By Joel Diamond, MD, FAAFP, an Adjunct Associate Professor of Biomedical Informatics at the University of Pittsburgh. He is a diplomat of the American Board of Family Practice and a fellow in the American Academy of Family Physicians. He cares for patients at Handelsman Family Practice in Pittsburgh and serves as chief medical officer for 2bPrecise.
In its earliest days, genetic and genomic testing typically fell under the purview of select specialties such as oncology, rare diseases and maternal-fetal medicine, but no longer. Increasingly, and appropriately, precision medicine is likewise finding a home within primary care.
It makes sense. The primary care provider (PCP) typically is the first-line point of access for a wide variety of medical services. Advances in genetic and genomic science equip PCPs with insights to speed accurate diagnosis of complex presenting conditions, improve medication safety for treatment of common conditions, and identify treatments and care plans most likely to produce desired outcomes.
Consider the value precision medicine can deliver in these three areas alone:
Improved medication safety. Healthcare has become adept at managing drug allergies, but lags in other areas that likewise influence medication safety and efficacy. Genetic variations drive how well – or poorly – a patient metabolizes a specific drug. If an individual is a fast metabolizer of clopidogrel, for example, his or her body will process it too quickly.
The medication may not provide appropriate protection against clotting which, in turn, has life-threatening consequences. Pharmacogenomic (PGx) testing provides PCPs with the information they need to select the safest, most effective medications for each patient. PGx is particularly valuable for PCPs treating behavioral health issues such as anxiety or depression (typical “trial-and-error” approaches delay therapeutic benefit for months), pain management (where efficacy is critical to timely recovery, management of comorbidities like high blood pressure and addiction avoidance) and common cardiovascular conditions like hyperlipidemia.
Schumpeter considered it the “essential fact about capitalism,” that things have to fall apart so better things can take their place. The familiar is violently displaced by the unfamiliar, but superior, alternative.
Buggy whip makers are sent out of business as car makers take over the transportation space. Typists go extinct as word processing becomes cheap and ubiquitous. Blockbuster goes bankrupt, so Netflix and all its streaming peers can take over the space. The notion that the New can mean bad news for the Old is nothing unique to our modern era, though perhaps the speed and distribution of change thanks to globalization and digital technology means we see this more and more.
Well, 2017 may well be the beginning of the end for primary care as we once knew it.
The “Who’s on First” of Healthcare
As with any other example of creative destruction, the signs in primary care have been there for anyone to read, though perhaps the conclusion they point to hasn’t been quite as clear as the contributing forces.
Nursing, as a profession, has been on a long arc over the last century or so, transforming patient care as well as clinical organization and even leadership. Nurses have evolved from subordinates to doctors to, in some cases, replacements–notably, in primary care clinics, especially critical access hospitals or in areas where patients might not otherwise get to see a doctor outside of an emergency room.
Primary care provider shortages aren’t strictly limited to rural or remote areas. Thanks to demographic trends, more people are living longer and managing more chronic conditions. Keeping this swell of aging patients from charging into Emergency Departments en masse was part of the logic behind elements of the Affordable Care Act shifting resources to clinics run by NPs as opposed to MDs. While nurses face a shortage of their own, they have still been tagged as a key element of preserving and expanding access to primary care. In 2007, the shift in nursing toward a more central leadership role was codified by the Association of Colleges of Nursing with its designation of the Clinical Nurse Leader as a new official role for nursing professionals.
Simply put, consistent access to primary care supports prevention strategies, which are altogether cheaper and more effective than sending everyone through an ED or into a long-term care clinic. While many–notably, the American Academy of Family Physicians and the American Medical Association–muckrake over this disruption of scope of practice, the change is one of necessity. Nurses today provide critical care, and lead diverse clinical and professional teams to coordinate whole-person health.
With or without the Affordable Care Act, the shortage in primary care will persist. Expanded access through insurance only exacerbated the underlying issue. As Millennials enter middle ages and Boomers carry on retiring and living longer than ever, primary care will be stretched. Whatever comes out of the Trump administration or the ongoing scope of practice debates, primary care requires providers, and nurses are showing up to work.