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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
- ↵⁎Address correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
From the time that I was an intern (which was some years ago), it was said that there was a shortage of primary care physicians. Over succeeding years this condition has worsened. Data now indicate that, although 56% of patients who seek medical attention do so for a primary care indication, only 37% of the physicians in the United States practice primary care (1). Further, only 8% of medical school graduates are choosing to enter general practice. The recently enacted Patient Protection and Affordable Care Act is estimated to provide health insurance to more than 16 million Americans, placing further strains on primary care manpower. The American Academy of Family Practice estimates that there will be a shortage of 40,000 family practitioners by 2020.
The reasons for the shortage of primary care physicians have never been precisely established. High workloads and long working hours, a lesser prestige than specialists, and the challenge of being knowledgeable about all areas of medicine are factors that are frequently mentioned as playing a role. However, it seems clear that compensation, or the lack thereof, is largely responsible for the failure of primary care to attract more physicians. The reimbursement of procedures versus evaluation and management services, and the tendency to pay for individual services in the United States have contributed to the lesser earnings of primary care practitioners compared with specialists.
Whatever the reason for the lack of primary care doctors, the remedy will entail considerable changes to the healthcare system, and it will certainly require a number of years to implement. Including college, it takes approximately 12 years to train a general practitioner, and the alternatives to immediately addressing the shortage are relatively few. A frequently proposed solution involves the greater use by family medicine of ancillary providers, such as physician assistants, nurses, or even relatively briefly trained medical technicians. Although the advantages of such a solution have been well delineated, an enhancement of the quality of care has not usually been among them. It seems clear, however, that an increased use of nonphysicians, alone or as part of a medical team, will be employed in the future. An alternative is a greater role for specialists in providing primary care. Although this might not be very feasible for many specialists, it seems to me that it is a definite possibility for internal medicine subspecialists.
In my view, cardiology is one of the specialties with a good potential to play a role in primary care. Heart failure is just one example. Whether cared for in organized heart failure clinics or an individual practice, patients with heart failure often have multiorgan problems and certainly require periodic and often frequent follow-up. These patients typically see their cardiologist more than their primary care physician. It seems more than reasonable that cardiology be the medical home for these patients. The same is often true for patients with chronic coronary artery disease, refractory hypertension, cardiac arrhythmias, and congenital heart disease. There is little question in my mind that cardiologists currently attend to many noncardiac problems for their patients, such as upper respiratory and urinary tract infections, minor trauma, diabetes, degenerative joint disease, and others. We are surely as capable of making an appropriate referral to another specialist for a specific medical issue as our primary care colleagues.
In many respects, I am a primary care cardiologist. My nurse, Vicki Nassar, and I tend to bond with our patients, many of whom see me more than their primary care physician. They often call us for minor medical problems, or for referral to another specialist. I feel comfortable treating minor infections and adjusting the dose of oral hypoglycemics or thyroid supplements: we even give flu shots in our clinic. I generally enjoy this interaction: it serves to fulfill the patient–doctor relationship that I envisioned when I went into medicine. However, it evolved primarily because the patients felt a greater attachment to us than their family doctor. (It is, of course, also entirely possible that we made ourselves more available to the patients than their family doctors.) Interestingly, a number of my patients see me regularly and have an annual visit to their primary care physician for immunizations, pap smears, and so on. Perhaps in some small way I am easing the shortage of family doctors.
The ability of cardiologists to play a role in the primary care of their patients would depend upon a number of factors. First, of course, would be the availability of time to deliver these services. It appears clear that there will be a general shortage of physicians as the baby boomers pass through their advanced years, an issue that will be particularly demanding on cardiologists. In addition, there are some services that can only be or are best delivered by cardiologists. It would be an inefficient use of training and skill to defer providing those services in favor of primary care. Indeed, attending a general cardiology clinic could be considered a waste of expertise for a highly-skilled interventional cardiologist or electrophysiologist. So, it remains uncertain what contribution that cardiovascular or other specialists could make toward ameliorating the lack of primary care physicians.
It is clear that there is currently a shortage of primary care physicians that will only be compounded in the future by the dwindling numbers entering the field and the effects of the Affordable Care Act. While ancillary medical personnel can and will serve to ease this deficit, they do not bring the same level of expertise to bear as a well-trained physician. I believe that there is considerable merit to the potential of at least some specialists playing a greater role in primary care. It would serve to keep them informed about areas of medicine other than their specialty, and it would simplify and expedite the general medical care of their patients. Of greatest importance, in my opinion, is that it would provide the satisfaction that we all anticipated experiencing when we envisioned medical practice in terms of our own family doctor. Finally, it would address the important societal need for greater access to primary care. While it may not be practical or prudent for many specialists to play a greater role in primary care, for those who can it will provide a great service to our patients and society and, based upon my experience, will bring an enduring satisfaction to our practices.
- American College of Cardiology Foundation
- Henry J.