Should your primary care physician be a generalist or specialist?

Your primary care provider (PCP) is usually your first medical contact when you're ill. Beyond taking care of you when you're sick, PCPs help coordinate your health care and make sure you're up-to-date with your check-ups, tests, and immunizations.

Typically, PCPs are family medicine practitioners, general internists, pediatricians (for children) and geriatricians (for older adults). Some health plans, such as health maintenance organizations (HMOs), require you to choose a PCP whom you must see first before being referred to specialists when necessary. These PCPs play a special role in coordinating your care.

However, other plans -- including traditional Medicare and most preferred provider organizations (or PPOs), don't require you to see a PCP before seeking more specialized care. As a result, many people may see a specialist as their main doctor rather than a PCP who would act as "gatekeeper."

Recently, researchers studied which option provided the best outcomes for older adults: Seeing a PCP or seeing a specialist for most of a person's outpatient care (care you receive outside a hospital). The research team published their findings in the Journal of the American Geriatrics Society.

The researchers studied data from nearly 4 million Medicare beneficiaries over the age of 65 who had at least two or more chronic conditions. The researchers compared the number of hospitalizations the participants experienced, as well deaths and total medical costs for the people who saw PCPs versus the people who saw specialists without a PCP "gatekeeper."

According to study findings:

• More than 30 percent of older adults with multiple chronic conditions used a specialist as their main doctor. These people had less continuity of care -- the term for making sure your healthcare professionals are coordinating your ongoing health management--and made more outpatient visits to more healthcare providers.
• All hospitalizations and costs were higher among the group who mostly saw specialists.
• People who saw PCPs saw fewer doctors and also had fewer hospitalizations and lower costs.

The researchers concluded that that the health outcomes of older adults who use PCPs, compared with the outcomes of those whose main doctors were specialists, are about the same. However, the costs of seeing specialists rather than PCPs tend to be higher, due to more testing and hospitalizations. This certainly doesn't mean that specialist care isn't important for many people in many different situations; it simply means that working with a PCP as your first or main healthcare contact may contribute to higher quality, more person-centered care.

"Make sure you know which of your doctors is in the quarterback role, helping to coordinate your care. One way to do that is to ask him or her, 'Are you the person I should have all my other doctors send my records to?'" advises study co-author Julie P.W. Bynum, MD, MPH, Associate Professor, Geisel School of Medicine at Dartmouth; Associate Professor, Medicine and Community & Family Medicine; and Associate Professor of The Dartmouth Institute for Health Policy & Clinical Practice (TDI).