By HANS DUVEFELT
(Note: Hans is rerunning some of his greatest hits. This one is from 2014 and leans right into my current and future obsession with fixing primary care-Matthew Holt)
Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?
SICK CARE
Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.
Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.
In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.
Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?
CHRONIC DISEASE MANAGEMENT
More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.
The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.
We already know that group visits can be very successful, because of the power of peer support. And even when they are limited to Zoom, they can be effective. They are certainly more efficient than speaking with patients one by one, again and again, like a broken record. Quite frankly, that is getting antiquated.
Besides through group visits, this aspect of primary care is also easily done or at least supported by technology. There are already apps for tracking blood sugar, blood pressure, exercise and sleep. I’m sure there are more applications out there already and even more in development. The feedback from all this data can easily be managed by artificial intelligence, leaving just the final decision making and personal touch for the medical provider. (More on why the personal touch is still necessary in an upcoming post.)
DISEASE PREVENTION AND SCREENING
You don’t need a dozen years of professional education to tell people to have their routine immunizations, to offer screening colonoscopies or to administer standardized questionnaires for anxiety, depression, alcohol or domestic abuse or whatever else the politicians and bureaucrats think we doctors should do.
My professional opinion is that this work is too routinized to require a medical license, but could safely be done by non-providers or even by computers with very rudimentary programming.
I also question the logic of bombarding patients with these when they come in for a sick visit with many worries and questions they hope to have time to address. In fact, I question why these things aren’t done outside the visit, through outreach via our patient portals, newsletters, phone calls, email or even printed letters.
What I do think, is that these screenings can and probably should be done under the umbrella of patients’ primary care “medical home”. But I strongly object to the misinformed assumption that this data collection is doctor work. The doctor should however be available in the loop to manage positive findings.
(In my EMR the doctor has to sign off even normal screening tests in a most cumbersome work flow as part of an office visit. Why not have a standing order and an automated process to only flag the provider for scores above a certain value?)
Prevention and screening services to 331,000,000 citizens, one by one and face to face, for innumerable diseases and risk factors is not the best use of our 209,000 primary care physicians. At least not if we want to be fiscally responsible. It is definitely not a good idea if we want doctors to also have time to treat the sick. And it is a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford to.
Hans Duvefelt is a physician, author, and creator of “A Country Doctor Writes” where this piece first appeared.
