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Johns Hopkins Health - Primary Care: The Comprehensive Approach to Overall Health

Summer 2012
Issue No. 17

Primary Care: The Comprehensive Approach to Overall Health

Date: July 18, 2012

primary care

Norman Poulsen, M.D., a physician for 34 years, recalls a patient he saw recently. “He described a set of symptoms to me, while I mostly just listened,” he says. “Then we talked about everything going on in his life, and after that I told him we should watch his symptoms for a while before trying a treatment. A few days later he sent me a note saying that our talk had made him feel much better. Just talking with him had made a difference.”

Medicine isn’t always as simple as a good chat, of course. But Poulsen, who leads family medicine and is a regional director at Johns Hopkins Community Physicians (JHCP), says this particular encounter illustrates the importance to people of gaining access to top-notch primary care, where a quality conversation can sometimes be as important as any other treatment.

“Primary care can handle 85 percent of the problems that patients have,” he says. “And it can coordinate all the care needed for the other problems.”

In fact, primary care providers—medicine’s front line in guarding our health—are increasingly being seen as the key to the best possible care, as well as to holding down health care costs. So important is it for people to engage with good primary care that many health care systems, including Johns Hopkins Medicine, are creating a new approach to primary care called “medical homes” that may become the heart of how care is delivered.

Broad Knowledge and Skills
If some people tend to underestimate the importance of primary care, it may be in part because of the very phrase “primary care,” says Steven Kravet, president of JHCP, the largest primary care network in Maryland. “The word ‘primary’ makes people think of ‘basic’ or ‘simple,’ as in ‘primary color’ or ‘primary school,’” he says. Kravet notes that the pivotal role of primary care in medicine has been dramatically driven home in studies of how health care costs and results vary around the world. Simply put, the stronger the emphasis a country places on its primary care system, the more likely it is to be highly ranked.

Primary care physicians aren’t technically considered “specialists,” Kravet says, but they do bring a special set of skills that can make a big difference in our health. For one thing, a primary care physician can be adept at spotting a broad, underlying condition responsible for a range of symptoms. Depression or a chronic inflammatory disorder, for example, can manifest in any number of ways: stomach discomfort, joint pain or problems with multiple organs.

“Primary care physicians are very good at thinking holistically,” Kravet says. “They know the patient and the patient’s family, and can put the illness into context.” What’s more, he adds, the primary care physician has an understanding of the medical system that allows him or her to refer the patient to the right specialist when needed.

But if primary care medicine has always been important, it is becoming increasingly so in the face of big changes taking place in health care. One of the biggest is a growing emphasis on preventive medicine.

“Cardiovascular disease, diabetes and other chronic conditions are very preventable,” says Patty Brown, president of Johns Hopkins HealthCare, the arm of Johns Hopkins Medicine that administers government and other medical coverage plans on behalf of about a quarter-million people. “When you look at the best way to make sure that someone achieves those lifestyle changes, it’s to ensure that individual has a good relationship with primary care providers.” The effect of healthy habits on a person’s life can be enormous, she adds, noting an example that there is recent preliminary evidence that a 5 percent reduction in weight in an overweight person can reduce the risk of diabetes by 65 percent.

Your Primary Care Team
To help ensure care is delivered most effectively and efficiently, health care systems are creating the “patient-centered medical home.” In short, the medical home transforms a primary care clinic or other facility into a home base, where most of what a person needs for better health is available. Though the primary care physician remains at the center of providing care, an emphasis on a team is paramount. This typically includes nurse practitioners, physician assistants, health coaches, community health workers and more. “There are many things that can contribute to a patient’s health that can be done, and done very well, by a team member other than the physician,” Poulsen says.

In particular, Kravet notes, nonphysician team members can do much of the coaching involved in preventive medicine. “Patients need to have time to discuss prevention with a care provider to really understand what it takes to stay well,” he says. “Are they wearing seat belts? Are they wearing bike helmets? How much stress is there at work and home? What are their relationships like? What are their exercise habits? What about smoking and drinking and drug use? All the components of our lives affect our health, and exploring them can take long and involved conversations with a trained professional.”

Kravet says this doesn’t mean the physician stays behind the scenes. Rather, the physician’s time can be used to zero in on the most challenging issues. “People trust their doctors, and want to hear their doctors tell them what they need to do to be healthy,” he says. “My role is to identify the key issues and discuss them with the patient to come up with a plan. Then team members can help work with the patient to carry out the plan.”

Technology Makes It More Personal
Another component of the medical home is electronic medical records that seamlessly weave together detailed notes from every care provider who sees the person, lab and imaging results, and the like. “We’re seeing a real transformation in the amount of information we can have at our fingertips now, and it’s letting us keep track of patient care in a way we’ve never been able to do before,” Poulsen says. “Even when we’re at home, we have full access to all the same information that we’d have at the office, and that means when we get a call at night we can make decisions that keep patients safer and healthier.”

What’s more, Poulsen adds, the primary care team can get reports on which patients are facing gaps in their care. “If patients don’t come into the office as often as we’d like, or aren’t getting that test they were supposed to get, or aren’t filling their prescriptions,” Poulsen says, “we know it now, and we know what they need.”

Armed with that sort of information, the medical-home team can reach out to get care to the person, wherever he or she is. “I can have nurses or pharmacists interacting with the patient by email or phone on a regular basis to reinforce the advice and prescriptions they got at the office,” Kravet says.

“It’s often what happens between visits to the doctor’s office that’s most important to health,” he adds. “Now we can contact them to see if there are any problems or any barriers to their improving, whether it’s depression, confusion about how to take their medication or difficulty in keeping up their exercise.” People can perform some of the between-visit monitoring themselves via a website or smartphone.

Not that any tool will ever fully replace the face-to-face conversation between patient and primary care physician. Poulsen recalls going on a long sailing vacation some years ago with his family, only to find himself thinking about those conversations. “I was really missing hearing patients tell me their stories,” he says. “I think the chance to listen to those stories is one of the reasons many of us go into this field.”

What to Look for in Primary Care
When searching for a primary care clinic or practice, consider these capabilities:

  • Team care. Increasingly, primary care physicians are relying on a team that might include a physician assistant, a nurse practitioner, a behavior coach and others.
  • An emphasis on prevention. Most people stand to realize big health benefits, including lower risks of most major diseases, if they adopt healthier lifestyles. Your primary care team should play a strong role in helping you achieve that goal.
  • Quality time with the physician. Although much of your care may come from others on your team, you should still have face time with a doctor you trust, who listens to you, and who can help you understand the big picture in your health.
  • Electronic records. Care providers should have the ability to access all of your records anywhere in the office, and even remotely. Providing you with Web or smartphone access is a big plus.

See related article - Dr. Oz on Managing Your Health 

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