Primary Care (Physician)???????

The ACP Advocate Blog by Bob Doherty

Are doctors and non-physicians speaking the same language when they define primary care?
I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.

The White House's primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to "What's my line?" style questioning, I think it would be become evident that their lines (roles) were very different from each other.

The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.

As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.

The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

Many of the professions represented at the White House's primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address "a large majority of personal health care needs" or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM's definition, but their skills and training are complimentary--not equivalent--to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.

I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.

But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.

Today's question: Do you think primary care means the same thing to the different health professions?

Looking up North?

The posting below is proof that a public funded health care entity can exist and be complemented by private enterprise

The Changing Face of Canadian Health Care

By Evan Falchuk

Many Americans look to Canada, as an example of a government-run health care system that works.

But is that really what it is?

Health care in Canada is funded mostly publicly, but is provided mostly privately. That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.

Americans often call this system “single payer,” but it’s really not true. There are many other payers.

For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums. Millions of Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services. There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost. As much as 30% of Canadian health care expenses are funded through these non-government payers.

However paid for, supply (and funding) for health care has not been able to keep up with increasing demand. The result has been well-documented: long waits for health care services. Waiting is a normal part of the Canadian health care experience, with provincial governments publishing information on wait times and working to fix them. The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”

And so an interesting dynamic has emerged.

Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles. But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet. As wait times have grown, so has a burgeoning private market.

Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day. So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis. While politically controversial, it made it possible to serve more patients without the need for additional government funding.

These types of ideas have grown, extending now to stand-alone diagnostic centers. A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary. This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work. So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources. They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face. Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system. And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.

Other kinds of private centers have opened up as well. Some operate almost as membership-only medical practices, offering much of what might be considered primary care. Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis. For certain specialties like orthopedics, some even offer complete hospital surgical services.

The Canadian system remains very different from the American one. Canadians do not want their system transformed into anything that reflects American “rugged individualism.” And yet the natural human desire to look after oneself and ones family poses dilemmas. When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.

We’re all entitled to that kind of help — Americans, Canadians, whatever.

The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.

The Physician may be a Patient

July 9, 2009
Doctor and Patient
When Doctors Make Mistakes
By PAULINE W. CHEN, M.D.

I met Ed (not his real name) during internship, the year after we both graduated from medical school. Built like a competitive wrestler, Ed was an Ivy League college graduate and one of his medical school’s top students, a 27-year-old who wanted nothing more than to become a general surgeon. Like me, he was enamored with the fearlessness that seemed to characterize the specialty. At a dinner during our first month on the job, Ed told the rest of us, “I love that nothing scares a general surgeon.” A dreamy look passed over his well-chiseled face as he continued, “They can take care of it all.”

Ed was determined to be that kind of surgeon and applied his intelligence and good nature to the huge workload we always had at hand. One night when I was on call I found Ed, who was supposed to have gone home for the night, in a patient’s room. A small mound of discarded alcohol swabs, blood-stained gauze pads and used test tubes stood by his side as the patient, an older woman, laughed and encouraged him on. When Ed saw me, he smiled sheepishly. “I never learned to draw blood in medical school,” he said. “It takes me a few tries.” The patient patted Ed’s hand and nodded as he continued, “If I can’t draw blood, how am I ever going to be able to operate?”

But several months later, I learned that Ed had gotten in trouble one night for not responding to a nurse’s page about a critically ill patient. “He must have been overwhelmed,” I thought, remembering that only a few nights earlier I had likewise forgotten a nurse’s request after several trauma patients rolled into the emergency room and I never returned to the wards as promised. I silently vowed to do better the next time and now hoped that Ed would do the same.

But a couple of weeks later, I heard that Ed overslept and missed morning rounds. A month later he was publicly reprimanded for examining and placing undue pressure on a patient’s freshly sewn incision. And a month after that, he was placed on probation because he had pulled a surgical tube out of a patient when it should have stayed put.

Suddenly it seemed as if Ed, the promising young surgeon, had disappeared into a vicious cycle of errors and mishaps and couldn’t pull himself out.

But Ed, the friend, had gone missing, too. He stopped smiling when we passed one another in the halls and refused to meet up with the rest of us for meals. “I’ve got to read,” he would say, his face stony. “I’ve got to study.” He still roamed the wards at all hours, but now he was like a man possessed. With his list of patients crumpled in one hand and a pen in the other, Ed studied patient charts and reports for hours, furiously jotting notes down on his list.

Despite his efforts, Ed continued to stumble. He soon developed a reputation for being testy, not only with other doctors and nurses but with patients. He argued, lost his temper and was too rough during procedures. One afternoon I heard Ed’s voice bellowing from a patient’s room: “But I never said that to you! Why did you have to tell the senior doctor that? You got me into trouble!”

Ed finally gave up on becoming a surgeon. In trying to understand what had happened to our once aspiring colleague, the other young doctors and I talked about how stress is inevitable and surmised that those who collapsed under the pressure were probably better suited to other lines of work. We speculated that Ed lacked a certain sense of humility.

But all of our ruminations finally boiled down to this: each of us was only one misstep away from that lonely and vicious cycle of errors that could unexpectedly and irrevocably spiral out of control.

In the years since, I have worked with other doctors who have had similar experiences. And while the discussions at disciplinary meetings and at morbidity and mortality conferences tend to focus (and rightly so) on the effects of these physicians’ errors on patients, there is rarely any time devoted to how such errors affect doctors and their subsequent interactions with patients.

I called Dr. Colin P. West recently, a practicing general internist and the associate director of the internal medicine residency training program at the Mayo Clinic in Rochester, Minn. About three years ago, Dr. West and his colleagues published an article in The Journal of the American Medical Association on the effect of errors on physicians-in-training and on the outcomes of their future patients. The researchers found that self-perceived errors not only increased the risk of burnout and depression but also adversely affected subsequent patient care. Over time, young doctors who believed they had made errors in the past felt less and less empathy toward their patients, which then led to an even greater risk of subsequent errors.

“What we are learning is that there’s clearly a cost for doctors and patients,” Dr. West said. “There’s probably a certain amount of stress that’s constructive, but when you deal with it for too long and take it too far, that’s when work suffers.”

While doctors should strive for as few errors as possible, “you can’t go through training without making an error unless you are not taking care of patients,” Dr. West said. “And if you are really invested in the care of patients, there’s a personal cost when things don’t go well.”

That cost can extend to patients. Doctors who are depressed are as much as two times more likely to make subsequent errors than doctors who are not. “From the point of view of the patient,” Dr. West observed, “it’s important whether the doctor treating you is experiencing symptoms of depression or burnout.”

And while Dr. West’s research focuses on doctors-in-training, he added, “I don’t think that as a practicing physician you ever stop thinking about how you could have done better, even sometimes with those events you probably couldn’t have prevented.”

Greater support for doctors from both the training process and patients could help to improve patient outcomes and strengthen the patient-doctor relationship. “In 21st century medicine, there’s no reason for a patient to accept suboptimal care,” Dr. West said. “At the same time, patients need to balance their expectations against the reality of the physician experience. And the medical establishment needs to do a better job of helping patients understand what physician lives are really like.”

“This doesn’t mean that physicians need to be coddled,” Dr. West continued, “but they need to be supported from within and by patients. They need to be supported in developing those relationships that help them to flourish. The reward is a stronger physician-patient bond. And that leads to more effective health care for everybody.”

Join the discussion on the Well blog: "For Doctors, the Personal Toll of Mistakes"