Clark Israel Journal of Health Policy Research (2015) 4:58

DOI 10.1186/s13584-015-0054-3 Israel Journal of

Health Policy Research

COMMENTARY Open Access

Role of primary care providers in a

pandemic – conflicting views and future
opportunities
Sarah J. Clark

Abstract
In pandemic situations, primary care providers may be involved in a variety of roles related to disease surveillance,
diagnosis and treatment, prevention, and patient education. This commentary describes the contextual factors that
may influence primary care providers’ perspectives on their pandemic roles and responsibilities. These factors
include the natural evolution of the pandemic situation, with early uncertainty affecting decision-making and
communication; the variation in typical practice patterns and clinical expertise across and within primary care
providers; and the lack of representation of practicing primary care providers in pandemic planning and
decision-making bodies.
Keywords: Primary care, Pandemic influenza, Public health

Background in process, based on the best available evidence about

In an innovative paper from the viewpoint of providers, disease severity, availability and effectiveness of thera-
Kunin and colleagues [1] offer a unique international peutic and preventive measures, and capacity for care
perspective on the challenges—and contradictions–of delivery. Policies frequently change, as new information
addressing public health and emergency preparedness emerges. In later stages of a pandemic, when the severity
goals in the primary care setting. The findings of these and disease patterns of the pandemic are better known,
interviews with primary care providers in three countries public health policies become more stable. However,
illustrate several common factors that affected primary many primary care providers have limited experience
care providers in these three countries, and likely in with this natural arc of a pandemic, and expressed frus-
many others; findings also point to unique challenges re- tration with what seemed to be constant policy changes
lated to specific policy choices made by these three and mismatches between public health policies and dis-
countries regarding the role of primary care in the pan- ease patterns and/or patient care preferences.
demic response. Another common factor is that the dynamics of com-
munication change over the arc of a pandemic [2]. The
Main text earliest stage is a time of intense interest among the
A common factor underlying the perspectives of primary public and the media, as well as a critical juncture for
care providers in these three countries is the inherent informing health care professionals about public health
mismatch between the uncertainty of a pandemic situ- policies and recommendation. From the public health
ation and the desire for clear and consistent roles and perspective communication must be frequent and dissem-
responsibilities for providers. The dynamics of public inated through numerous channels, to ensure that all
health response change over the arc of a pandemic [2], stakeholders have an opportunity to receive the most up-
though this is not always recognized at the provider to-date information. In later stages, as policies become
level. In the earliest stage, public health policy-making is more stable and the media attention wanes, com-
munication can be less frequent. However, many primary
Correspondence: saclark@umich.edu care providers in this study expressed frustration with
Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, too-frequent and seemingly redundant communication
300 N Ingalls, Rm 6E06, Ann Arbor, MI 48109-5456, USA

© 2015 Clark. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative
Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Clark Israel Journal of Health Policy Research (2015) 4:58 Page 2 of 3

of the early stage. Unlike hospital-based providers who This article focuses on the pre-vaccination period, and
tend to have a well-articulated chain-of-command proto- thus did not address the role of primary care providers
col for emergency situations, primary care providers in in administering vaccinations during the 2009 pandemic.
many countries are more diffuse organizationally, It is unclear whether the views of primary care providers
geographically, and with regard to emergency contact in these three countries views regarding vaccination re-
methods; as a result, public health officials may not be sponsibilities would have been more consistent. Regard-
able to identify a single pathway for efficient communica- less, vaccination represents a key topic of engagement
tion with all primary care providers. Moreover, many pri- and collaboration for primary care providers, public
mary care practices have not designated a formal plan or health officials, and emergency preparedness officials at
process for monitoring public health communications and the national, regional and local levels. Pandemic plan-
updating staff as needed. If responsibility for monitoring ning that incorporates a detailed scheme for identifying
communication is not designated to certain staff, there is vaccination sites, delineating vaccine delivery protocols,
likely to be duplicated effort; if there is uncertainty over and outlining emergency communication processes will
which communication channels will provide accurate and stimulate conversation about what is feasible in the pri-
up-to-date information, there is likely to be unnecessary mary care setting, and how public health and emergency
time spent sorting through communications from a broad preparedness officials can adequately and efficiently in-
set of organizations. As a result, it is not unexpected that form and support their primary care partners. In turn,
primary care providers would feel overwhelmed with the primary care providers will gain a clearer understanding
pace and amount of communication at the early stage of a of what to expect in a pandemic situation, and will have
pandemic. developed relationships with key partners, facilitating a
Importantly, while the article presents many provider mechanism for feedback as the arc of the pandemic
criticisms of pandemic policies, it is clear that there was unfolds.
a variable response of primary care providers to pan- Finally, this study calls into question the adequacy
demic policies, and no singular view of an appropriate with which primary care is represented in public health/
primary care role in a pandemic situation. This variation emergency preparedness planning and decision-making
is likely due to differences in practice patterns and clin- efforts, both prior to and during a pandemic situation.
ical experience of primary care providers across and Some of the pandemic recommendations (e.g., required
within the three countries. For example, primary care use of personal protective equipment, patient segrega-
providers offered conflicting views on policies requiring tion) were perceived by providers as an ill fit with typical
them to use a centralized clinical or public health au- primary care practice, including the structure and func-
thority for tasks typically performed in the primary care tion of the outpatient office setting. There is a critical
setting. While some providers disparaged their country’s need for decision-making entities to include representa-
requirement to get approval for antiviral medications, tion of, or consultation with, practicing primary care
arguing that primary care providers are competent to providers who can speak to the feasibility of implement-
perform this function independently, others expressed ing proposed policies into day-to-day clinical practice.
uncertainty about their lack of familiarity with antiviral This need goes beyond having representatives of phys-
medications, implying a benefit to centralizing this func- ician specialty organizations; rather, there should be a
tion at a higher level. Similarly, several primary care pro- mechanism to solicit input from providers currently
viders disapproved of the protocol to have patients call a practicing in primary care (not hospital-based) settings.
centralized telephone triage line for pandemic influenza- Documenting the composition of decision-making bod-
related questions, but concurrently lamented their lack ies, and exploring the link with primary care-appropriate
of time in clinic for the increased number of pandemic- policies, is an important area for future research.
related patient visits, often from patients seeking infor-
mation or reassurance. Given primary care providers’ Conclusion
constraints of time and/or clinical expertise, it is not Primary care providers’ perspectives on, and satisfaction
unreasonable for countries to implement policies that with, their pandemic roles and responsibilities are likely
consolidate certain pandemic-related clinical activities to reflect both the context of decision-making and com-
under the direction of a smaller number of trained clin- munication during a pandemic situation, as well as the
ical providers or public health officials. However, even extent to which the designated primary care roles and
when such policies are justified in order to facilitate responsibilities are feasible in the primary care setting.
consistency in implementation of clinical protocols, it is Involving practicing primary care providers in pandemic
clear that some primary care providers will disagree with planning may help to articulate responsibilities that
this disruption to clinical care, or to the perceived threat are feasible and acceptable to primary care providers
to their autonomy. and their public health partners. Central government
Clark Israel Journal of Health Policy Research (2015) 4:58 Page 3 of 3

purchase of personal protective equipment, vaccine

supplies, and other materials necessary for primary
care providers to carry out their assigned responsibilities
is necessary to eliminate financial barriers to their partici-
pation in the pandemic response. Establishing and com-
municating the availability of dedicated information and
communication channels for primary care providers will
help to mitigate clinical uncertainty and inexperience
and to ensure a more consistent response across pri-
mary care sites.
Competing interests
I have no competing interests related to this manuscript.

Authors’ contributions
Sarah Clark wrote this commentary.

Authors’ information
Sarah Clark is a public health researcher with the Child Health Evaluation and
Research (CHEAR) Unit at the University of Michigan. During the 2009 H1N1
pandemic, she conducted a situational awareness study of state vaccination
policies and processes across the United States.

Commentary on
Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. Challenges of the
Pandemic Response in Primary Care during the Pre-Vaccination Period.Israel
Journal of Health Policy Research. 2015;4:32.

Acknowledgements
None.

Received: 21 October 2015 Accepted: 10 November 2015

References
1. Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. Challenges of
the Pandemic Response in Primary Care during the Pre-Vaccination Period.
Israel Journal of Health Policy Research. 2015;4:32.
2. Reynolds B, Deitch S, Schieber R. Crisis and emergency risk communication:
Pandemic Influenza. Atlanta, GA: Centers for Disease Control and
Prevention. Revised, October 2007. Available at: http://www.bt.cdc.gov/cerc/
resources/pdf/cerc-pandemicflu-oct07.pdf

Submit your next manuscript to BioMed Central

and take full advantage of:

• Convenient online submission

• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution

Submit your manuscript at

www.biomedcentral.com/submit