Category Archives: Healthcare Delivery Systems

Telemedicine Rising

Posted on March 5, 2018 | 1 comment

In a “Viewpoint” published in JAMA a month ago,[1] Michael Nochomovitz and Rahul Sharma suggest that the time has come to create a new medical specialty: virtual medicine.  Extrapolating from the manner in which medical specialties have traditionally arisen (viz., “by advances in technology and expansion of knowledge in care delivery”), they submit that telemedicine has advanced to the point of providing the basis for a new kind of specialty care.  Telemedicine, as they define it, comprises various web-based telecommunications modalities, social media, teleconferencing, video face-to-face communications with patients, among them.  They place before us  medical virtualists, physicians who “will spend the majority or all of their time caring for patients using a virtual medium.”

Unlike today’s physicians, who make use of this or that “virtual medium” haphazardly and without formal training, the virtualist will achieve a set of “core competencies” through formal training.  Their curriculum for certification, according to the authors, should include “knowledge of legal and clinical limitations of virtual care, competencies in virtual examination using the patient or families, ‘virtual visit presence training,’ inclusion of on-site clinical measurements, as well as continuing education.” Among the techniques in their arsenal will be those aimed at achieving “good webside manner” (authors’ italics).

Now, far be it from me to discourage the use of  remote technologies to render health care delivery more efficient and especially to bring primary care to underserved communities. The value of “remote surgery” that ranges from telementoring and remote guidance to actual robotic operations is well-documented.  But is a new medical virtualism specialty really in our best interest?  Certainly,  telemedicine will play an  increasing role in medicine; the question is whether this “role” should become the basis of a bounded specialty.  This would make the medical virtualist the first medical practitioner whose practice excluded (or drastically marginalized) patients, making it radically different from nonpractice specialties such as pathology or diagnostic radiology.

It is problematic especially in the cognitive specialties.  We would have a subspecies of primary care doctors who specialized in care that was patient-uncentered, i.e., that was premised on the self-sufficiency of piece-person care as opposed to whole-person care.  The proposal takes the current fragmentation of care among subspecialists and refashions it into a virtue.  That is, we will have virtuous physicians who only practice virtual medicine and feel good about doing so.  Such care differs from subspecialty care in a key respect:  we typically see our subspecialists in the flesh.  We can ask them questions, demand explanations, and criticize them for not giving us the time and attention we seek.  In the absence of adequate time and attention, we can seek out a different subspecialist who is more patient-centered and welcoming.   With the medical virtualist, on the other hand, dehumanization is integral to the specialty itself.  The patient has no recourse; he is outside the virtualist’s purview altogether.

It is striking that the issue of patient trust is nowhere mentioned in the article,   even though empirical research suggests that trust is the “basic driver” of patient satisfaction.  It has been linked to less treatment anxiety, greater pain tolerance, and greater compliance.[2]  But the authors subordinate all such issues to their focus on efficiency and ease of use.   As such, their case rests on the assumption that informed the patient rights movement of the 1970s and ’80s:  that patients are simply consumers in search of a commodity.  Now, a half century after passage of the Patient’s Bill of Rights, the commodity is increasingly mediated by technology.[3]  And “the success of technology-based services,” according to the authors, “is not determined by hardware and software alone but by ease of use, perceived value, and workflow optimization.”  The need to humanize the delivery of technology, to convey to the patient some sense of what I have termed “caring technology,”[4] falls outside a conversation framed in terms of consumerist values.

But once we factor trust into the equation, we open a can of worms.  For patient trust implicates the doctor’s touch, which includes both the laying on of hands and the implementation of office-based procedures.  It also implicates human qualities such as caring, empathy, and the willingness to tolerate ambiguity.  Finally, it puts us in contact with the  Hippocratic Oath, in which ethical obligations revolve entirely around physicians treating patients who are full-fledged human beings, fellow sufferers.  This is why Jennifer Edgoose and Julian Edgoose, writing in a recent issue of Annals of Family Medicine about “Finding Hope in the Face-to-Face,” begin with this sentence:  “The daily work of clinicians is conducted in face-to-face encounters, whether in exam rooms, homes, or alongside hospital beds, but little attention has been paid to the responsibilities and ethical implications generated by this dimension of our relational work.”[5]  Among these implications is the physician’s obligation not merely to be an instrument of diagnosis and treatment, but also to contain the patient’s “wounded humanity” in the sense of Pellegrino.[6]

I wrote In the Hands of Doctors precisely to explore, both historically and in the present, this dimension of physicians’ “relational work,” including the better and worse ways in which it can appropriate technologies that are not only sought after by patient-consumers, but viewed as remote and intimidating by patient-persons.  Physicians who know their patients as wounded and vulnerable can humanize technology by pulling it into a trusting doctor-patient relationship.

These thoughts are a counterpoise to the authors’ brief for “the medical virtualist.”  Their proposal is provocative and troubling.  It inverts figure and ground, so that telemedicine, heretofore an adjunct to face-to-face care, becomes the ground of a specialty in which face-to-face care is incidental at best.  In the domain of primary care, it segues into the philosophical question of who or what primary care virtualists are being trained to care for.  Can one be a primary care physician of any type and care for some “thing” other than whole persons?  The status of virtualism in surgical specialties is no doubt different.

I invite others to reply to this posting with their thoughts on a topic that will only grow in importance in the years ahead.

_______________________

[1] Michael Nochomovitz & Rahul Sharma, “Is It Time for a New Medical Specialty?  The Medical Virtualist,” JAMA, 319:437-438, 2018.

[2] Paul E. Stepansky, In the Hands of Doctors: Touch and Trust in Medical Care (Montclair: Keynote, 2017), 21 and references cited therein.

[3] Stepansky, In the Hands of Doctors, 133-135

[4] Stepansky, In the Hands of Doctors, 82-98.

[5] Jennifer Y. C. Edgoose & Julian M. Edgoose, “Finding Hope in the Face-to-Face,” Ann. Fam. Med., 15:272-274, 2017.

[6] E. D. Pellegrino, Humanism and the Physician (Knoxville:  University of Tennessee Press, 1979), 124, 146, 184, and passim.

 

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Posted in Healthcare Delivery Systems, Medical Technology, Old & New, Primary Care, Telemedicine

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The Politics of Medical Freedom

Posted on September 8, 2017 | Leave a comment

Winner of an Independent Publisher Books Award Bronze Medal for 2017, Paul Stepansky’s In the Hands of Doctors:  Touch and Trust in Medical Care is now available in paperback and as an eBook.  For the paperback edition, Stepansky has written a new preface, a stirring defense of Obamacare as a path to universal health care in America.  It is given here in its entirety in appreciation of the readers of “Medicine, Health, and History.”

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In the Hands of Doctors:  Touch and Trust in Medical Care

Preface to the Paperback Edition
Copyright © 2017 by Paul E. Stepansky.  All rights reserved.

~

 In our time, political speech and writing are largely the defense of the indefensible.
                                         — George Orwell, “Politics and the English Language” (1946)

Now, less than a year after publication of In the Hands of Doctors, the Patient Protection and Affordable Care Act of 2010 (aka Obamacare), which I roundly endorse in this book, is gravely imperiled.  Congressional Republican legislators have joined a Republican President in a commitment to repeal the bill that has provided health insurance to over 20 million previously uninsured Americans.  The legislation thus far presented to replace it by the U.S. Senate  (the “Better Care Reconciliation Act of 2017”) would, according to the Congressional Budget Office, leave 15 million Americans uninsured in 2018 and 22 million by 2026.   Proposed cuts and caps to the Medicaid budget, which are part of the legislation, would, according to the CBO, decrease enrollment in the program by 16% over the next decade.  In brief, these cuts and caps would jeopardize the health and well-being of the one in five Americans and one in three American children dependent on the support provided by Medicaid.  Disabled and other special-needs children as well as elderly nursing home residents would suffer the most.  A Congressional vote simply to repeal Obamacare absent new legislation would have even more catastrophic consequences.
      Congressional opponents of the Affordable Care Act, no less than President Donald Trump, appear to live in a hermetically sealed bubble that makes only grazing contact with the socioeconomic ground below.  They share space in the bubble with colliding political abstractions that they grasp, one after the other, and radio back down to earth.  The political bubble dwellers offer us yet again the palliatives of context-free “medical choice” and “medical freedom” as remedies for the real-world suffering addressed by Obamacare.
     But these terms, as used by politicians, do not speak to the realties of American health care in  2017.  Rather, they hearken back to the era of the Founding Fathers, when issues of health, illness, freedom, and tyranny were much simpler.  Freedom, as the founders understood it, operated only in the intertwined realms of politics and religion.  How could it be otherwise?   Medical intervention did not affect the course of illness; it did not enable people to feel better and live longer and more productive lives.  With the exception of smallpox inoculation, which George Washington wisely made mandatory among colonial troops in the winter of 1777, governmental intrusion into the health of its citizenry was nonexistent, even non-sensical.
     Until roughly the eighth decade of the nineteenth century, you got sick, you recovered (often despite doctoring), you lingered on in sickness, or you died.  They were the options.  Medical freedom, enshrined during the Jacksonian era, meant being free to pick and choose your doctor without any state interference.  So liberty-loving Americans picked and chose among mercury-dosing, bloodletting “regulars,” homeopaths, herbalists, botanical practitioners, eclectics, hydropaths, phrenologists, Christian Scientists, folk healers, and faith healers.   State legislatures stood on the sidelines, rescinding or gutting medical licensing laws and applauding the new pluralism.  It was anarchy, but anarchy in the service of medical freedom of choice.
     Now, mercifully, our notion of medical freedom has been reconfigured by two centuries of medical progress.  We don’t just get sick and die.  We get sick and get medical help, and, mirabile dictu, the help actually helps.  In antebellum America, deaths of young people under 20 accounted for half the national death rate, which was more than three times the death rate today.  Now our children  don’t die of  small pox, cholera, yellow fever, dysentery, typhoid, and pulmonary and respiratory infections before they reach maturity.  When they get sick in early life, their parents take them to the doctor and they almost always get better.  Their parents, on the other hand, especially after reaching middle age, don’t always get better.  So they get ongoing medical attention to help them live longer and more comfortably with chronic conditions such as diabetes, coronary heart disease, inflammatory bowel disease, Parkinson’s, and many forms of cancer.
     When our framers drafted the Constitution, the idea of being free to live a productive and relatively comfortable life with long-term illness did not compute.  You died from diabetes, cancer, bowel obstruction, neurodegenerative disease, and major infections.  Among young women,  such infections included the uterine infection that routinely followed childbirth.  A major heart attack simply killed you.  You didn’t receive dialysis and possibly a kidney transplant when you entered kidney failure.  Major surgery, performed on the kitchen table if you were of means or in a bacteria-infested public hospital if you were not, was rarely attempted because it invariably resulted in massive blood loss, infection, and death.
     So, yes, our framers intended our citizenry to be free of government interference, including the Obamacare “mandate” that impinges on Americans who choose to opt out of the program.  But then, with the arguable exception of Benjamin Franklin, the framers never envisioned a world in which freedom could be extended by access to expert medical care that relieves suffering, often effects cure, and prolongs life.  But then, neither could they envision the enfranchisement of former slaves and women, the progressive income tax, compulsory vaccination, publicly supported health clinics, mass screening for TB, diabetes, and  syphilis, or Medicare and Medicaid.  Throughout the antebellum era, when physicians were reviled by the public and when neither regular medicine nor the rival alternative sects could stem the periodic waves of cholera, yellow fever, and malaria that decimated local populations, it mattered little who provided one’s doctoring.  Many, like the thousands who paid $20.00 for the right to practice Samuel Thomson’s do-it-yourself botanical system, chose to doctor themselves.
     Those who seek repeal of Obamacare without a credible legislative alternative that provides equal, preferably greater, health benefits to all Americans seem challenged by the very idea of medical progress.  Their use of terms like “choice” and “freedom” invokes an eighteenth-century political frame of reference to deprive Americans of a kind of freedom associated with a paradigm-shift that arose only in the final quarter of the nineteenth century.  It was only then that American medicine began its transition to what we think of as modern medicine.  Listerian antisepsis and asepsis; laboratory research in bacteriology, immunology, and pharmacology; laboratory development of specific remedies for specific illnesses; implementation of public health measures informed by bacteriology; modern medical education; and, yes, government regulation to safeguard the public from incompetent practitioners and toxic medications – all were part of the transition.  The Jacksonian impulse persisted into the early twentieth century, flaring up in organized opposition to compulsory childhood vaccination, and  finally petering out in the 1930s, by which time it was universally accepted that scientific medicine was, well, scientific, and, as such, something more than one medical sect among many.
     “We hold these truths to be self-evident,” Thomas Jefferson began the second paragraph of the Declaration of Independence, “that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  What Jefferson did not stipulate, indeed what he could not stipulate in his time and place, were the hierarchical relationships among these rights.  Now, in the twenty-first century, we are able to go beyond an eighteenth-century mindset in which  “Life, Liberty, and the pursuit of Happiness” functioned as a noun phrase whose unitary import derived from the political tyrannies of King George III and the British parliament.  Now we can place life at the base of the pyramid and declare that quality of life is indelibly linked to liberty and the pursuit of happiness.  To the extent that quality of life is diminished through disease, liberty and the pursuit of happiness are necessarily compromised.  In the twenty-first century, health is life; it is life poised to exercise liberty and pursue happiness to the fullest.
     Why, then,  is it wrong to require all citizens to participate in a national health plan, either directly or through a mandate (i.e., a tax on those who opt out), that safeguards the right of people to  efficacious health care regardless of their financial circumstances, their employment status, and their preexisting medical conditions?  What is it about the Obamacare mandate that has proven so troubling to our legislators?  When you buy a house in this country, you pay local property taxes that support the local public schools.  These taxes function like the mandate:  They have a differential financial impact on people depending on whether they directly benefit from the  system sustained by the tax.  To wit, you pay the tax whether or not you choose to send your children to the public schools, indeed, whether or not you have children at all.  You are obligated to subsidize the public education of children other than your own because public education has been declared a public good by the polity of which you are a part.  The same goes for that portion of local taxes that provides police and fire protection.  We accept a mandate to support policemen and firefighters whether or not we will ever need them, in the knowledge that other members of the community assuredly will.  Similarly, those who opt out of Obamacare should pay a price, because they remain part of a society committed to health as a superordinate value without which liberty and the pursuit of happiness are enfeebled.
     It is inconceivable that the Founding Fathers would have found unconstitutional or unfair or governmentally oppressive a law that provided life-promoting health care that enabled more Americans to discharge the duties of citizenship and live more freely and productively in pursuit of happiness.  They declared that citizens – all of whom, be it noted, were white, propertied males – were entitled to life consistent with the demands and entitlements of representative democracy.  Their pledge, their declaration, was not in support of a compromised life that limited the ability to fulfill those demands and enjoy those entitlements.
     When, in our own time, the word “choice,” as used by Republican politicians, means that millions of Americans who rely on Obamacare will end up leading compromised lives, the word becomes semantically contorted and ethically bankrupt.  The absence of Obamacare does not, ipso facto, empower lower-income, assistance-dependent Americans to buy the comprehensive health insurance they need, especially when the tax credits under legislation proposed thus far provide far less support than the subsidization lower-income families now receive.  Freeing insurers from Obamacare regulations so that they can offer inadequate policies that lower-income Americans can afford to buy does nothing but maximize the medical risks of these financially choice-less Americans.  Here is a fact:  Economic circumstances wipe out the prerogative to make prudent choices in one’s own best interest.  For lower-income Americans, a panoply of inadequate choices is not the pathway to right-minded decision making.  With the Senate’s “Better Care Reconciliation Act,” unveiled in June and updated in July, 2017, millions of low-income Americans, especially those dependent on Obamacare subsidies and Medicaid, would have had an absence of credible and affordable choices for obtaining health care adequate to their needs.  The call simply to repeal the Affordable Care Act, which the Senate has rejected as of this writing, would take us back to a status quo ante when millions of Americans were either priced out of, or completely denied, health coverage.
     Of course, adult citizens may repudiate mainstream health care altogether on the basis of philosophical or religious  predilections.  Christian Scientists and Jehovah’s Witnesses, for example, hold theological beliefs that often lead them to refuse medical treatment.  Certainly, they are free to pursue health through spiritual healing or, in the manner of medieval Christians, to disavow corporeal health and earth-bound life altogether.  But by law they cannot deny their children, who deserve to live to maturity and make their own choices, the healing power of modern medicine, whether it comes in the form of insulin, antibiotics, blood transfusions, or surgery.  Nor should they be allowed to undermine social and political arrangements, codified in law, that support everyone else’s right to pursue life and happiness through twenty-first century medicine.  Those who, prior to the Affordable Care Act, had inadequate insurance or no insurance at all are not struggling to free themselves from the clutches of federal regulation; they are not crying out for new free market health plans through which they can exercise freedom of choice.  Rather, they are struggling to put food on the table and keep themselves and their families healthy.  To this end, they need to be free to avail themselves of what modern medicine has to offer, unencumbered by politically debased notions of freedom and choice.
     At this moment in history, in a fractionated society represented by a President and Congressional leaders whose daily missives bear out George Orwell’s acute observation about the corruption of language brought on by political orthodoxies, In the Hands of Doctors may have a wistful ring.  I hope not.  I am addressing the personal side of health care – the reality of a doctor and patient, alone in a consulting room, often surrounded by high-tech diagnostic aids but always containing those vital low-tech instruments with which one person reaches out to the other:  the physician’s eyes and hands and voice.  The human face of doctoring, which now includes the doctoring of nurse practitioners and physician assistants, remains essential to the success of any doctor-patient relationship, whatever the institutional arrangements that bring together this doctor and this patient, the former to help the latter.
     Endeavoring to understand the several aspects – and possibilities – of the doctor-patient relationship, I write about the nature of clinical caring; the relation between caring and patient trust; the need to recruit and train physicians who can bring this caring sensibility to their patients; the role of empathy in medical caring; and the obligation of medical educators to revivify primary care medicine to meet the critical shortage of frontline physicians within underserved American communities.  These issues will not go away, whatever the fate of Obamacare.
     When federal legislation, through the practical assistance it provides, extends the reach of trusting doctor-patient relationships to the most vulnerable  groups in society, it has a  function that is both binding and enabling.  It fortifies the webbing that underlies the increasingly disparate parts of our national mosaic.  Obamacare, the Children’s Health Insurance Program, Medicaid – these programs do not “bring us together” in a feel good way.  They do, however, prevent a free fall in which the subcommunities and interest groups into which society has decomposed land so far apart they are no longer in hailing distance of one another.  As to the enabling function, a comprehensive medical safety net for all Americans – let’s call it what it is: universal health care – revitalizes political democracy by extending to all Americans a greater possibility of life, liberty, and the pursuit of happiness.  In the everyday world, this pursuit boils down to the ability of more people to stay on the job or to work from home rather than not work at all.  Society benefits, since chronically ill people pursuing happiness under the umbrella of universal health care will better resist the complications and collateral illnesses that follow from their primary illness or illnesses.  Society also benefits by enabling healthier happiness-pursuers to avoid hospitalization and, among the elderly, to push back the time when nursing home care is required.  And finally, society benefits by seeing to it that all children, especially those who are disabled, receive every medical advantage as they traverse their own challenging paths to productive, choice-wielding citizenship.
     Obamacare is a far cry from universal health care, but for all its limitations and current financial straits, it has provided these binding and enabling functions for millions of Americans previously without a medical safety net.  Woe to politicians who shred it in the name of choice, a pleasing vacuity that evades the reality of disease and pain among many who are relieved to have a single avenue of subsidized care where none was previously available.
     Health care should be a national trust; everyone deserves what twenty-first century medicine has to offer, regardless of how much or how little choice can be worked into the offering.  Politicians who feel otherwise are enemies of the polity.  Jefferson, who as president helped set up the first smallpox vaccination clinics in the south and then, in retirement, planned a state-supported clinic to provide free medical care to those who could not afford it, would not have brooked the empty insistence that medical freedom and medical choice, unhinged from socioeconomic reality, trump access to medical care per se.  Nor, for that matter, does choice, whatever it may or may not mean, obviate our moral obligation as a society to see to it that best available treatment, whatever the pathway that leads to it, means treatment rendered by caring doctors willing to know their patients as people.

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In the Hands of Doctors:  Touch and Trust in Medical Care, 1st pbk ed

Paul E. Stepansky

978-0983080770        2016/2017pbk        348pp        $26.95pbk

Release date: September 12, 2017

Order now at Amazon.com

 

 

 

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Posted in General, Health Care Reform, Healthcare Delivery Systems, Medical Politics

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It Takes a Village in Health Care, Too

Posted on July 18, 2013 | Leave a comment

It Takes a Village in Health Care, Too

David W. Stepansky, M.D.**

A few weeks ago, while rounding on patients at Phoenixville Hospital, I began to experience a vague tightness in my upper chest as I walked from one nurses’ station to the next.  The pain was fairly mild, but I also became a little sweaty with it.  The symptoms did not cause me to stop and rest, but when I did sit down to write on a chart, the discomfort would subside, only to recur when I began walking again.

As a physician, I well knew what my symptoms might have represented, but being just as susceptible to denial as any other human, I chose to ignore things for a little while, not wanting to believe that I might be experiencing angina.  I knew what would take place as soon as I said anything to anyone and only wanted to forget that it was happening.  I actually went out to my car to drive to the office to start my outpatient hours, again experiencing that same mild but gnawing pressure in my chest.  I sat in my car for a minute or two, just trying to think it all through, when I finally came to the realization that if I was indeed ignoring cardiac symptoms, than I was being very foolish.

Even then, I did not go directly to the emergency room.  Instead, I wandered through the hospital until I found one of my cardiologist partners and told him my story. Of course, from that moment on, I ceased to be a doctor and somewhat begrudgingly became a patient.  I knew from that moment that I would have to  completely relinquish my regular identity and become wholly reliant not only on the judgment and skill, but also on the compassion of the many who then began to care for me.

What happened after that was at once extraordinary and commonplace. Following my evaluation in the emergency room, I was taken directly to the cath lab where a 95% occlusion of my circumflex artery was discovered and uneventfully stented.  I recuperated in the post-op area, was transferred briefly to an inpatient room, and was ultimately discharged at 6:00 PM.  In the aftermath of this whirlwind, surreal day, I found myself at home safe, healed, and marveling with my wife at how I had had my heart fixed from a tiny hole in my wrist.  All that remained was for me to take it easy for a few days, contemplate how my life had changed, and reflect on this stark and jolting recognition of my own frailty.

The care that I received while a patient at the hospital was wonderful – efficient, accurate, and at the same time compassionate and reassuring.  As an attending physician at Phoenixville Hospital for over 30 years, as well as the organization’s CMO and Patient Safety Officer, I have spent countless hours in countless meetings overseeing the hospital’s quality and safety.  Yet experiencing the care provided from this new (and hopefully not oft repeated) vantage point was eye-opening in some unexpected ways.

In particular, I was repeatedly struck by the realization that exemplary health care is truly the sum total of the well-intended, expert actions of a multitude of people.  With due gratitude to, and respect for, the talented physicians who cared for me, their actions would not have been possible without the support of a highly competent and reliable team that comprised both people and machines.  I was repeatedly impressed and comforted by the confident attitudes of nearly everyone I encountered.  Some of these people I knew well and some I had never seen before.  The people who participated in my care, aside from my doctors, included ER nurses, x-ray technicians, laboratory technicians, cath lab personnel, post-op nurses, and telemetry nurses.  But this barely scratches the surface when one considers that the technology brought to bear on me was developed and refined by scores of dedicated individuals whose ultimate purpose was to provide accurate and safe healing to individuals like me.  In many ways, this was a humbling experience, as I must be thankful to a multitude of people, most of whom are actually behind the scenes and will never be known to me.

Many individuals who are involved in the front line of health care, including me, worry about the dehumanizing effect that high technology and specialization has had on patient care.  Doctors and the systems in which they work are so often criticized for being aloof and insensitive to the emotional needs of patients. Health care has become highly business-oriented, often at the expense of the human needs of those for whom the system ostensibly came into being.  Unfortunately, there is much truth to this concern.

However, the realization that I had during my brief hospital stay was that the human aspects of health care can be maintained even in the face of “dehumanizing” technology.  Doctors do less “hand holding” than in the past, but this is at least in part because there is so much more they can do.  Patients expect, and are entitled to, the high technology that modern medicine brings to them,  but they are also  entitled to  the warmth and  caring of the people who deploy that technology on their behalf.  I can happily report that I received both when I was ill.  It was, once again, an eye-opening experience.

The reality is that high-quality health care can only be the result of painstaking design.  The care that I received could never happen were it not for the coordinated actions of hundreds of dedicated individuals.  And so I would like to acknowledge the many people and machines that brought me back to good health.  To my doctors, nurses, technicians and others who provided efficient and compassionate care; to the many people behind the scenes whom I will never know who also contributed to my well-being; and finally to Community Health Systems for providing the structure necessary for all of this to happen – my heartfelt thanks.

Copyright © 2013 by David W. Stepansky.  All rights reserved.

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**Internist David Stepansky is Chief Medical Officer and Patient Safety Officer at Phoenixville Hospital, Phoenixville, PA, and Chair of the Patient Safety Committee of Community Health Systems, Inc., Franklin, TN.

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Procedural Rural Medicine

Posted on March 22, 2013 | 2 comments

“Primary care practice in the future may be more akin to an Amish barn-raising than care delivered by the fictional Marcus Welby.” – Valerie E. Stone, et al., “Physician Education and Training in Primary Care” (2010)[1]

Current proposals to remedy the crisis in primary care, especially among those Americans living in small, rural communities, are politically correct (or, in the case of J-1 waivers for foreign-trained physicians, ethically unacceptable) gestures.  Small adjustments in Medicare reimbursement schedules for physicians serving the underserved and unenforceable mandates by state legislatures that public medical schools “produce” more primary care physicians are all but meaningless.  Rural medicine programs at a handful of medical colleges basically serve the tiny number of rural-based students who arrive at medical school already committed to serving the underserved.  Such programs have had little if any impact on a crisis of systemic proportions.  If we want to pull significant numbers of typical medical students into primary care, we must empower them and reward them – big time.  So what exactly do we do?

  1. We phase out  “family medicine” for reasons I have adduced and replace it with a new specialty that will supplement internal medicine and pediatrics as core primary care specialties.  I term the new specialty procedural rural medicine (PRM) and physicians certified to practice it procedural care specialists.  Self-evidently, many procedural rural specialists will practice in urban settings.  The “rural” designation simply underscores the fact that physicians with this specialty training will be equipped to care for underserved populations (most of whom live in rural areas) who lack ready  access to specialist care.  Such care will be procedurally enlarged beyond the scope of contemporary family medicine.
  2. Procedural care specialists will serve the underserved, whether in private practice or under the umbrella of Federally Qualified Health Centers, Rural Health Centers, or the National Health Service Corps. They will  complete a four-year residency that equips all rural care specialists to perform a range of diagnostic and treatment procedures that primary care physicians now occasionally perform in certain parts of the country (e.g., colposcopy, sigmoidoscopy, nasopharyngoscopy), but more often do not.  It would equip them to do minor surgery, including office-based dermatology, basic podiatry, and wound management.   I leave it to clinical educators to determine exactly which baseline procedures can be mastered within a general four-year rural care residency, and I allow that it may be necessary to expand the residency to five years.  I further allow for procedural tracks within the final year of a procedural care program, so that certain board-certified procedural care specialists would be trained to perform operative obstetrics whereas others would be trained to perform colonoscopy.[2] The point is that all rural care proceduralists would be trained to perform a range of baseline procedures.  As such, they would be credentialed by hospitals as “specialists” trained to perform those procedures and would receive the same fee by Medicare and third-party insurers as the “root specialists” for particular procedures.
  3. Procedural care specialists will train in hospitals but will spend a considerable portion of their residencies learning and practicing procedurally oriented primary care in community health centers.  Such centers are the ideal venue for learning to perform “specialty procedures” under specialist supervision; they also inculcate the mindset associated with PRM, since researchers have found that residents who have their “continuity clinic” in community health centers are more likely to practice in underserved areas following training.[3]
  4. On completion of an approved four- or five-year residency in procedural rural medicine and the passing of PRM specialty boards, procedural care specialists will have all medical school and residency-related loans wiped off the books. Period.  This financial relief will be premised on a contractual commitment to work full-time providing procedural primary care to an underserved community for no less than, say, 10 years.
  5. Procedural care specialists who make this commitment deserve a bonus. They have become national resources in healthcare.  Aspiring big league baseball players who are drafted during the first four rounds of the MLB draft, many right out of high school, typically receive signing bonuses in the $100,000-$200,000 range.  In 2012, the top 100 MLB draftees each received a cool half million or more, and the top 50 received from one to six million.[4]  I propose that we give each newly trained procedural care specialist a $250,000 signing bonus in exchange for his or her 10-year commitment to serve the underserved.  Call me a wild-eyed radical, but I think physicians who have completed high school, four years of college, four years of medical school, and a four- or five-year residency program and committed themselves to bringing health care to underserved rural and urban Americans for 10 years deserve the same financial consideration as journeymen ball players given a crack at the big leagues.
  6. Taken together, the two foregoing proposals will make a start at decreasing the income gap between one group of primary care physicians (PCPs) and their colleagues in medical subspecialties and surgical specialties.  This gap decreases the odds of choosing primary care by nearly 50%; it is also associated with the career dissatisfaction of PCPs relative to other physicians, which may prompt them to retire earlier than their specialist colleagues.[5]
  7. I am not especially concerned about funding the debt waiver and signing bonuses for board-certified procedural care specialists.  These physicians will bring health care to over 60 million underserved Americans and, over time, they will be instrumental in saving the system, especially Medicare and Medicaid, billions of dollars.  Initial costs will be a  drop in the bucket in the context of American healthcare spending that consumed 17.9% of GDP in 2011.  Various funding mechanisms for primary care training – Title VII, Section 747 of the Public Health Service Act of 1963, the federal government’s Health Resources and Services Administration, Medicare – have long been in place, with the express purpose of expanding geographic distribution of primary care physicians in order to bring care to the underserved.  The Affordable Care Act of 2010 may be expected greatly to increase their funding.

————

These proposals offer an alternative vision for addressing the crisis in primary care that now draws only 3% of non-osteopathic physicians to federally designated Health Professional Shortage Areas and consigns over 20% of Americans to the care of 9% of its physicians.  The mainstream approach moves in a different direction, and the 2010 Macy Foundation-sponsored conference, “Who Will Provide Primary Care and How Will They Be Trained,” typifies it.  Academic physicians participating in the conference sought to address the crisis in primary care through what amounts to a technology-driven resuscitation of the “family practice” ideology of the late 1960s.  For them, PCPs of the future will be systems-savvy coordinators/integrators with a panoply of administrative and coordinating skills.  In this vision of things, the “patient-centered medical home” becomes the site of primary care, and effective practice within this setting obliges PCPs to acquire leadership skills that focus on “team building, system reengineering, and quality improvement.”

To be sure, docs will remain leaders of the healthcare team, but their leadership veers away from procedural medicine and into the domain of “quality improvement techniques and ‘system architecture’ competencies to continuously improve the function and design of practice systems.”  The “systems” in question are healthcare teams, redubbed “integrated delivery systems.”  It follows that tomorrow’s PCPs will be educated into a brave new world of “shared competencies” and interprofessional collaboration, both summoning “the integrative power of health information technology as the basis of preparation.”[6]

When this daunting skill set is enlarged still further by curricula addressing prevention and health promotion, wellness and “life balance” counseling, patient self-management for chronic disease, and strategies for engaging patients in all manner of decision-making, we end up with new-style primary care physicians who look like information-age reincarnations of the “holistic” mind-body family practitioners of the 1970s. What exactly will be dropped from existing medical school curricula and residency training programs to make room for acquisition of these new skill sets remains unaddressed.

I have nothing against prevention, health promotion, wellness, “life balance” counseling, and the like. Three cheers for all of them – and for patient-centered care and shared decision-making as well.  But I think health policy experts and medical academics have taken to theorizing about such matters – and the information-age skill sets they fall back on – in an existential vacuum, as if “new competencies in patient engagement and coaching”[7] can be taught didactically as opposed to being earned in the relational fulcrum of clinical encounter.  “Tracking and assisting patients as they move across care settings,” “coordinating services with other providers,” providing wellness counseling, teaching self-management strategies, and the like – all these things finally fall back on a trusting doctor-patient relationship.  In study after study, patient trust, a product of empathic doctoring,  has been linked to issues of compliance, subjective well-being, and treatment outcome.  Absent such trust, information-age “competencies” will have limited impact; they will briefly blossom but not take root in transformative ways.

I suggest we attend to first matters first.  We must fortify patient trust by training primary care doctors to do more, procedurally speaking, and then reward them for caring for underserved Americans who urgently need to have more done for them.  The rest – the tracking, assisting, coordinating, and counseling – will follow.  And the patient-centered medical home of the future will have patient educators, physician assistants, nurse practitioners, and social workers to absorb physicians’ counseling functions, just as it will have practice managers and care coordinators to guide physicians through the thicket of intertwining  information technologies.  We still have much to learn from Marcus Welby – and William Stepansky – on the community-sustaining art of barn-raising and especially the difference between barns well and poorly raised.

[1] Quoted from “Who Will Provide Primary Care And How Will They Be Trained?”  Proceedings of a conference chaired by L. Cronenwett & V. J. Dzau, transcript edited by B. J. Culliton & S. Russell (NY:  Josiah Macy, Jr., Foundation, 2010), p. 148.

[2] The prerogative to develop specialized knowledge and treatment skills within certain areas has always been part of general practice, and it was explicitly recommended in the Report of the AMA Ad Hoc Committee on Education for Family Practice (the Willard Committee) of 1966 that paved the way for establishment of the American Board of Family Practice in 1969.  See N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p.  41.

[3] C. G. Morris & F. M. Chen, “Training residents in community health centers:  facilitators and barriers,” Ann. Fam. Med., 7:488-94, 2009; C. G. Morris, et al., “Training family physicians in community health centers,” Fam. Med., 40:271-6, 2008; E. M. Mazur, et al., “Collaboration between an internal medicine residency program and a federally qualified health center: Norwalk hospital and the Norwalk community health center,” Acad. Med., 76: 1159-64, 2001.

[5] “Specialty and geographic distribution of the physician workforce:  What influences medical student & resident choices?”  A publication of the Robert Graham Center, funded by the Josiah Macy, Jr. Foundation (2009), pp. 5, 47; “Who Will Provide Primary Care And How Will They Be Trained” (n. 1), p. 140.

[6] “Who Will Provide Primary Care And How Will They Be Trained”(n. 1), pp. 147, 148.

[7] Ibid, p. 151.

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

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Re-Visioning Primary Care

Posted on January 2, 2013 | Leave a comment

Existing approaches to the looming crisis of primary care are like Congressional approaches to our fiscal crisis.  They have been, and will continue to be, unavailing because they shy away from structural change that would promote equity.  I suggest the time has come to think outside the financial box of subsidization and loan repayment for medical students and residents who agree to serve the medically underserved for a few years.  Here are my propositions and proposals:

  1. We should redefine “primary care” in a way that gives primary care physicians (PCPs) a fighting chance of actually functioning as specialists. This means eliminating “family medicine” altogether.  The effort to make the family physician (FP) (until 2003, the “family practitioner”) a specialist among specialists was tried in the 70s and by and largely failed – not for FP patients, certainly, but for FPs themselves, who, by most accounts, failed to achieve the academic stature and clinical privileges associated with specialist standing.  It is time to face this hard fact and acknowledge that the era of modern general practice/family medicine, as it took shape in the 1940s and came to fruition in the quarter century following World War II, is at an end.  Yet another round of financial incentives that make it easier for medical students and residents to “specialize” in family medicine will fail.  “Making it easier” will not make it easy enough, nor will it overcome a specialist mentality that has been entrenched since the 1950s.  Further policy-related efforts to increase the tenability of family medicine, such as increasing Medicare reimbursement for primary care services or restructuring Medicare to do away with primary care billing costs, will be socioeconomic Band-Aids that cover over the professional, personal, familial, and, yes, financial strains associated with family medicine in the twenty-first century.  Vague and unenforceable “mandates” by state legislatures directing public medical schools to “produce” more primary care physicians have been, and will continue to be, political Band-Aids.[1]
  2. As a society, we must re-vision generalist practice as the province of internists and pediatricians.  We must focus on developing incentives that encourage internists and pediatricians to practice general internal medicine and general pediatrics, respectively.  This reconfiguring of primary care medicine will help advance the “specialty” claims of primary care physicians.  Historically speaking, internal medicine and pediatrics are specialties, and the decision-making authority and case management prerogatives of internists and pediatricians are, in many locales, still those of specialists. General internists become “chief medical officers” of their hospitals; family physicians, with very rare exceptions, do not.  For a host of pragmatic and ideological reasons, many more American medical students at this juncture in medical history will enter primary care as internists and pediatricians than as family physicians.
  3. Part of this re-visioning and reconfiguring must entail recognition that generalist values are not synonymous with generalist practice.  Generalist values can be cultivated (or neglected) in any type of postgraduate medical training and implemented (or neglected) by physicians in any specialty. There are caring physicians among specialists, just as there are less-than-caring primary care physicians aplenty.  Caring physicians make caring interventions, however narrow their gaze.  My wonderfully caring dentist only observes the inside of my mouth but he is no less concerned with my well-being on account of it.  The claim of G. Gayle Stephens, one of the founders of the family practice specialty in the late 1960s, that internists, as a class, were zealous scientists committed to “a mechanistic and flawed concept of disease,” whereas family physicians, as a class, were humanistic, psychosocially embedded caregivers, was specious then and now.[2]  General internists are primary care physicians, and they can be expected to be no less caring (and, sadly, no more caring) of their patients than family physicians.  This is truer still of general pediatrics, which, as far back as the late nineteenth century, provided a decidedly patient-centered agenda for a cohort of gifted researcher-clinicians, many women physicians among them, whose growth as specialists (and, by the 1920s and 30s, as pediatric subspecialists) went hand-in-hand with an abiding commitment to the “whole patient.”[3]
  4. We will not remedy the primary care crisis by eliminating family medicine and developing incentives to keep internists and pediatricians in the “general practice” of their specialties.  In addition, we need policy initiatives to encourage subspecialized internists and subspecialized pediatricians to continue to work as generalists.  This has proven a workable solution in many developed countries, where the provision of primary care by specialists is a long-established norm.[4]   And, in point of fact, it has long been a de facto reality in many smaller American communities, where medical and pediatric subspecialists in cardiology, gastroenterology, endocrinology, et al. also practice general internal medicine and general pediatrics.  Perhaps we need a new kind of mandate:  that board-certified internists and pediatricians practice general internal medicine and general pediatrics, respectively, for a stipulated period (say, two years) before beginning their subspecialty fellowships.

Can we remedy the shortage of primary care physicians through the conduits of internal medicine and pediatrics?  No, absolutely not.  Even if incentive programs and mandates increase the percentage of internists and pediatricians who practice primary care, they will hardly provide the 44,000-53,000 new primary care physicians we will need by 2025.[5]  Nor will an increase in the percentage of medical students who choose primary care pull these new providers to the underserved communities where they are desperately needed.  There is little evidence that increasing the supply of primary care physicians affects (mal)distribution of those providers across the country.  Twenty percent of the American population lives in nonmetropolitan areas and is currently served by 9% of the nation’s physicians; over one third of these rural Americans live in what the Health Resources and Services Administration of the U.S. Department of Health and Human Services designates “Health Professional Shortage Areas” (HPSAs) in need of primary medical care.[6]  Efforts to induce foreign-trained physicians to serve these communities by offering them J-1 visa waivers have barely made a dent in the problem and represent an unconscionable “brain drain” of the medical resources of developing countries.[7]  The hope that expansion of rural medicine training programs at U.S. medical schools, taken in conjunction with increased medical school enrollement, could meet the need for thousands of new rural PCPs is not being borne out.  Graduating rural primary care physicians has not been, and likely will not be, a high priority for most American medical schools, a reality acknowledged by proponents of rural medicine programs.[8]

Over and against the admirable but ill-fated initiatives on the table, I propose two focal strategies for addressing the primary care crisis as a crisis of uneven distribution of medical services across the population:

  1. We must expend political capital and economic resources to encourage people to become mid-level providers, i.e., physician’s assistants (PAs) and nurse practitioners (NPs), and then develop incentives to keep them in primary care.  This need is more pressing than ever given (a) evidence that mid-level practitioners are more likely to remain in underserved areas than physicians,[9] and (b) the key role of mid-level providers in the team delivery systems, such as  Accountable Care Organizations and Patient-Centered Medical Homes, promoted by the Patient Protection and Affordable Care Act of 2010.  Unlike other health care providers, PAs change specialties over the course of their careers without additional training, and since the late 1990s, more PAs have left family medicine than have entered it.  It has become incumbent on us as a society to follow the lead of the armed forces and the Veterans Health Administration in exploiting this health care resource.[10]  To wit, (a) we must provide incentives to attract newly graduated PAs to primary care in underserved communities and to pull specialty-changing “journeyman PAs” back to primary care,[11] and (b) we must ease the path of military medics and corpsmen returning from Iraq and Afghanistan into PA programs by waiving college-degree eligibility requirements that have all but driven them away from these programs.[12]  Although the Physician Assistant profession came into existence in the mid-1960s to capitalize on the skill set and experience of medical corpsman returning from Vietnam, contemporary PA programs, with few exceptions, no longer recruit military veterans into their programs.[13]
  2. Finally, and most controversially, we need a new primary care specialty aimed at providing comprehensive care to rural and underserved communities.  I designate this new specialty Procedural Rural Medicine (PRM) and envision it as the most demanding – and potentially most rewarding – primary care specialty.  PRM would borrow and enlarge the recruitment strategies employed by the handful of medical schools with rural medicine training programs.[14]  But it would require a training curriculum, a residency program, and a broad system of incentives all its own.

In the next installment of this series, I will elaborate my vision of Procedural Rural Medicine and explain how and why it differs from family medicine as it currently exists.

[1] D. Hogberg, “The Next Exodus: Primary-Care Physicians and Medicare,” National Policy Analysis #640 (http://www.nationalcenter.org/NPA640.html); C S. Weissert & S. L. Silberman, “Sending a policy signal: state legislatures, medical schools, and primary care mandates,” Journal of Health Politics, Policy and Law, 23:743-770, 1998.

[2] G. G. Stephens, The Intellectual Basis of Family Practice (Tucson, AZ: Winter Publishing, 1982), pp. 77, 96.

[3] See E. S. More, Restoring the Balance: Women Physicians and the Profession of Medicine, 1850-1995 (Cambridge: Harvard University Press, 1999), pp. 170-72.  Edith Dunham, Martha Eliot, Helen Taussig, Edith Banfield Jackson, and Virginia Apgar stand out among the pioneer pediatricians who were true generalist-specialists.

[4] See W. J. Stephen, An Analysis of Primary Care: An International Study (Cambridge: Cambridge University Press, 1979) and B. S. Starfield, Primary Care: Concept, Evaluation and Policy (Oxford : Oxford University Press, 1992).

[5] The percentile range denotes the different protocols employed by researchers.  See M. J. Dill & E. S. Salsberg, “The complexities of physician supply and demand: projections through 2025,” Association of American Medical College, 2008 (http://www.innovationlabs.com/pa_future/1/background_docs/AAMC%20Complexities%20of%20physician%20demand,%202008.pdf); J. M. Colwill, et al., Will generalist physician supply meet demands of an increasing and aging population?  Health Affairs, 27:w232-w241, 2008;  and S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10: 503-509, 2012.

[6] See the Federal Office of Rural Health Policy, “Facts about . . . rural physicians” (http://www.shepscenter.unc.edu/rural/pubs/finding_brief/phy.html ) and J. D. Gazewood, et al., “Beyond the horizon: the role of academic health centers in improving the health of rural communities,” Acad. Med., 81:793-797, 2006.  In all, the federal government has designated 5,848 geographical areas HPSAs in need of primary medical care (http://datawarehouse.hrsa.gov/factSheetNation.aspx).

[7] These non-immigrant visa waivers, authorized since 1994 by the Physicians for Underserved Areas Act (the “Conrad State 30” Program), allow foreign-trained physicians who provide primary care in underserved communities for at least three years to waive the two-hear home residence requirement.  That is, these physicians do not have to return to their native countries for at least two years prior to applying for permanent residence or an immigration visa.  On the negative impact of this program on health equity and, inter alia, the global fight against HIV and AIDS, see V. Patel, “Recruiting doctors from poor countries: the great brain robbery?, BMJ, 327:926-928, 2003; F. Mullan, “The metrics of the physician brain drain,” New Engl. J. Med., 353:1810-1818, 2005; and N. Eyal & S. A. Hurst, “Physician brain drain:  can nothing be done?, Public Health Ethics, 1:180-192, 2008.

[8] See H. K. Rabinowitz, et al., “Medical school programs to increase the rural physician supply: a systematic review,” Acad. Med., 83:235-243, at 242:  “It is, therefore, unlikely that the graduation of rural physicians will be a high priority for most medical schools, unless specific regulations require this, or unless adequate financial resources are provided as incentives to support this mission.”

[9] U. Lehmann, “Mid-level health workers: the state of evidence on programmes, activities, costs and impact on health outcomes,” World Health Organization, 2008 (http://www.who.int/hrh/MLHW_review_2008.pdf).

[10] R. S. Hooker, “Federally employed physician assistants,” Mil. Med., 173:895-899, 2008.

[11] J. F. Cawley & R. S. Hooker, “Physician assistant role flexibility and career mobility,” JAAPA, 23:10, 2010.

[12] D. M. Brock, et al., “The physician assistant profession and military veterans,” Mil. Med., 176:197-203, 2011.

[13] N. Holt, “’Confusion’s masterpiece’:  the development of the physician assistant profession,” Bull. Hist. Med., 72:246-278, 1998; Brock, op cit., p. 197.

[14]H. K. Rabinowitz, et al., “Critical factors  for designing programs to increase the supply and retention of rural primary care physicians,” JAMA, 286:1041-48, 2001; H. K. Rabinowitz, et al., “The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later,” Acad. Med., 87:493-497, 2012; H. K. Rabinowitz, et al., “The relationship between matriculating medical students’ planned specialties and eventual rural practice outcomes,” Acad. Med., 87:1086-1090, 2012.

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

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Posted in Family Doctors, Then & Now, Health Care Reform, Healthcare Delivery Systems, Primary Care, Rural Medicine

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Wanted: Primary Care Docs

Posted on November 26, 2012 | Leave a comment

“It will readily be seen that amid all these claimants for pathological territory there is scarcely standing-room left for the general practitioner.” – Andrew H. Smith, “The Family Physician” (1888)

“The time when every family, rich or poor, had its own family physician, who knew the illnesses and health of its members and enjoyed the confidence of the upgrowing boys and girls during two or three generations, is gone.” – Abraham Jacobi, “Commercialized Medicine” (1910)

“More recent investigation shows that almost one-third of the towns of 1,000 or less throughout the United States which had physicians in 1914 had none in 1925. . . . it will be seen at a glance that the present generation of country doctors will have practically disappeared in another ten years.” – A. F. van Bibber, “The Swan Song of the Country Doctor” (1929)

“But complete medical care means more than the sum of the services provided by specialists, no matter how highly qualified.  It must include acceptance by one doctor of complete responsibility for the care of the patient and for the coordination of specialist, laboratory, and other services.  Within a generation, if the present situation continues, few Americans will have a personal physician do this for them.” – David D. Rutstein, “Do You Really Want a Family Doctor?” (1960)

“Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.” – Thomas Bodenheimer, “Primary Care – Will It Survive?” (2006)

“Potential access challenges”—that’s the current way of putting the growing shortage of primary care physicians (PCPs).  Euphemism melodious of care incommodious. Aggravated by the 33 million Americans shortly to receive health insurance through the Patient Protection and Affordable Care Act of 2010 – health insurance leads to increased use of physicians – the chronic shortage of primary care physicians is seen as a looming crisis capable of dragging us back into the medical dark ages.  Medical school graduates continue to veer away from the less remunerative primary care specialties, opting for the  well-fertilized and debt-annihilating verdure of the subspecialties.  Where then will we find the 51,880 additional primary care physicians that, according to the most recent published projections,[1] we will need by 2025 to keep up with an expanding, aging, and more universally insured American population?

Dire forecasts about the imminent disappearance of general practitioners or family practitioners or, more recently, primary care physicians have been part of the medical-cum-political landscape for more than a century.  Now the bleak scenarios are back in vogue, and they are more frightening than ever, foretelling a consumer purgatory of lengthy visits to emergency rooms for private primary care – or worse.  Dr. Lee Green, chair of Family Medicine at the University of Alberta, offers this bleak vision of a near future where patients are barely able to see primary care physicians at all:

Primary care will be past saturated with wait times longer and will not accept any new patients.  There will be an increase in hospitalizations and increase in death rates for basic preventable things like hypertension that was not managed adequately.[2]

I have no intention of minimizing the urgency of a problem that, by all measurable indices, has grown worse in recent decades. But I do think that Dr. Green’s vision is, shall we say, over the top.  It is premised on a traditional model of primary care in which a single physician assumes responsibility for a single patient.  As soon as we look past the traditional model and take into account structural changes in the provision of primary care over the past four decades, we are able to forecast a different, if still troubling, future.

Beginning in the 1970s, and picking up steam in the 1980s and 90s, primary care medicine was enlarged by mid-level providers (physician assistants, nurse practitioners, psychiatric nurses, and clinical social workers) who, in many locales, have absorbed the traditional functions of primary care physicians.  The role of these providers in American health care will only increase with implementation of the Patient Protection and Affordable Care Act and the innovative health delivery systems it promotes as solutions to the crisis in healthcare.

I refer specifically to the Act’s promotion of “Patient-Centered Medical Homes” (PCMHs) and “Accountable Care Organizations” (ACOs), both of which involve a collaborative melding of roles in the provision of primary care.  Both delivery systems seek to tilt the demographic and economic balance among medical providers back in the direction of primary care and, in the process, to render medical care more cost-effective through the use of electronic information systems, evidence-based care (especially the population-based management of chronic illnesses), and performance measurement and improvement.  To these ends, the new delivery systems equate primary care with “team-based care, in which physicians share responsibility with nurses, care coordinators, patient educators, clinical pharmacists, social workers, behavioral health specialists, and other team members.”[3]  The degree to which the overarching goals of these new models – reduced hospital admissions and readmissions and more integrated, cost-effective management of chronic illnesses – can be achieved will be seen in the years ahead.  But it is clear that these developments, propelled by the Accountable Care Act and the Obama administration’s investment of $19 billion to stimulate the use of information technology in medical practice, all point to the diminished role of the all-purpose primary care physician (PCP).

So we are entering a brave new world in which mid-level providers, all working under the supervision of generalist physicians in ever larger health systems, will assume an increasing role in primary care.  Indeed, PCMHs and ACOs, which attempt to redress the crisis in primary care, will probably have the paradoxical effect of relegating the traditional “caring” aspects of the doctor-patient relationship to nonphysician members of the health care team.  The trend away from patient-centered care on the part of physicians is already discernible in the technical quality objectives (like mammography rates) and financial goals of ACOs that increasingly pull primary care physicians away from relational caregiving.

The culprit here is time.  ACOs, for example, may direct PCPs to administer depression scales and fall risk assessments to all Medicare patients, the results of which must be recorded in the electronic record along with any “intervention” initiated.  In all but the largest health systems (think Kaiser Permanente), such tasks currently fall to the physician him- or herself.  The new delivery systems do not provide ancillary help for such tasks, which makes it harder still for overtaxed PCPs to keep on schedule and connect with their patients in more human, and less assessment-driven, ways.[4]

So, yes, we’re going to need many more primary care physicians, but perhaps not as many as Petterson and his colleagues project.  Their extrapolations from “utilization data” – the number of  PCPs we will will need to accommodate the number of office visits made by a growing, aging, and better insured American population at a future point in time – do not incorporate the growing reality of team-administered primary care.  The latter already includes patient visits to physician assistants, nurse practitioners, and clinical social workers and is poised to include electronic office “visits” via the Internet.   For health services researchers, this kind of  distributed care suggests the reasonableness of equating “continuity of care” with “site continuity” (the place where we receive care) rather than “provider continuity” (the personal physician who provides that care).

Of course, we are still left with the massive and to date intractable problem of the uneven distribution of primary care physicians (or primary care “teams”) across the population.  Since the 1990s, attempts to pull PCPs to those areas where they are most needed have concentrated on the well-documented financial disincentives associated with primary care, especially in underserved, mainly rural areas .  Unsurprisingly, these disincentives evoke financial solutions for newly trained physicians who agree to practice primary care for at least a few years in what the federal government’s Health Resources and Services Administration designates “Health Professional Shortage Areas” (HPSAs).  The benefit package currently in place includes medical school scholarships, loan repayment plans, and, beginning in 1987, a modest bonus payment program administered by Medicare Part B carriers.[5]

The most recent and elaborate proposal to persuade primary care physicians to go where they are most needed adopts a two-pronged approach.  It calls for creation of a National Residency Exchange that would determine the optimal number of  residencies in different medical specialties for each state, and then “optimally redistribute”  residency assignments state by state in the direction of underrepresented specialties, especially primary care specialties in underserved communities.  This would be teamed with a federally funded primary care loan repayment program, administered by Medicare, that would gradually repay participants’ loans over the course of their first eight years of post-residency primary care practice in an HPSA.[6]

But this and like-minded schemes will come to naught if medical students are not drawn to primary care medicine in the first place.  There was such a “draw” in the late 60s and early 70s; it followed the creation of “family practice” as a residency-based specialty and developed in tandem with social activist movements of the period.  But it did not last into the 80s and left many of its proponents disillusioned.  Despite the financial incentives already in place (including those provided by the federal government’s National Health Service Corps[7]) and the existence of “rural medicine” training programs,[8] there is no sense of gathering social forces that will pull a new generation of medical students into primary care.  Nor is there any reason to suppose that the dwindling number of medical students whose sense of calling leads to careers among the underserved will be drawn to the emerging world of primary care in which the PCP assumes an increasingly administrative (and data-driven) role as coordinator of a health care team.

In truth, I am skeptical that financial packages, even if greatly enlarged, can overcome the specialist mentality that emerged after World War II and is long-entrenched in American medicine.  Financial incentives assume that medical students would opt for primary care if not for financial disincentives that make it harder for them to do so.  Now recent literature suggests that financial realities do play an important role in the choice of specialty.[9]  But there is more to choice of specialty than debt management and long-term earning power.  Specialism is not simply a veering away from generalism; it is a pathway to medicine with its own intrinsic satisfactions, among which are prestige, authority, procedural competence, problem-solving acuity, and considerations of lifestyle. These satisfactions are at present vastly greater in specialty medicine than those inhering in primary care.  This is why primary care educators, health economists, and policy makers place us (yet again) on the brink of crisis.

Financial incentives associated with primary care are important and probably need to be enlarged far beyond the status quo.  But at the same time, we need to think outside the box in a number of ways.  To wit, we need to rethink the meaning of generalism and its role in medical practice (including specialty practice).  And we need to find and nurture (and financially support) more medical students who are drawn to primary care.  And finally, and perhaps most radically, we need to rethink the three current primary care specialties (pediatrics, general internal medicine, and family medicine) and the relationships among them.  Perhaps this long-established tripartite division is no longer the best way to conceptualize primary care and to draw a larger percentage of medical students to it.  I will offer my thoughts on these knotty issues in blog essays to follow.

[1] S. M. Petterson, et al., “Projecting US primary care physician workforce needs:  2010-2025,” Ann. Fam. Med., 10:503-509, 2012.

[2] Quoted in Nisha Nathan, “Doc Shortage Could Crash Health Care,” online at http://abcnews.go.com/Health/doctor-shortage-healthcare-crash/story?id=17708473.

[3] D. R. Rittenhouse & S. M. Shortell, “The patient-centered medical home:  will it stand the test of health reform?, JAMA, 301:22038-2040, 2009, at 2039.  Among recent commentaries, see further D. M. Berwick, “making good on ACOs’ promise – the final rule for the Medicare shared savings program,” New Engl. J. Med., 365:1753-1756, 2011; D. R. Rittenhouse, et al., “Primary care and accountable care – two essential elements of delivery-system reform,” New Engl. J. Med., 361:2301-2303, 2009, and E. Carrier, et al., “Medical homes:  challenges in translating theory into practice,” Med. Care, 47:714-722, 2009.

[4] I am grateful to my brother, David Stepansky, M.D., whose medical group participates in both PCMH and ACO entities, for these insights on the impact of participation on PCPs who are not part of relatively large health  systems.

[5]E.g., R. G. Petersdorf, “Financing medical education: a universal ‘Berry plan’  for medical students,” New Engl. J. Med., 328, 651, 1993;  K. M. Byrnes, “Is there a primary care doctor in the house? the legislation needed to address a national shortage,” Rutgers Law Journal, 25: 799, 806-808, 1994.  On the Medicare Incentive Payment Program for physicians practicing in designated HPSAs – and the inadequacy  of the 10% bonus system now in place – see L. R. Shugarman & D. O. Farley, “Shortcomings in Medicare bonus payments for physicians in underserved areas,” Health Affairs, 22:173-78, 2003 at 177 (online at http://content.healthaffairs.org/content/22/4/173.full.pdf+html) and S. Gunselman, “The Conrad ‘state-30’ program:  a temporary relief to the U.S. shortage of physicians or a contributor to the brain drain,”  J. Health & Biomed. Law, 5:91-115, 2009, at 107-108.

[6]G. Cheng, “The national residency exchange: a proposal to restore primary care in an age of microspecialization,” Amer. J. Law & Med., 38:158-195, 2012.

[7] The NHSC, founded in 1970, provides full scholarship support for medical students who agree to serve as PCPs in high-need, underserved locales, with one year of service for each year of support provided by the government.  For medical school graduates who have already accrued debt, the program provides student loan payment for physicians who commit to at least two years of service at an approved site. Descriptions of the scholarship and loan repayment program are available at http://nhsc.hrsa.gov/

[8] See the rationale for rural training programs set forth in a document of the Association of American Medical Colleges, “Rural medicine programs aim to reverse physician shortage in outlying regions,” online at http://www.aamc.org/newsroom/reporter/nov04/rural.htm.  One of the best such programs, Jefferson Medical College’s Physician Shortage Area Program, is described and its graduates profiled in H. K. Rabinowitz, Caring for the country:  family doctors in small rural towns (NY: Springer, 2004).

[9] See especially the 2003 white paper by the AMA’s taskforce on student debt, online at http://www.ama-assn.org/ama1/pub/upload/mm/15/debt_report.pdf and, more recently, P. A. Pugno, et al., “Results of the 2009 national resident matching program: family medicine,” Fam. Med., 41:567-577, 2009 and H. S. Teitelbaum, et al., “Factors affecting specialty choice among osteopathic medical students, Acad. Med., 84:718-723, 2009.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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