Let’s discuss primary care. That’s primary care, as in P-R-I-M-A-R-Y C-A-R-E.

Why the emphasis?

• Because I believe high-quality primary care is the bedrock of a well-functioning health care system.
• Because I believe access to primary care is a marker of a healthy nation.
• Because I believe quality primary care can save lives, extend lifespan and healthspan, and importantly:
• Because I believe quality primary care can reduce health care costs.

Sadly, I don’t believe we have any of the above today. And my prediction is it will be worse tomorrow and going forward.

Looking to the future, I can see a time when we have no useful primary care, other than as a routing station between specialists. What a sad state of affairs that would be.

In a nutshell, primary care has become an afterthought in our race to outdo each other with the latest technology and specialization we can offer, even if that technology has not been proven to make a genuine difference in health outcomes. We are awash with technology and specialty health care, and we spend oodles more money than any other nation using it. For most folks, we can’t show that it makes a real difference.

It has become so bad that when Sandra needed an ENT exam, the doc examined her nose and sinuses, but not her larynx, which was necessary because Sandra’s problem was a chronic cough.

When Sandra asked the physician to look at her throat, the response was, “Oh, you need to come back another day to see Dr. [Name] for that. I just take care of the nose and sinuses.”

Yowza. Really?

It is my firm unshakable belief (even speaking as an oncologist) that primary care makes a difference. I say that as a patient and I say that as a husband of a wonderful wife who have benefitted from the good fortune of having access to primary care physicians who gives a damn about us as people in need of care.

A recent issue of The New England Journal of Medicine has an excellent article on the problems besetting primary care from a medical student and physician perspective. Dr. Lisa Rosenbaum was the author, and she knows the issues first-hand.

While she acknowledges the need for well-trained and well-compensated specialist physicians, she also lets loose on the problems with the current primary care workforce, where students are encouraged to pursue careers in more technical areas of expertise in no small part because of better remuneration, better professional status and satisfaction, and recognition that primary care as a profession has fallen to the bottom of the prestige totem pole when it comes to caring for patients.

(In a moment of flagrant self-promotion, I am quoted in the article with regard to physician payment. But for now, I am going to focus on the core issues facing primary care. Payment problems and self-aggrandizement may come in a later blog.)

When professors tell students they deserve better than a career in primary care (as recounted by Dr. Rosenbaum) you know primary care is in trouble. And when docs who take residency training in primary care vote with their feet and leave that area of practice several years after starting their careers, it only reinforces the notion that primary care is not the place where you want to spend the rest of your professional life.

In sum, primary care is no longer a rewarding pursuit for most young physicians, either professionally or financially, especially when you graduate with an overwhelming financial debt that demands attention when you begin your career. Free tuition and/or shorter medical school training over three years are not turning out to be effective solutions to a serious problem.

Borrowing from James Carville’s famous phrase about the economy, “It’s the job, stupid!”

Yet (and this is the amazing part, since MAHA folks and I seem to agree on this) if we are to tackle the chronic problems with health care in this nation we need teams of professional folks who are able to gain the trust of their patients and steer them on a course where disease is prevented instead of constantly focusing on “sick care,” which today is what we do very well as a nation.

You can’t control overweight and obesity, diabetes, heart disease, hypertension and more if you don’t have a meaningful, effective primary care health system with clinicians who know the names of their patients and patients who know the names of their clinicians.

You can’t control illness if you can’t pick up the phone and get someone who cares about you to answer the phone. Call centers just don’t cut the mustard when it comes to getting appointments or giving advice that folks need at a particular moment when they need it. “Go to the urgent care center” is not a substitute for having your care in the hands of someone who has a relationship with you as a patient and more importantly as a person.

Thirteen years ago when I had a life-threatening staph infection in my knee after surgery and I was lying in a hospital bed with every one of my vital systems shutting down (read that: kidneys, blood, liver, and more) from a bizarre reaction to an antibiotic, it was my primary care internist who was there to help me navigate out of my impending spiral further down the hole.

I survived and did well. I have never forgotten what the emotion of that moment felt like, and the gratitude I felt to have someone who knew me standing/sitting there by my bedside working with me to save my life.

When Sandra had a serious medical problem, it was her primary care physician who turned her chair from the desk in the office where she had been typing her note, took Sandra’s hands in both of hers, looked her in the eyes and said, “I am here to help you, and I am here to support you,” and meant it. The tears in my eyes were genuine. Finally, there was someone who was willing to enter the fray by our sides, provide much-needed support, and share the burden we had carried alone.

You never forget those moments.

Those are the special rewards that happen in primary care from time to time. They exist in every practice, but they are becoming harder and harder to separate from the chaff that is blowing around primary care services these days.

Endless bureaucratic crap makes primary care stressful and professionally unappealing. Dealing with insurance companies and their denials is a full-time job. Patients expect messages to be answered promptly, and those messages come in by the hundreds every week in a busy practice. Late hours and long work weeks don’t lend themselves to emotional health, especially when stress is so much a part of your everyday professional existence.

Some folks believe that primary care is the place to deal with all the ills of society, like homelessness and food insecurity. Not that those issues aren’t important, and not that some clinicians and their staffs are committed to doing social support service well. But many find it difficult and stressful, one more burden to deal with on top of an ever-demanding load of clinical care.

As they say in that memorable Teddy Bridgewater commercial from Progressive Insurance: “You’re not a mechanic. It’s not your job to fix him.” Neither can primary care physicians fix all the ills of society they frequently confront these days in their outpatient practices.

There are only so many things you can do in a ten-minute visit, umpteen times a day. Patients don’t like those quick visits, and neither do the clinicians.

To make matters worse, and although no one likes to talk about money, the compensation paid primary care clinicians is paltry compared to other clinicians. That is the result of issues that have built up over decades.

Today in large health systems, primary care practices are considered (and treated) as loss-leaders, a place where people go to get referrals elsewhere within the system where the system (and the clinicians who practice those specialties) make a heck of a lot more money than the poor primary care person who has to make the referral in the first place.

There is a lot of discussion about old politicians these days, filed under the term “gerontocracy.” The general tenor of the body politic is, “Get out of the way.”

Well, in medicine, they are getting out of the way.

Those old folks (like me) remember what it was like to be a primary care physician caring for patients. You handled a lot of things yourself, referring when necessary, seeking advice from your specialist colleagues when you needed it, and sending patients to the specialist only if the problem was beyond your ability. And the specialist responded directly and promptly. You were part of a well-orchestrated team of colleagues, each depending on the other to work together to give comprehensive and continuing care to the person in need.

Today, a lot of primary medical care is simply triage.

The cardiologist takes care of my hypertension and cholesterol in addition to my atrial fibrillation. The nurse practitioner who saw Sandra for anemia ordered intravenous iron (expensive) and requested a hematology referral, ignoring that this was a simple condition where a test of oral iron was successful when the IV stuff wore off. (Nixay on the heme referral and bone marrow. We knew where the anemia originated, so it wasn’t a matter of ignoring a GI tract cancer. A simple, inexpensive therapy is all she needed then, and her anemia never recurred several years later.)

Everything we do these days jacks up the cost of health care to incredible levels. Yet we won’t make the basic investments we need to create that quality, accessible primary care workforce I mentioned at the beginning of this blog.

Other countries spend less and have better outcomes than we do while “doing” a lot less to their patients. They live longer, healthier lives than we do. Spending more and doing more is not always the answer when it comes to our health.

While MAHA is focused on food dyes, and saying that exercise is the answer to everything, what they should be saying is that we need to start by tackling the real issues facing us with our health, namely trying to prevent disease in the first place. It’s easy to talk the talk, but it is much more difficult to walk the walk. And if we are going to take that journey successfully, then we need to address the primary care workforce decline that has been building for years.

If we don’t do that, then there is no way we are going to make America healthy. Ever.

Preventing illness by having quality primary care available to all is a battle we are losing, but truth be told it is a battle that we must address and win if our nation ever has a hope of tackling the medical problems we face and the expense we are bearing by ignoring the need to find fundamental solutions to those problems.

The health of our nation is a terrible thing to waste. Primary care is a key part of the solution, and it is high time we recognized that immutable truth.

Our lives and the health of our nation depend on it.

J. Leonard Lichtenfeld is an oncologist.