Monday, May 31, 2010

Outsiders' perspectives on primary care

You've probably had the experience of going to see a primary care physician and wondering about the many aspects of that visit that just didn't make sense. Why is it so important for me to arrive on time when, in reality, I won't be called back until half an hour (or more) later? What's the point of waiting for another 20 minutes in a chilly examining room for the doctor to show up? Why does my doctor always seem so rushed? And most importantly, why do they always insist that I come for an appointment for a minor problem that could just as easily be handled by phone or e-mail?

Two articles in the current issue of the journal Health Affairs provide outsiders' perspectives on these issues. The first article, an anthropological "field study" of three general internal medicine practices, describes the primary care experience as separated into three "social silos," consisting of physicians ("the frantic bubble"), practice staff ("the flexible team"), and patients ("in limbo"). As I've described previously, family physicians often feel as if they're behind from the get-go:

Their days began with a review of what we dubbed the "fictive schedule," in which the physicians would grab a printed schedule or look at a monitor and see a long string of 15-minute appointments stretching through the morning. They would tap a pen down the list and mutter something like, "This one will take at least half an hour," or "This one's a real nightmare ..." In addition, many unscheduled patients would need to be "fitted in" to these already tight schedules. The fictive schedule showed uniform, precisely measured blocks of time. The "real" schedule in physicians' heads was informed by their knowledge of their actual patients.

The authors go on to observe that little or no time is scheduled for already-harried physicians to perform all of the other essential tasks that go into running a practice (for a nice description of these, see this recent piece in the New England Journal of Medicine).

The second article takes the perspective of a Martian (one wonders if the editors who designed this theme issue of the journal recently read neurologist Oliver Sacks' classic An Anthropologist on Mars) who concludes that primary care physicians' time would best be spent on longer, "necessary" in-person visits, defined as:

1) for a first visit
2) when it may be necessary to engage in some physical maneuver for diagnostic purposes
3) for specific therapeutic purposes, such as injecting a joint
4) when the patient has problems for which lengthy discussion would be helpful
5) when for psychological or emotions reasons it seems better to see the patient face-to-face
6) when face-to-face visits are necessary to build trust

Even with longer appointment times, the author points out, physicians would still end up with additional time in their schedules to devote to coordinating staff activities (such as health behavior counseling) and supervising population-based preventive health and chronic care improvement activities.

The primary obstacle is that a practice redesigned with these principles would rapidly bankrupt itself, since traditional health insurers almost uniformly pay only for in-person encounters with physicians and do not pay for health education delivered by non-physician staff. Only integrated health systems such as Washington State's Group Health Cooperative have been able to thus far afford the changes necessary to transform their old-style practices into what is being called the patient-centered medical home. And though Group Health has already seen their efforts result in improved patient satisfaction and cost savings, for many docs, adapting to the changes hasn't been easy. In a future post, I'll explain why it's difficult for family physicians to transition to being team players.

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