By Kirsten Meisinger, M.D.
In honor of National Primary Care Week, I was asked to respond to the question “Why is primary care the future of health care?” I assert that the future of health care is health, and primary care is the present and future of everyone’s health.
Why such a bold assertion?
The countries with the best health outcomes have shown that access to primary care is the common denominator for excellence. People become and stay healthy when they have just the right amount of health care, when and where they need it, and for little to no cost. Outcomes from countries who have been able to provide this kind of primary care to their citizens are a powerful indication that whole person care, in the context of their family and community, is the path to health that health care systems will be obliged to follow in order to succeed.
The WHO defines health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.” Primary care is the only specialty responsible for the complete health of the patient for the length of his or her life and across the breadth of his or her existence.
Achieving complete physical, mental and social well being is best approached by viewing the patient in the context of their family and their community and moving past the four walls of the exam room and beyond the patient-doctor interaction. Keeping people in a state of health is a nearly impossible task for a single provider. It requires longitudinal partnerships with primary care teams.
These teams pluck expertise from each member to assemble a set of services that engage, challenge and push patients to embrace health and not just react to disease.
Some primary care providers across the allied health professions have already adopted this model; others are poised to do so in the near future. Meanwhile, we are beginning to see some payers and some state governments shift their focus away from the fee-for-service payment model and toward overall patient outcomes and the care it takes to get the patient there. In this way, the focus will naturally move from disease to health. And primary care, when done well, maintains health best.
In our teams, built to take small steps over time through longitudinal relationships, we watch and wait as a patient whose chronic pain once threatened his ability to walk now smiles and jumps in exercise class. We lead patients to a place where they control their bodies, not their numbers, and discover on their own that a simple daily walk will lift their spirits and bring their numbers back in line. Like the river that made the Grand Canyon, these small steps change the landscape of patients’ health over time. Primary care leads them there. Primary care is the future of health, so it has to be the future of health care.
Kirsten Meisinger, M.D., is medical director at Union Square Family Health Center, a community health center within the Cambridge Health Alliance, where she has practiced since 1999. Dr. Meisinger earned her medical degree from Case Western Reserve University and completed a family medicine residency at the Greater Lawrence Family Health Center. She speaks fluent Portuguese, Spanish and French.
Read MORE from Progress Notes here.]]>
The first pictures came in at a fairly languid pace. They were mainly the PCP National Team, our friends, our family, our cats, even the locals in our neighborhood in Inman Square in Cambridge (see the pickleman photo in the slideshow below).
Then one morning, after refreshing the Voices gallery for what seemed like the 100th time that hour, Cat Rizos, our Community and Content Manager, yelled from her cubicle, “We got one- and it’s not from PCP staff!” (note: this might not be entirely accurate as Cat rarely raises her voice, but I’m sure she’ll forgive me for the sake of storytelling). The submission was from Heather Bennett, a PCP chapter member at University of California, San Francisco(UCSF), and two of her fellow interns and residents. Their message was “Primary Care…Only for the Best and the Brightest- Like You.” Though we consider UCSF part of the PCP family, this was the first submission we didn’t actually have to plead for. It came on its own. Honestly, even if we ended the campaign there, we would have been happy. Here were three people, passionate about pursuing a career in primary care – and they liked the idea of the campaign. They liked it enough to be among the first folks to “raise their voices” in support of primary care.
From that point on, we knew Voices would be okay. Over the next few weeks, our little gallery of “Voices” grew and grew. The messages were written on stickies, posterboard, banners, ipad screens, the “official” signboard, and even in a word cloud. Some messages were only a few words. Others were elaborate and complex. Some were fun. Many were caring. A bunch were witty. So many were insightful. Quite a few people thought primary care is the future. Many said it should be a priority. One very popular theme emerged: primary care rocks!
Nearly 900 voices later, we couldn’t feel more proud of the primary care community and the outpouring of enthusiasm and camaraderie from everyone- patients & clinicians alike- who values primary care. Whenever we got a submission from someone who took his or her own photo (evidenced by a missing limb in the pic), we were particularly touched. This person cares so deeply about primary care, they pulled this off without help.
But the submissions that resonated most with us at PCP were the team pics. These Voices got to the very core of National Primary Care Week and the future of primary care. Working together in teams is more important than ever; it is the future of primary care. We saw pictures of teams working together in primary care clinics, oral health clinics, community health centers, schools, government offices, nonprofits, and professional associations. Over two dozen groups took part in the campaign- making a powerful statement about how invested the primary care community is in spreading the word about the value of primary care. This was a moment for the full primary care team, in all it’s diversity and power, to come together, whether we’re doctors or nurses, family medicine or internal medicine, student or seasoned clinician…we came together as one.
Truth be told, it’s more than the messages, or voices. The Voices gallery shows us the faces of nearly 1000 people who support primary care. This is our community. They are diverse in age, race, geography, and field. We talk about community a lot here at PCP. And now we have a strong visual of who makes up our community- of their talent, potential, passion and drive.
It made us think. Why stop with pictures? There are two journalists and one public health specialist on PCP’s media team. We use a lot of multimedia to tell the story of primary care. We use our blog. We use videos. We use our forums. We use social media and our website. We’ve decided we want to take “Voices” even deeper. We want to go behind the messages, to tell the stories of the primary care supporters who felt proud enough of their relationship to primary care to participate in the campaign. Over the next few months, we’ll be gathering stories and creating a living gallery of primary care stories. Through interviews, blogs, videos, photo essays, and audio clips, we’ll be depicting the stories of the value of primary care. We hope you’ll let us know if you’d like to go deeper with your story, or if you know others whose stories should be shared. The story of primary care is being written by all of you. We want to make sure we help capture it, and help spread the word about the value and power of primary care.
Thank you everyone who lent their voice to primary care during this campaign.
Director of Media, PCP
Special thanks to the following Twitter superstars for helping us give a voice to primary care throughout the campaign:
Kim Yu, MD, @drkkyu
PAFP and Foundation, @PAFPandF
Jay W Lee MD MPH, @familydocwonk
Kansas AFP, @KansasAFP
Kevin Bernstein, MD, @BernieMD31
Mike Sevilla, MD, @drmikesevilla
This week medical schools including University of Utah and Tulane observe Primary Care Week, so we asked members of our community to reflect on this year’s theme, “primary care: the future of health care.” We’ll be posting their responses here throughout the month of October.
By John Geyman, M.D.
As is common knowledge, the U.S. health care system is beset by increasing problems of inadequate access, soaring costs that leave many millions of Americans without essential care, and variable and often-mediocre quality of care. Perverse financial incentives in a largely for-profit system drive provision of services by physicians, hospitals and other stakeholders in our market-based system that are inappropriate or unnecessary in almost one-third of instances. Among all of the advanced countries around the world, we have by far the most expensive health care, the least access and reliability, and the most inequity and disparities.
Added to these problems is the crisis in primary care itself. Specialization and subspecialization over the last five decades have reduced the primary care workforce in this country to a shadow of its former self. Rebuilding primary care as the foundation of our health care system is a key part of addressing our basic systemic problems. We have several decades of experience and numerous health policy studies that show us the following:
The more primary care physicians in an area, the better the access, coordination and outcomes of care.
The higher the ratio between primary care physicians and specialists, the lower the costs, number of hospital days and number of physicians seen by patients over a year.
Our multi-payer financing system, with 1,300 private insurers competing to cover the 80 percent of the population that uses the least health care is more profit-oriented than service-oriented; “denial management” and limiting their “medical-loss ratio,” not service, are the modus operandi.
Since fee-for-service reimbursement rewards procedures and highly specialized services over more time-consuming cognitive services typical of primary care, a large majority of each year’s graduates of U.S. medical schools opt for training and careers in non-primary care specialties. As a result, the nation faces a critical shortage of primary care physicians.
The politics of so-called “health care reform” have so far avoided the most fundamental questions concerning the future of health care, such as—should health care be a right or a privilege; should we have a system based on medical need vs. ability to pay; should our system be oriented to service (as has been the tradition among the health professions for many years) vs. profits on the supply side; and is health care just another commodity for sale on an open, deregulated market?
Primary care can, and should be, a main part of our approach to health care reform for this and future generations of Americans. But any incremental steps in that direction, including by the Affordable Care Act, will not get us there. Unless we rebuild primary care as the foundation of our system, we can expect increasing fragmentation and depersonalization of care with less access, coordination, and worse outcomes in an even more dysfunctional system than we have today.
We should strive for a generalist, primary care workforce that approaches a 50:50 balance between primary care and the other specialties. This will require us to address the basic questions raised above and to take a multi-faceted approach to reform that includes redesign of primary care practice, with increased emphasis on team care; changing how physicians are paid, with emphasis on salaried group practice; adopting single-payer national health insurance as the only way we will ever achieve universal access; and emphasizing evidence of efficacy and cost-effectiveness in coverage and reimbursement policies. Such an approach will probably require a couple of generations to achieve our goal of the best possible health care that we can afford for all Americans, so we should start now!
John Geyman, M.D., is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, where he served as Chairman of the Department of Family Medicine from 1976 to 1990. He was the founding editor of The Journal of Family Practice (1973 to 1990) and the editor of The Journal of the American Board of Family Practice (1990 to 2003). He has authored nine books on the health care industry including the 2011 Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans.]]>
Director, PCMH Initiative
Pennsylvania Academy of Family Physicians and Foundation
Ohio State Office of Rural Health
Bureau of Community Health Services and Patient-Centered Primary Care
Courtesy of Dr. Kim Yu
Michigan Academy of Family Physicians
Dr. Cherelle Smith
University of North Carolina
Dr. Asaf Bitton
Harvard Medical School
Department of Health Policy]]>
Special thanks go to Dr. Mike Sevilla, practicing Family Medicine physician in northeastern Ohio, social media guru and the man behind Family Medicine Rocks, who has been tirelessly promoting Voices for Primary Care, and who recently highlighted the campaign in a recent blog post and podcast. Dr. Sevilla shared his thoughts after meeting with Dr. Andrew Morris-Singer, President and Co-Founder of Primary Care Progress, who was speaking at Northeastern Ohio Medical University (NEOMED) in celebration of National Primary Care Week.
Dr. Sevilla also spoke of the great potential for collaboration among all primary care advocates, writing “…there is common ground that can be found among Family Medicine, General Internal Medicine, Pediatrics, and other primary care groups. We must stop working in our separate advocacy silos and come together with one Primary Care message.” We could not agree more with Dr. Sevilla; we can accomplish great things by working together and uniting our voices for primary care!
Dr. Mike Sevilla and Dr. Andrew Morris-Singer. (Photo courtesy of Family Medicine Rocks)
By Matthew Mintz, M.D.
While the question “What is the future of primary care?” is more difficult to answer, whether primary care is the future of health care is crystal clear. Our health care system and the health of our country cannot survive without primary care. Here are three reasons, in my opinion, primary care is the future of health care.
First, primary care is high-value care. Health care spending is out of control at about 18% of the GDP. We are essentially at the tipping point of health care spending in that if the percent of GDP spent on health care grows any higher, we are going to have make substantial cuts to spending in other places that are deemed essential to the functioning of our country such as social security, education and defense. It would be as if your electricity bill started to match your monthly mortgage. If that happened, you couldn’t live in that house much longer. Yet despite spending so much on health care, we are not getting a great value. A large segment of our country is currently uninsured or under-insured, and health indicators, such as mortality, access and safety, used to compare health across countries show that other countries outperform the US. So our current spending is crushing our economy without giving us a good return on our investment. Thus, the future of health care is going to have to be about value. And there is no better health care dollar value than that of primary care. Many studies demonstrate that strong primary care is associated with lower costs and improved quality. Countries that have a more robust primary care infrastructurehave healthier citizens at a lower cost.
Primary care is also critical to reducing waste. The Institute of Medicine just released a report that shows $750 billion in health care waste. This is more than what we spend on defense! There are many sources of waste – $210 billion on overuse and unnecessary care; $130 billion in inefficiency, including mistakes and harm; and $190 billion in excess administrative costs.
The reasons behind all this waste are complicated, and there is no “magic bullet.” Yet one likely factor is that there are “too many cooks in the kitchen.” Medicine has gotten incredibly complex, and sub-specialization is rampant. Instead of just going, for example, to a cardiologist, patients need to go to an interventional cardiologist or an electrophysiology cardiologist.
A 2007 study in the New England Journal looking at practice patterns about a decade ago noted that in the course of two years, Medicare patients saw a median of two primary care physicians and five specialists working in four different practices. My guess is that care today is even more disparate. In addition, as more care is being delivered in the outpatient setting, there is an increase in other health care providers, such as home care, rehabilitation, and physical therapy, involved in a single patient’s care. The more health care professionals that care for an individual patient, the more likely errors in communication and administration and duplication of care occur. It is not that we don’t need so many players on the team. We actually do as advances in health care have made things more complex. However, we need better coordination in care to prevent potential waste and errors. Primary care is perfectly positioned to do this, which is why it is the future of heath care.
Finally, increasing technology and access to information require navigation and experience. We live in a DIY world. Cable TV shows about remodeling your own house or preparing a gourmet meal are numerous. I have personally used YouTube to help me cook a Thanksgiving turkey and fix a toilet. Legal web sites allow you to create your own will or incorporate your own business.
But patients are not translating all the health information on the web into DIY health care. Even though the latest study published in major medical journals is on the web and in a sound bite on the morning news well before I have even had a chance to read it, patients who have access to this information still want their personal physician’s interpretation because, in most cases, the more information we have, the more complicated decisions become.
Prostate cancer screening, for example, has been in the news lately. More evidence suggests that screening for prostate cancer may not only be unnecessary but also potentially harmful. The current US government guidelines now recommend against this practice. Though most of this data is publicly accessible, how to interpret the data and apply it to an individual patient requires expertise and experience.
DIY projects gone wrong might lead to a burnt dinner or having to call the plumber after all. However, DIY health, in many cases, is a life and death decision that most people don’t want to make on their own. Health care in the future promises not only more innovations in diagnostics and therapies, but also more difficulty in how to apply these tests and treatments to individual patients. Advances in technology, even with unprecedented access to this information, require a skilled navigator and interpreter. Because of their breadth of knowledge, holistic approach and familiarity with patients they have known for some time, no health care professional is better suited for this role than the primary care physician.
Dr. Mintz is an Associate Professor of Medicine in the Department of Medicine at the George Washington University Medical Center in Washington, DC, where he directed the Primary Care Clerkship for 10 years and currently serves as Director of the Practice of Medicine Course, Years I-III as well as the director of GW’s Premier Access and Executive Services. Dr. Mintz blogs at www.drmintz.com and can be followed on Twitter @drmintz.
Read More Progress Notes Here.]]>
By Kevin Bernstein, M.D., M.M.S.
The future of our country’s health care delivery depends on a foundation in primary care, but a number of barriers continually threaten this foundation.
(Caution: Elephants in the room will be attacked head on. That means you, Payment Reform and Medical School Bureaucracy.)
Since the beginning of the fee-for-service era and the founding of the American Medical Association’s Relative Value Scale Update Committee (RUC) in 1991, the gap between specialty and primary care salaries has steadily widened. Dominated by specialists, the RUC calculates reimbursement for cognitive and procedural services and makes recommendations to the Center for Medicare and Medicaid Services, which has accepted over 90% of these recommendations over time. As the gap has widened, the number of medical students and residents choosing primary care has decreased to the point that our nation is scrambling to rebuild its primary care workforce.
Many people say medical school debt is the main driver in the choice of specialty, so they push to enhance student loan forgiveness programs for those who choose careers in primary care. But would debt be a factor at all if the gap between primary care and specialty salaries closed? The debt argument is nothing more than a distraction from the real driver of specialty choice: reimbursement.
We must quit investing money in procedures and interventions that don’t decrease morbidity or mortality. We’re paying more to keep people sick and less to keep them healthy. In turn, we attract more medical students to areas that keep people sicker longer than to careers in primary care where we can make the biggest impact on people’s lives with the lowest cost to our health care system.
We need to shift our investments to efforts to prevent diseases from occurring in the first place, such as cognitive evaluation and patient management. By doing so, we will attract the best and brightest medical and other health professionals students to careers in patient-centered medical homes. Our patients deserve nothing less than the best to provide ongoing, life-long, multidisciplinary care.
In addition to reimbursement reform, we must also reform the way medical schools are “ranked” and funded.
Most NIH-funded research at academic institutes takes place in tertiary care centers, so these centers benefit from the funding though less than 1% of our population actually receives care there. Research funding needs to be shifted towards community health centers and ambulatory clinics to best represent the needs of the 99% of us who never make it to the ivory tower, academic tertiary care centers; the 99% who would be better served by research that actually addresses the problems that we face.
Without NIH recognition of the value of these settings, there is no incentive for schools to produce the primary care workforce our country needs.
And what’s more, medical schools have ways of looking like they are growing the primary care workforce. But don’t be fooled by “The Dean’s Lie,” in which medical schools count all students choosing internal medicine, family medicine, and pediatrics among those going into primary care without accounting for the 80-90% of them that will eventually specialize and never practice primary care. In any other profession, this would be considered fraud. How can we let them get away with this misrepresentation of how they contribute to our primary care workforce?
Should NIH funding be granted in proportion to primary care workforce production?
Medical schools argue that their main job is to educate and train future physicians and that the choices of students are out of their hands. Yet medical students are exposed to schools’ biases toward sub-specialty from the first day of their medical education. How many family physicians teach core competencies, including anatomy and pathology, during the first two years of medical school? Does the school even have a family medicine department (Caution: Harvard, Hopkins, considered leaders in primary care)? Does the admissions committee involve primary care physicians in the selection of students? Do other departments tell medical students that they are “too smart” for primary care?
Our country’s future health must be based on competent, patient-centered, cost-effective, and easily accessible primary care. We must fix discrepancies in our payment system and our educational system to get there. Until then, the future of health care in our country will continue to be just that: “the future” rather than the present.
Kevin Bernstein, MD, MMS is a Family Medicine resident and advocate for all things primary care. He is the Resident Chairman of the 2012 AAFP National Conference of Family Medicine Residents and Medical Students, member of the AAFP Commission on Education and co-founder of the Future of Family Medicine Blog. He is a leading social media contributor for Family Medicine and Navy Medicine. Follow him on Twitter: @BernieMD31.
Read More Progress Notes here.]]>
By Andrew Morris-Singer, M.D.
It’s National Primary Care Week, an annual celebration when members of the primary care community come together across the country in events largely organized by trainees to celebrate, promote and advance primary care. So what makes this year different?
Put simply, the momentum for advancing primary care in the US has never been stronger. Those of us who believe that a robust foundation of primary care is essential to the health of individuals and society as a whole now face an unprecedented constellation of financial and political opportunities.
States such as Ohio, Oregon and Maryland are investing in their overall primary care infrastructure, and payers, such as Blue Cross Blue Shield, are boosting payments to primary care providers. They know that upfront investment will lead to improved overall health and lower costs in the long run. However, building upon this progress and turning our collective vision of a primary-care centered system into a reality will require us to do something that doesn’t always come naturally to health care professionals: work as a team, not only to deliver primary care but to advocate for it.
By “sharing the care” among a larger, more diverse group of health professionals with complementary skill sets, we provide comprehensive, front-line, patient-centered care that’s been shown to catch diseases earlier, better manage chronic conditions, and keep patients out of hospitals and away from crowded, costly emergency rooms. Payers, both public and private, are reasonably delighted by this new, patient-centered medical home model, that’s already being utilized by groups including Kaiser and Thedacare, who are increasingly investing in it to take advantage of its well-documented overall improvement in quality and costs.
Despite this model’s early promise and growing base of support, however, some challenges remain. Patient-centered medical homes only constitute small proportion of primary care practices across the country, and transforming a practice into this team-based model is no small feat. Additionally, most providers in the US still operate in markets that do not financially support this style of delivery. So building on early pilots’ success will require up-front investment from various payers. Then, teaching our colleagues how to transform their practices will depend on resources and support from various professional societies. Also critical for success will be increased engagement from patients, in their own care and in the redesign of practices to get them the care they want and need. Finally, all primary care disciplines will need to share and collaborate with one another as we’ve never done before – not only to quickly learn the most efficient and effective way to transform care delivery, but also to make the case to payers and patients alike for this new, team-based model.
But that’s not all. Experts unanimously agree that we don’t have the primary care workforce to populate team-based clinics. Our primary care pipeline has dried up after years of financial neglect, active discouragement of careers in primary care at medical schools, and misguided training strategies that have prioritized turning out highly sub-specialized practitioners at the expense of generalists. To stop this cycle, government funding of medical schools must incentivize updated primary care curricula and rebuilding the primary care workforce. Pushing for this kind of change will require advocates of primary care to mobilize. The power to do this exists only when all primary care disciplines, namely family medicine, internal medicine and pediatrics, and all primary care professional networks, including but not limited to nurses, physician assistants and physicians, work together, and focus on our common interests as opposed to defending what we perceive to be our respective turfs.
It’s no wonder that numerous calls for this type of interdisciplinary, inter-professional and cross-generational partnership to advance primary care have echoed through our community recently, including a push for creating a new umbrella primary care organization. Without such a unified front, we’ll never be able to take on the fee-determining, specialty-dominated Relative Value Committee, the “RUC,” nor advance family medicine at one of the nine “orphan” medical schools that have shamefully excluded it from their curricula, nor motivate allied health professional training schools to update their curricula to prepare future grads for patient-centered primary care. All of these initiatives will require us to leverage the power and influence that we only possess if we break down our silos and come together.
So this National Primary Care Week, let’s kick off a spirit of collaboration and partnership among all members of the primary care community, not only to celebrate and promote the profound value of primary care, but also to collaboratively advocate for the financial support, educational reforms and renewed workforce that our collective primary care team needs in order to give Americans the high value care they deserve.
Andrew Morris-Singer, M.D., is an internal medicine physician and president and co-founder of Primary Care Progress.
Read more Progress Notes here.]]>
By David Margolius, M.D.
National Primary Care Week is October 8-12. We’ve asked members of our community to reflect on this year’s theme: The Future of Health Care. Over the next few weeks, we’ll be posting their responses here.
Why is primary care the future of health care?
Well, let’s first imagine if it weren’t.
In a world where primary care isn’t the future of health care, the current trend of our shrinking primary care workforce would continue. Medical schools would be applauded for graduating 5% of students into primary care careers. Overworked primary care providers would continue retiring early or changing careers so they could finally spend time with their families or maybe feel good about having the time to make a difference in their patients’ lives…as cardiologists. Until one day, maybe just twenty years from now, nobody would have access to primary care.
Most of us young folks would just continue to get primary care the way we always have: through the Internet. Hits to WebMD, and to multiple competitive sites which would have emerged and begun charging monthly enrollment fees, would continue to skyrocket. And insurance companies would endorse these means of accessing primary care by offering discounts to members who enrolled in these sites.
Entrepreneurial owners of MRI machines and CT scanners would offer direct-access scheduling through medical advice websites for those who enter a programmed set of symptoms. Medications would be prescribed online through the same mechanism. Direct-to-consumer pharmaceutical advertising would no longer end with a plea to “ask your doctor today,” but instead urge consumers to “visit our website today if you have the following symptoms.”
In a world without referrals from primary care, specialists would have contracts with medical advice websites and hospitals in order to recruit patients. Patients unable to diagnose themselves online would report to the emergency room for “expedited work-ups.” Each hospitalization would be followed by an average of four separate follow-up appointments with specialists to ensure that no major organ system was missed. Every insured individual over the age of 65 would have been hospitalized at least once to obtain appropriate specialist follow-up.
On the bright side, in a world where health care spending accounts for half of all spending in the United States, job growth would be at an all-time high. Out of work teachers, construction workers, farmers, and engineers would all be hired as sales reps for competing medical advice websites, pharmaceutical companies, or expedited work-up hospitals. Without money for public education, medical corporations would happily fill the void with sales training programs that begin just after kindergarten, the last year of public education that would still exist. Those who can afford private education, roughly 0.1% of the population, would become society’s elite physician specialists and company CEOs.
Now imagine a health care system where we work together to promote better experience for the individual and improved health of the population. Imagine a system in which patients have a doctor that knows them, and knows the difference between symptoms induced by stress or by the onset of serious disease, and the doctor diagnoses and prescribes accordingly. In this system, the costs of unnecessary procedures, prescriptions and misdiagnoses are avoided, and diseases are prevented before they start, lowering health care costs over all. And this savings goes back into education, farming, construction, engineering, so that we don’t all live to serve the health care system. In that scenario, primary care is the future of health care.
David Margolius, M.D., is a resident at UCSF in the San Francisco General Hospital Primary Care Track. Between his third and fourth years at Brown Medical School, David spent a year working with community health center staff and physicians in San Francisco to improve their delivery of primary care. David is working with PCP as a member of the national Primary Care Innovation Collaborative team.]]>
National Primary Care Week is October 8-12. We’ve asked members of our community to reflect on this year’s theme: The Future of Health Care. Over the next few weeks, we’ll be posting their responses here.
In the ancient and oft-told story of the blind men and the elephant, several sightless men seek to learn the nature of the great beast, none of them familiar with it prior to the encounter. One, who feels the trunk, describes the elephant as powerful and snake-like. Another who examines one of the mighty legs, opines that the animal is like a great tree. Still another, having first touched a large floppy ear, speculates that this must be part of a wing, leading to the suggestion that pachyderms might be able to fly. In his own way, each was correct, but being deprived of sight and focusing only on that part he was able to examine, missed entirely the true form of the elephant.
My father, who for many decades practiced medicine in the small Georgia town where I live and practice primary care, once told me of an older gentleman who presented to the doctor’s office with an advanced carcinoma of the descending colon, a diagnosis that would eventually take his life. When asked why he had waited so long to come to the doctor, he replied rather indignantly that he’d been under a doctor’s care for a couple of years. Several doctors, in fact.
The patient had been in remarkably good health until he suffered a myocardial infarction that led to a series of cardiovascular complications. In the process, a thyroid disorder was discovered and he was referred to an endocrinologist. As all this was going on, he developed persistent back pain, and sought the care of an orthopedist. Scarcely a month went by that he did not have one or more scheduled appointments with one of his specialists. All of his doctors were quite competent physicians, and ministered well to the individual problems for which they were following him.
During the course of his treatment, he began to develop some vague abdominal complaints, and even noted a little blood in his stools. He said he told each of his physicians about his symptoms, but was dutifully advised that such problems were outside of their specialty. He was told to see his “regular doctor.” The problem was, he didn’t have one. The way he put it, “They didn’t seem all that concerned about it, and I figured I shouldn’t be either. And I was seeing too many doctors, anyway.” His heart, thyroid and back problems were well managed, but by the time he got around to seeing my father for his stomach complaints, the only option available was palliative treatment.
The range and depth of medical care available to the average American is among the best in the world. Many, perhaps most, patients have direct access to specialists and subspecialists. Their decision to seek a more specialized (and frequently narrower) level of care is oftentimes driven by their own perceived diagnoses. More than once over the years, I have seen patients seek orthopedic care for the back pain of a dissecting aortic aneurysm. The care rendered was excellent, but resulted in unneeded costs and unnecessary delays.
As we move forward into the twenty-first century, medical care delivery remains one of the larger problems faced by our ever more complex society. With limited resources, and—in many areas—a shortage of physicians, we must seek ways to promote efficiency while not degrading the level of care rendered the patient. I believe one major trend that will persist and grow is the concept of the “medical home,” the idea that each patient be linked to a personal primary care physician who assumes responsibility for the overall short- and long-term direction of that individual’s health care. The advantages of such an arrangement are multiple.