Tuesday, July 13, 2010

Medical homes and the meaning of "P.C." - Part 2 of 2

In my last post, I discussed the high hopes many have for improving health care through the medical home and the sobering results of the AAFP's National Demonstration Project, which fell short of fulfilling those hopes. The "PC" in PCMH stands for "patient-centered," which means changing primary care practice to better meet the needs of patients rather than allowing patients access to care only when convenient for the practice (which I'd call a "practice-centered" approach). Some ways that the AAFP's demonstration practices did this were to offer same-day scheduling and phone or electronic mail consultations in lieu of face-to-face visits.

The potential of primary care teams will not be achieved if medical homes are too "physician-centered." This point requires some clarification. Physicians have the most education and training of any person in the practice, and they should be doing primary care tasks commensurate with their training and ability, and no more. But the primary care team that succeeds will expect the same from all of its members, including the nurse practitioner, the physician assistant, the health educator, the medical assistant, etc. and just as importantly, be responsive to their input about improving inefficient or inadequate processes of care.

Reflecting in the Annals of Family Medicine on the lessons from the AAFP's attempt at creating a sustainable patient-centered medical home model, my friend and colleague Dr. Larry Green from the University of Colorado, Denver makes several valuable observations:

The PCMH is useful, even galvanizing, but limited, as a political construct and is best understood as the rallying point for robust, modernized primary care that now necessitates a new mind model from all of medicine, policy makers, and especially those wonderful clinicians and staff members taking care of most of the folks in the US today. PCMH is really not a thing, a collection of techniques; it is presently a journey toward a destination not yet crystal clear. ...

I am not at all concerned about all the "hoopla" around patient experience getting worse during a 26 month period and small effect sizes. ... What would one expect from a traffic survey of travelers on a road under repair if asked, "Does this ride delight you? Are you getting exactly what you want from this road the way you want it when you want it?" And to lament small effect sizes is akin to lamenting less than gorgeous blossoms on roses planted in a desert, with the gardener having only a cup of water each day.

Well said, Larry.

1 comment:

  1. One of the great challenges of family medicine is to do what is not urgent but very important while doing what is very urgent and important. These competing equally valuable demands frequently obstruct our ability to engage in meaningful change. The greatest value that family medicine brings as a component of the public trust is that it brings value to healthcare if it is iterated in an effective fashion. However, if we surrender to the tyranny of the immediate, we become our own worst enemies.
    Since initiating an electronic medical record in our practices we have seen our Pap smear rates decline significantly. Less than half of our female patients are getting a Pap smear in the recommended interval. When they do get one the follow-up is appropriate if something is abnormal.

    I surveyed our physicians and our support staff using survey monkey about their attitudes toward Pap smears. They overwhelmingly agreed that Pap smears are highly effective at preventing cancer and preventing premature morbidity and mortality in women, overwhelmingly agreed that women were more likely to have their Pap smear if they were able to have it done in their primary-care office, and also overwhelmingly agreed that our group delivers a competent service when it comes to performing Pap smears. Yet, our physicians and staff felt they were too busy to remember to remind their patients that they needed one.

    So, my next step is to see what the level of provider engagement is about this. And that is where my trepidation lies. I know as physicians this has to bother us. But what really worries me is, are we too busy to be effective?