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INTRODUCTION

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Primary care is coordinated, comprehensive, and personal care, available on both a first-contact and a continuous basis. It can be defined by several tasks: (1) medical diagnosis and treatment; (2) psychological diagnosis and treatment; (3) personal support of patients of all backgrounds; (4) communication of information about diagnosis, treatment, prevention, and prognosis; (5) maintenance of patients with chronic illness; and (6) prevention of disability and disease through detection, education, behavioral change, and preventive treatment.

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This chapter addresses the common clinical problems encountered by physiatrists in office practice of adult patients with disability. In this setting, the physician’s responsibilities and tasks extend beyond the narrow technological confines of medical diagnosis and treatment. As the number of patients requiring rehabilitation increases, the medical problems of those with physical disabilities become more complex, and the availability of primary care physicians who understand the needs of chronically ill patients become relatively less available, it becomes more important for physiatrists to understand the tasks that comprise the clinical work of physicians providing primary care for patients with such problems.

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HEALTH MAINTENANCE OF CHRONICALLY ILL PATIENTS

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Historically, there has been little coordination across the multiple settings, providers, and treatments encompassed in the care of chronically ill patients. The treatments for chronic diseases are often complicated, making it difficult for patients to comply with treatment protocols. Effective medical care usually requires longer visits to the physician’s office than is common in acute care. Moreover, in treating chronic illnesses, effectiveness of the same intervention, whether medical or behavioral, may differ depending on when in the course of the illness the intervention is suggested. Fragmentation of care is a risk for patients with chronic diseases, because frequently multiple chronic diseases coexist. Physiatrists, because of their broad scope of practice, are ideally positioned to assume the role of gatekeeper in the overall medical management of patients with chronic illness and disability.

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PREVENTIVE SCREENING

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Preventive screenings are an important part of health promotion efforts. Many preventive screenings have been recognized as a cost-effective way to identify and treat potential health problems before they develop or worsen. However, it can be challenging to keep up with the latest scientific thinking regarding screenings. Age- and gender-specific preventive screening recommendations exist for dozens of health concerns, but the recommendations may vary from organization to organization and are frequently changed as new information becomes available.

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Physicians must acknowledge their primary role in prevention as that of educators. Accurate information regarding risk factors is most likely to reinforce health-enhancing behavior and alter self-destructive behavior. The physician must appreciate the potential for behavior modification and familiarize himself or herself with local resources. Routine screening for specific diseases, the maintenance activity most closely identified with the physician, should be performed selectively. The limits of screening tests as well as their potential health benefits should be clearly understood by every physician, ...

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