Primary Care Settings Posted on January 20, 2009 Dr. William A. Vega delivers sage advice about conducting research in primary care.

Primary care is an interesting phenomenon for a whole variety of reasons that, I won't go into them all, but it's an area that is the primary point where you merge, I think, public health with medical care. Because primary care people, doctors, are concerned with prevention as a first line of defense.

They're the people that most commonly are seen and represent prevention and maintenance of health to the general public because most people just don't put a face on public health per se. They tend to see it in the form of a physician who gives them an inoculation for whatever it is, the flu, or takes their blood, their blood pressure or checks their blood for glucose or whatever.

But they know that this is the place they go for sustainment of their health and also where their children are going to be taken care of, so the custom develops of going to that doctor. Now that means that it's obviously a site that is also going to be a place where most mental health problems are going to be presented for the first time, if they're recognized. So the issue of developing the skills and mental health and all that is really a challenge.

And especially in the context of primary care is a site where you only have eight to fifteen minutes, most of the time, to make a decision on what you're treating, especially in safety net providers, where the poorer go. Low-income people primarily are treated by safety net providers, especially Latinos.

So it's a tremendous challenge, and that means that for people who want to do research in these areas, it's not an endless opportunity from the standpoint of you can just develop all kinds of innovations that these people can now absorb into their practice because they have such a very tight, guideline-based regimen. And all the paperwork associated with billing and tracking those patients over time: there's a lot of work that goes into it that is not direct patient communication to sustain one patient contact and one patient as your own patient over time.

So to get into that world and to find a way in is, a lot of that is what you have to learn in doing work with any form of medical care because they all have their unique idiosyncrasies and the constraints to go along with the context of care. So I think it's something that has tremendous promise from the standpoint that we're trying to introduce more and more awareness in physicians and more opportunities for physicians to treat both mental health problems and substance abuse problems now that we have biological or chemical agents for both. They have compounds for both.

But the difficulty is that they have to take the extra step. You have to induce the physician, given their constraints and given where their incentives are and disincentives, to add on this extra burden and streamline it in such as way that it causes them minimum difficulty to make the transition into whatever technology you're trying to teach them and where it takes minimal time away from their actual contact time with a patient.

So therein lies the great challenge. And it has proven very difficult to do it. I mean, you can demonstrate that you can do it and that you can actually train primary care physicians to do these things effectively, but adopting those new techniques and strategies and putting them into a seamless clinical program really requires thinking.

And we are getting quite a bit out of, for example, using now depression, a depression list of symptoms like the PHQ, for example, which is a common one where the patient themselves fills it out before they come in to see the physician, so it doesn't take any physician time.

And then that is put into the physician's folder for that patient, and they can just look at it quickly and see if there is anything to worry about and some extra questions to ask about mood or any other problems associated with substance abuse for example. And I think those are tiny little steps. So there's a lot of steps involved in the process of carrying this forward beyond just discovery of the information of what probably needs to be done because most of these things are refined through iterations of work in stages.

And it takes years to do it. And the average medical innovation takes 17 years to get into practice, even after it's demonstrated empirically. So it's not a simple thing at all. It takes continuous work.