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In Defense of Primary Care

I recently spoke to a group of medical students at Hofstra University about the continuum between physical therapy, physiatry, and orthopedic sports medicine.  I was also invited by a primary care physician there to listen to the multidisciplinary team she manages discuss difficult patient cases, most of whom were on Medicaid (health insurance for low income families), to help her determine which patients might be candidates for physical therapy.  This experience reinforced for me how underappreciated primary care providers are in the medical system. In fact, they are often unfairly criticized. Primary care providers are frequently responsible for managing complex disease processes that are both poorly understood and influenced by so many individual, systemic and cultural variables.  

People in the wellness space periodically reference what they perceive to be the ineptitude of primary care disciplines.  If only primary care providers knew more about exercise and nutrition, they say, there would be less heart disease, diabetes, obesity, or chronic disease.  Wellness providers tend to practice in a very utopian environment, however. First, they generally work with people who have enough disposable income to pay for things like personal training, gym memberships, organic food, and out of network healthcare specialists that aren’t constrained by insurance-based reimbursement models.  In network physicians and allied health professions must necessarily spend less time with their patients because the reimbursements for services rendered tend to be low hence their volume-based practices. Family practice and internal medicine providers recognize that five minutes with a patient is inadequate. Insufficient time for patient treatment is a systemic constraint, however, not a medical decision.   

Second, people who are willing to pay out of pocket for wellness services typically already care about things like macronutrient ratios and which muscles they’re activating when they exercise.  The point is that these people are already healthy and not at risk for most chronic diseases. They’re spending their disposable income not on health per se but on the construct, perpetuated by the wellness industry, of optimal.  The wellness industry sells people on the concept of perfection. Consequently, there’s always something else to chase and more money to spend.

Most wellness providers work with niche populations that do not reflect the greatest challenges faced by the healthcare system.  While niche providers worry about whether people should do Crossfit, yoga, pilates, triathlons, or Olympic weightlifting, primary care practitioners would generally be satisfied if their patients went for a 15 minute walk every day as the sole means of exercise.  Their outcomes with patients would probably not improve if they knew more about periodization schemes or the biochemistry of steady state aerobic training compared to HIIT. Niche providers argue about the relative merits of the Paleo and Mediterranean diets while nutritional “choices” in primary care medicine are adversely influenced by so many behavioral, financial, and systemic barriers.   

The wellness industry tends to pathologize many normal behaviors and generally isn’t responsible for solving the healthcare system’s hardest problems.  I hope I can do an overhead squat when I’m eighty years old but that’s not a goal the healthcare system should prioritize, nor is it something to which formal medical education should devote much time.  People assume that the medical system holds the answer to every health problem but managing disease states is much different than pursuing wellness. Primary care physicians, physician assistants, and nurse practitioners are responsible for applying an incredible bandwidth of clinical knowledge in a highly challenging environment.  I would encourage anybody who thinks that healthcare is simple to shadow a primary care provider who works mainly with Medicaid patients for a day. Even people who don’t eat processed carbs can be served a dose of humble pie.