Why primary care physicians should be the quarterbacks in patient care

“There are, in truth, no specialties in medicine, since to know fully many of the most important diseases, one must be familiar with their manifestation in many organs.”
– Sir William Osler, MD.

I agree with this statement to an extent. However, I wholeheartedly respect and admire many subspecialists whom we all rely on. Disease does not usually wave a red flag and manifest extravagantly in one organ system. It usually is very subtle and entangles its way throughout the body, especially if discovered early.

Therefore, I have concluded that no one physician can be the master of all. It takes numerous brains, thought processes, and puzzle makers to carefully set the chessboard properly. I do, however, think that every complexity in medicine requires someone to step back and evaluate the entirety, not in a judgmental way, but in a collective way. Someone needs to quarterback. When Joe Burrow was leading LSU, I began using the quarterback position analogy as a way to describe the purpose of an internist. If nothing else, it gave a sense of commonality between physician and patient and a chuckle or a smile.

In all seriousness, someone needs to be the “Joe” or the “BURREAUX” as the Tigers would say. Someone needs to step back, with the picture in mind of the MD in serious thought, perhaps rubbing their chin, and put the pieces together, deciding on the next appropriate play.

When I first stepped out of residency and into the “real world” of medicine, I was aghast at what I walked into. In my head, I foresaw a practice of true complexity as I did in residency. However, much to my dismay, I walked into a setting where there was improper delineation of the body, on both the patient and physician side. Nearly every patient above the age of 50 had a subspecialist for everything! I could not believe it. If a stomach hurt, GI was involved. If one of the 200 plus muscles ached, ortho was necessary. You get the idea, etc.

Obviously, subspecialists are needed, but I am sure every chest pain that ends up being reflux does not need an interventional cardiologist involved. We have to spare subspecialists for when they are truly needed given their scarcity.

This made me unpopular in the beginning. This was also when I stepped into “fast food” type medicine. The expectation was for me to say, “Next customer, I’ll take your order.”

It took several years to build up what I would consider a true internal medicine practice – utilizing subspecialists appropriately and utilizing internal medicine training and complexity appropriately. In other words, not every cough needs to see a pulmonologist.

The point boils down to letting your internist or primary care provider be your quarterback or “Burreaux.” Someone knowledgeable and competent, confident in their skills, but not so cocky as to know when the appropriate time is to bend the subspecialist’s ear.

Brandi Fontenot is an internal medicine physician.


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