Problems for primary care generalists
Richard Horton in this week’s Lancet writes
Family practitioners in the US are facing extinction. In their place must come nurse-practitioners. Nurses are better educated to navigate and refer patients to specialists. They don’t have any illusions about managing complex illness. Their lower threshold for referral means less risk of missing diagnoses or delaying expert care. This is one vision for nursing to be found at the University of Pennsylvania’s extraordinary School of Nursing. The Penn health system is astonishing in many ways. It is part of a university—led by its President, Amy Gutmann—that has transformational knowledge, policy, and global ambitions.
I haven’t seen the argument put this way before. In the UK it often appears that criticising primary care is treasonable, largely because GPs seem to ration care. Yet, for much of medicine, I do not think primary care serves patients well. Medicine really is too vast and complex, and the traditional strengths of primary care (continuity of care, 24 access) are fast disappearing. There is also a confusion between hospital versus non-hospital care (i.e. primary care) and the need for specialists or generalists. The UK situation is very parochial. There is no reason for many specialists to be based in hospitals at all. On the other hand — for dermatology at least — I fail to see why anybody would out of choice see a generalist rather than a specialist (or at least not have the choice of who to see). When I lived and worked in France, and my children were ill, we would visit a office based paediatrician, or even get house calls from him. I have never understood why we force the necessary diversity of clinical skills on to one person. But perhaps I am seeing this all wrong: it is the nurse practitioners or physician assistants who are going to take on much of traditional general practice.