New Practice

A version of this content was recently published on STAT.

One of the best-known impacts of the Covid-19 pandemic has been the stress and overwhelm experienced by frontline healthcare workers. Often under-resourced and taking casualties within their own ranks, they have been straining under the weight of responsibility to care for a tsunami of Covid casualties from the community. In the center of this relentless firestorm has been the emergency medicine physician. These countless heroes have been called to give more of themselves than should ever be asked of anyone, and their burnout and exhaustion is unsustainable.

Perhaps it was the pandemic which sparked an emerging, yet largely unreported phenomenon I’ve witnessed firsthand where emergency medicine physicians are leaving the ER and opening independent primary care practices in the Direct Primary Care (DPC) sector of healthcare. DPC operates at the fringes of the standard healthcare industry, funded by subscription-based payments usually paid out of pocket by patients. No insurance billing means no credentialing, no quality reporting, no oversight of any kind. Many primary care physicians have sought refuge in this model to escape the insurance-based toxicity of the traditional fee-for-service payment system – and anecdotally, it’s working. The DPC model seems better for both PCPs and their patients. Win-win. And without regulatory and reimbursement oversight, the rules are honorary, leaving room for much needed innovation but also interlopers.

The U.S. desperately needs more primary care clinicians. Yet, as a residency-trained, board certified family medicine physician, I have concerns about this phenomenon. Primary care physicians (PCP) are trained to provide care in diverse settings, including primary care clinics, urgent care clinics, emergency rooms, inpatient units, and long-term care facilities. Emergency physicians, on the other hand, are residency-trained and board certified to provide care in urgent and emergency care settings only. My colleagues in emergency medicine are the experts at saving lives and identifying serious problems. If the patient is not admitted to the hospital, they are sent out the door with instructions to follow up with someone else — usually the PCP. This is a very different approach to care from that of the primary care physician, who is specifically trained to cultivate a longitudinal relationship with their patients — managing multiple acute and chronic diseases, serving as a healthcare quarterback, setting treatment goals, and collaborating with their patients to address the fundamental lifestyle behaviors and social determinants that impact health. It isn’t clear to me what qualifies emergency physicians to function in a primary care capacity without primary care expertise.

There is an antiquated mindset that primary care physicians, who ideally are the foundation of a high functioning and sustainable healthcare system, are “general practitioners” who know just enough to diagnose and treat the basic stuff. In this misinformed framework, physicians who specialize in other areas of medicine are doing the harder, more important work which requires greater expertise beyond primary care — expertise that only they possess. Not everyone can be a neurologist — you have to have special training for that; not everyone can be an ophthalmologist — you have to have special training for that, too. But anyone can work in primary care — no special training required. The premise seems to be that primary care requires the basic healthcare knowledge that everyone learns in the beginning of their medical training, and every other specialty is “more” than that.

When I was a medical director at a large military treatment facility earlier in my career, there were occasionally resident physicians from a variety of specialty programs who were sent to my primary care clinic when they couldn’t perform to standard within their subspecialty training programs. They were considered “flunkies,” for lack of a better term, so they were sent to primary care where they could do the least damage — because “primary care is easy.” But it turned out primary care was not easy, and these physicians performed poorer clinically and had more patient complaints than their primary care-trained coworkers. They also required greater supervision by the very primary care physicians they were sent to work with because they didn’t know how to do the work. 

This distorted image of primary care is part of the problem in our dysfunctional American sick care system. Primary care is powerful. High quality primary care has the ability to influence 90% of our $4 trillion in annual healthcare spending in the U.S. We know for every $1 invested in primary care, the U.S. saves $13 in downstream spending. And primary care increases life expectancy, improves quality of life, and increases patient satisfaction. Primary care achieves this through proactive, comprehensive, coordinated care based on a longitudinal relationship between the patient and a PCP they trust. No other medical specialty can claim these outcomes including emergency medicine.

On behalf of primary care specialists everywhere, I’m here to say that primary care is not “easy.” There is a reason that primary care residency programs and board certifications exist. It takes a particular personality type and intensive training in a unique skillset to be a “comprehensivist.” Primary care physicians provide more mental health care in the U.S. than mental health specialists do. Primary care physicians are available for their patients, educating them, advocating for them, and guiding them through the best and worst times of their lives. They prevent disease, ensure early detection of cancer, and assist with end-of-life planning. 

The idea of an emergency physician opening a primary care practice, representing themselves as a PCP to patients and communities, is anathema. I cannot open a practice and represent myself as a neurologist or an ophthalmologist. Not only would insurance companies not credential me in those specialties, it would appall people when they inevitably discovered I was masquerading in a different specialty outside my field of expertise. Should we not have similar responses to the emergency physician described here? This comes with risk to patients and our communities.

I have incredible gratitude and compassion for my emergency medicine colleagues. Their work throughout this pandemic has been arduous and traumatic. I wish for them to experience respite and relief. Yet if they want to be practicing primary care physicians, they need to complete a primary care residency program and pass a primary care specialty board examination. We’re committed to our patients and our craft, and would love for them to join our ranks — the ethical and honorable way. 

Sara Pastoor, MD Bio:

Dr. Sara Pastoor is a family medicine doctor practicing in innovative primary care models for the last twenty years with a focus on patient-centered medical home and health system transformation. She is director of primary care advancement for Elation Health, a technology platform for independent primary care practices, and co-director for Presence Health, a direct primary care practice in Austin, Texas.