physicians more satisfied with their work.
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.”
Shailey Prasad is a family physician who blogs at Primary Care Progress.
