Monday, June 28, 2010

Can primary care practices be "Dream Teams"?

The greatest U.S. Olympic basketball team ever assembled, dubbed the "Dream Team," dominated the rest of the world at the 1992 Summer Olympics. This team, which beat opponents by an average of 44 points en route to a gold medal, included 10 eventual NBA Hall-of-Famers, including Michael Jordan, Patrick Ewing, Karl Malone, Magic Johnson, and Larry Bird. Now that professional basketball players were eligible to represent the U.S. in world competitions, many observers predicted that the U.S. would be unbeatable for decades.

It turned out to be a single decade. At the 2002 World Championship, the U.S. team didn't even medal, finishing a shocking 6th. At the 2004 Summer Olympics, the U.S. barely managed to take home the bronze. And it wasn't as if these were teams of second-stringers; in particular, the 2004 team included perennial All-Stars Tim Duncan, Allen Iverson, LeBron James, and Dwayne Wade. But that was actually the problem - too many stars, too little teamwork. So USA Basketball changed its program, assembling a team with fewer individual stars and more role players who all committed to playing together for long stretches prior to the 2008 Olympics, where the "Redeem Team" took back the gold medal for the U.S.

In many ways, family medicine in 2010 is where U.S. basketball was in 2004. Three years ago, four major organizations representing primary care physicians agreed to an outline of "Joint Principles of the Patient-Centered Medical Home," which included this statement: "The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care." Unfortunately, this "physician-centric" approach prevents the development of true primary care teams, and instead reinforces the traditional medical hierarchy: the doctor gives orders to staff, and the staff carry out the orders without question or debate. As the evaluators of American Academy of Family Physicians' National Demonstration Project of 36 medical home practices concluded:

Becoming a PCMH requires more than just implementing sophisticated office systems: it involves adopting substantially different approaches to patient care that requires moving away from a physician-centered approach and toward a team approach shared with prepared office staff. ... The role of the primary care physician in the context of the practice and the larger health care system will continue to be important but needs to be encouraged to evolve in new and innovative ways.

Can physicians evolve from being authoritative bosses to being facilitators and players on primary care "Dream Teams"? Even recent residency graduates may be poorly prepared for these new roles, despite heroic efforts to transform residency training to prepare family doctors to work in practices of the future. However, as Atul Gawande noted in his 2009 bestseller, surgeons, pilots, and architects have managed to put aside their inner prima donnas and successfully integrate into teams in equally demanding professions. Given the right economic incentives, there's no reason why we can't, too.


  1. Wonderful post.

    It is very refreshing to read your comments.

    Thank you,