A Shout Out for Primary Care

A big event came and went with little news coverage. Perhaps it is because it happened in Kazakhstan. Or was it because it was the World Health Organization, and we in the US are more worried about ourselves. Or perhaps it was because it was about primary care, not the latest medical technology or drug—primary care is not a sexy topic so the media pays little attention. On October 25-26, 2018, the Global Conference on Primary Health Care revisited the forty-year-old Declaration of Alma-Ata (1978). Heads of state, ministers and representative of states and government around the world gathered once again in Astana, Kazakhstan, then called Almaly (Alma-Ata), Kazakh Soviet Socialist Republic, to reaffirm a commitment to prioritizing, promoting and protecting people’s health and well-being at both population health and individual levels through strong health systems. That means good primary care and public health.If you live and breathe health care and family medicine like I do,

Dr. Barbara Starfield is a pillar. Dr. Starfield (1932-2011), a pediatrician by training, the Director of the John Hopkins University Primary Care Policy Center and a member of the Institute of Medicine, spent her career researching health care and demonstrating that primary care, in contrast to specialty care, helps prevent illness and death. She talked about the 4 Cardinal Cs of primary care: contact accessibility, coordination, comprehensiveness and continuity. Patients must have access, service must be coordinated and comprehensive and follow up over time is critical. In a nutshell she showed strong associations between strong primary care, cost control and higher quality.The term primary care refers to generalist practitioners in pediatrics, internal medicine, family medicine and sometimes obstetrics and gynecology. It is thought to date back to the 1920s, and the Dawson Report in the United Kingdom that mentions the importance of primary health care centers as the hub of regionalized services and the cornerstone of health care in the UK. This concept has been threatened in the US by our love affair with subspecializing (cardiology, pulmonology, infectious disease, intensivisit—ICU medicine, infectious disease, etc.) and as a result most US medical school graduates do not chose primary care.

A recent JAMA report showed that the efforts to increase the number of medical students has not resulted in more primary care physicians. The increased number of medical schools and expanded class sizes turned out 23% more students [1997-98: 16,114 grads; 2017-18: 19,750 grads]. At the same time Osteopath (DO) schools doubled their enrollment. Despite these increases training in primary care has not ramped up and is not adequate for addressing projected needs: less than 10% of graduates choose FM, 14% internal medicine, 6% pediatrics and half of those in internal medicine and pediatrics subspecialize. It is also interesting to note that in order to fill all the available family medicine training slots—the specialty that does the majority of primary care and is well suited to do it in small communities that cannot support a pediatrician, internist (adult medicine) and obstetrician—we depend on graduates from medical schools outside the US to fill 50% our family medicine residency slots.Despite efforts to improve salaries for primary care physicians, the lack of planning in the US means we will fall short of our needs.

In Rhode Island, health insurers want patients to have a primary care physician, but patients report waiting many months to see one. I used my connections and it took me five months.Of course, we are not alone. In my recent work with Jordanian family medicine academicians I learned that Jordan graduates 3000 medical students every year. There are residency spots of any type for only 10% of the grads and about 1% can train in Family Medicine. That means that 2700 medical students go into general practice with only hospital based training. If you haven’t done outpatient care, you might conclude that patient care is patient care whether in the hospital or clinic. Not true! In ambulatory care we learn to live with uncertainty as we figure out what might be going on with patients, we balance the realities of their lives with what is needed to manage their illness. We look at population health—what is important in the community for which we are responsible—which means screening and preventing illness with immunizations, routine Paps, mammograms, helping patients quit smoking, etc.

So back to what happened in Astana, Kazakhstan. On the occasion of the 40th anniversary of the Declaration of Alma-Ata (1978) the commitment to strong primary care was reaffirmed. Back in 1978, the goal of primary Health Care for All by 2000, was criticized as an idealistic and unrealistic goal, and in 2018 we can say that it has not been achieved, even in the US. But we can all agree that vision and stretch goals are important.

While the Bill and Melinda Gates Foundation doesn’t focus on primary care, they do focus on health and their Goalkeepers report demonstrates that despite all the negative news these days progress has been made. A quick look at their graphs show that around the world:

--Poverty is decreasing

--Maternal mortality is down-

-Under-5 mortality is down

--Neonatal mortality is down

--Access to family planning for women ages 15-49 have their needs satisfied has improved, but could regress.

--Access to universal health care has improved, but could regress.

This is a call to action. The attached slide shows why it is important to invest in strong primary care. The Ecology of Medical Care demonstrates the importance of primary care and public health based on where people go for care in a month’s time looking at US data. In an average month, 800 out of 1000 report some type of illness symptom, 217 will seek medical care, 113 in a primary care office, while only 13 go to an emergency department, 8 to a hospital and <1% in academic hospital. In the US we focus our research and health care dollars on the small boxes. Caring for patients in the ED, hospital and academic health center is pricey. Making sure that is access to a clinic instead of the ED, or caring for a patient’s problem in the clinic or with home care so they don’t’ get hospitalized, saves money. Investment in public health and primary care is essential in the US and around the world.

Think of that when you consider voting in November. Talk to your legislators and health care administrators about supporting and investing in primary care. Get your flu shot. And if you have enough income to donate money, donate to organizations that are working for health care for all.