Broad Scope Primary Care Adds Value

But like any paradise, it is hard to find.  Too few family physicians are clinically capable of offering it. Too few patients understand that this is the level of care they need to seek out. Too few third party payors understand that they have built a system that minimizes and punishes the delivery of broad scope primary care.

Most DPC physicians understand the need to offer broad scope primary care.  This is how you add value for patients.  Studies have shown that broad scope family medicine increases patient life expectancy.  Specialists cannot make this claim.  Unfortunately obtaining an experience and education in broad scope primary care has become difficult due to the orientation of teaching hospitals toward third party payors over education and specialist turf wars on highly lucrative procedures.  Broad scope primary care is about more than procedures.  

In my first year as a DPC physician fresh out of residency I diagnosed STEMIs, PEs, acute bleeding esophageal varices, and a traumatic pneumothorax - and none of these cases presented in an emergency department.  I managed the stable PE on an outpatient basis but of course all the others required hospitalization (sometimes via direct admission to the ICU - I love bypassing the ER whenever possible).  The more common acute complaints ranging from lacerations, angioedema, rashes, and URIs were certainly treated as well.  While treating patients with acute conditions can be life saving and exciting, anybody that has analyzed medical claims data knows that while patients certainly appreciate a DPC physician's ability to treat acute issues, the majority of financial savings comes from the management of chronic conditions.

I've diagnosed (and treated) patients with many rarer conditions including myasthenia gravis, acral melanoma, and multiple sclerosis.  The most common chronic conditions I manage likely do not vary much from other broad scope DPC practices: HTN, CAD, CHF, A fib, RA, OA, DM, CKD, COPD, OSA, Asthma, GERD, Hep C, HIV, Migraines, Seizures, Parkinsons, Hypothyroidism, Psoriasis, Atopic Dermatitis, Diverticulosis, Ulcerative Colitis, Crohn's, Depression, Anxiety, and metabolic syndrome.  I'm sure I missed a few.  Maintaining the clinical skills and updated understanding of the medical literature to diagnose, manage, and treat these conditions and their unending list of complications is not easy, but I wouldn't have it any other way.  From my point of view going into a specialty is boring.  Now you only diagnose and treat a small number of conditions, and since your source of patients comes from referrals you rarely face the challenge of an undifferentiated complaint - often the diagnosis has already been made.

Now for the caveat:  You might wonder how I had such a wide variety of cases right away in a DPC setting (where one typically must build up a full panel over a two year period) right out of residency. The answer is that I wasn't practicing in a typical DPC setting.  I was seeing patients in the rural correctional medicine (though still DPC) setting.  My panel of around 1,000 patients was instantly full and there was never a shortage of complicated patients needing care.  Most were grateful for the care they received, and I am grateful they trusted me to provide it. Without question my patients have made me a better physician.  

Now for the indictment:  I'm weary of complacency within the family, internal, and pediatric medicine communities.  We cannot be content to treat only HTN, diabetes, and asthma.  We did not go through seven (or more) years of education to be an HMO gatekeeper that merely shuffles patients off to one specialist or another.  Our referral rates as a group have doubled from nearly 5% to 10% in over the past decade.  We should be critical of our own referral decisions.  We MUST expect more of ourselves, and then we MUST educate our patients about our broad knowledge and scope.  How many family physicians do you know that never manage insulin?  We should be capable of doing these things!  Needing insulin should not lead to an automatic endocrinology referral.

The DPC model forces these kinds of difficult scope-extending conversations, and other third party fee for service models tend to do the opposite, literally not leaving enough time for prevention. In rural communities broad scope family medicine has persisted via necessity. When the closest specialist is over an hour away patients will ask you to do more.  In most traditional practices patients would not ask me to perform excisional biopsies at all, and certainly not on more challenging areas like the face or tongue. DPC patients have already paid you, so if you are capable and comfortable doing the procedure then you should do it (and if you are not capable this gives you an incentive to learn).  I know other DPC physicians that have been asked by their patients to perform a cholecystectomy, but obviously we all have our limits.

In the words (apparently incorrectly) often attributed to John Wesley: "Do all the good you can. By all the means you can. In all the ways you can. In all the places you can. At all the times you can. To all the people you can. As long as ever you can."