Primum Non Nocere, Secundum Treat Patients Not Diseases
There is a battle raging behind the scenes over how to address the shortage of primary care physicians in the current climate of diminishing revenues, increased patient loads, and lack of universal health care coverage. Enticing recent graduates of U.S. medical schools to enter the field of primary care has become an exercise in futility, as the amount of student loan debt accrued by newly trained physicians warrants entrance into more lucrative fields of specialization, such as those which are procedure-oriented and provide substantial reimbursement for instrumental and invasive therapies. While primary care is, indeed, a rewarding arena of endeavor, the current number of board certified primary care practitioners is hardly sufficient to buttress even the “tip of the iceberg,” which is beginning to topple, as older physicians leave the field for retirement and other pursuits, and as the few remaining go home on a nightly basis worried to death that they’ve made mistakes or not completed their work. If that were not enough, the increasing amount of paperwork inherent in the profession, the growing number of therapeutic options and new drugs available, and the added responsibility of providing continuous preventive care to patients whose socioeconomic backgrounds often pose additional limitations to an already complex patient management scenario often render job satisfaction a non sequitur. And for those of you out there who say that, “It’s all about the Benjamins” (Franklins, that is, and money, in short), there is much more to this story than financial remuneration. It has been found, for example, that when payments to primary care physicians are increased, they work no harder, and, in fact, reduce the number of patients they see. So, perhaps there are things more influential than money as motivators to primary care physicians to do a better job, and to neophyte physicians to enter the field of primary care. They might be, namely, a sane life, more leisure time, and the value of a job well done. For those who have truly dedicated their lives to the study and practice of medicine, no price tag can be placed on the latter.
We know the problem. Where does it all fit in the public health arena, and what can we, the public, policymakers, legislators, medical school faculty, state medical boards, and the Department of Health and Human Services do to increase the allure of primary care medicine, or to “conscript” new physicians into the ranks, perhaps in exchange for student loan debt forgiveness or other inducements? What we already know is this, that the current U.S. health care system is chaotic and in utter disarray, and that unless we, both the public health and clinical professionals “in the trenches,” come up with suitable and workable solutions to the primary care shortfall, provision of first-line health care is destined to worsen.
Solutions have not been immediately forthcoming, and the call to arms has been hampered by the sheer enormity of the undertaking and statistics showing that, in many cases, patients are cut off and interrupted by their physicians due to time concerns after an average of only 23 seconds of explaining their problems, that 50 percent of patients leave office visits not understanding what the physician has told them, and that it would take 18 hours per typical workday for primary care physicians to provide all the preventive and chronic cares services needed by their patients. Recently, two solutions have come to the fore, and perhaps it would be wise to look at them closely. One idea proposed has been to reduce daily patient load for primary care physicians to 10 patients per day. That would allow them more time per patient, but would most likely aggravate the already acute shortage of primary care physicians. The second solution, which appears more sage, would be to adopt a team approach to primary care. As a medical degree is not needed to perform all the daily tasks of a primary care physician, the latter might be delegated to ancillary staff. Physicians would become team leaders, seeing fewer patients per day, consulting with team members, handling telephone and electronic encounters requiring a physician, and ordering medication changes. All other duties currently managed by primary care physicians would be transferred to “health coaches” on the team, and their tasks would run the gamut from contacting patients and explaining changes made by the physician to their treatment regimens to listening to patients’ concerns and following up on patient compliance to treatment plans.
The solutions mentioned here are in their experimental stages, and nothing is written in stone. However, without serious attention turned to the monumental problem of primary care, the numbers of those physicians will most likely continue to dwindle, with obvious repercussions on the concern for hurt (nocere) inflicted on patients and with the little physician involvement available for patient care directed at numbers and diseases, not at living, breathing human beings and the plethora of interactive elements composing their well being as a whole.
We know the problem. Where does it all fit in the public health arena, and what can we, the public, policymakers, legislators, medical school faculty, state medical boards, and the Department of Health and Human Services do to increase the allure of primary care medicine, or to “conscript” new physicians into the ranks, perhaps in exchange for student loan debt forgiveness or other inducements? What we already know is this, that the current U.S. health care system is chaotic and in utter disarray, and that unless we, both the public health and clinical professionals “in the trenches,” come up with suitable and workable solutions to the primary care shortfall, provision of first-line health care is destined to worsen.
Solutions have not been immediately forthcoming, and the call to arms has been hampered by the sheer enormity of the undertaking and statistics showing that, in many cases, patients are cut off and interrupted by their physicians due to time concerns after an average of only 23 seconds of explaining their problems, that 50 percent of patients leave office visits not understanding what the physician has told them, and that it would take 18 hours per typical workday for primary care physicians to provide all the preventive and chronic cares services needed by their patients. Recently, two solutions have come to the fore, and perhaps it would be wise to look at them closely. One idea proposed has been to reduce daily patient load for primary care physicians to 10 patients per day. That would allow them more time per patient, but would most likely aggravate the already acute shortage of primary care physicians. The second solution, which appears more sage, would be to adopt a team approach to primary care. As a medical degree is not needed to perform all the daily tasks of a primary care physician, the latter might be delegated to ancillary staff. Physicians would become team leaders, seeing fewer patients per day, consulting with team members, handling telephone and electronic encounters requiring a physician, and ordering medication changes. All other duties currently managed by primary care physicians would be transferred to “health coaches” on the team, and their tasks would run the gamut from contacting patients and explaining changes made by the physician to their treatment regimens to listening to patients’ concerns and following up on patient compliance to treatment plans.
The solutions mentioned here are in their experimental stages, and nothing is written in stone. However, without serious attention turned to the monumental problem of primary care, the numbers of those physicians will most likely continue to dwindle, with obvious repercussions on the concern for hurt (nocere) inflicted on patients and with the little physician involvement available for patient care directed at numbers and diseases, not at living, breathing human beings and the plethora of interactive elements composing their well being as a whole.
© 2009, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
3/13/2009 10:21:00 PM
0 Comments:
Post a Comment
<< Home