By HANS DUVEFELT
(Note: Hans is reprising some of his greatest hits. This one is from 2014 and leans directly into my current and future obsession with fixing primary care.Matthew Holt)
Primary care doctors, as things are organized in this country, perform three types of services. If we don’t recognize very clearly how fundamentally different they are, we run the risk of feeling overwhelmed, exhausted, 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, at least in this country, has become more or less seen as a nuisance in primary care offices. We keep some spaces open for sick people, in part because the Patient-Centered Health Home recognition process requires it. But our clinics may be concerned that those spaces will remain empty and cause a loss of revenue.
Instead, the sick disperse to emergency rooms with overcrowding, high overhead, and liability-driven testing overloads or to free-standing walk-in clinics that are only sometimes integrated with the primary care office but universally staffed by providers who do not know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced physicians within their organizations, and they do what I believe is the most challenging job in healthcare: separating very sick patients from moderately sick or even completely healthy but concerned patients.
In the worst case, the outpatient clinic is independent and operates without any access to primary care or hospital records, starting from scratch with each patient. Some of these clinics are well equipped, with laboratories and X-ray facilities and highly qualified staff. But some are set up in a room in the back of a pharmacy and staffed by a lone nurse practitioner with minimal equipment and no backup.
Since healthcare in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anyone think it would be like this?
MANAGEMENT OF CHRONIC DISEASES
More and more people suffer from chronic diseases such as diabetes, hypertension and autoimmune diseases. This is where most of the primary care work is done. Much of this is simple and predictable: diabetics have their glycated hemoglobin checked every three months, hypertensives have their blood pressure records and blood tests checked at certain intervals. And unfortunately, much of it is ineffective. Few people lose weight, improve their blood sugar levels, or change their lifestyle. Our visits follow the same tired routine from time to time: “I’ll do better this time, doctor.”
The more the burden of chronic disease increases in our country, the more doctors’ time and effort this type of work will consume. And we need to ask ourselves if there isn’t a better way to manage chronic diseases.
We already know that group visits can be very successful thanks to the power of peer support. And even when limited to Zoom, they can be effective. They are certainly more efficient than talking to patients one by one, over and over again, like a broken record. Frankly, that’s getting old.
In addition to group visits, this aspect of primary care can also be easily performed or at least supported by technology. There are already apps to monitor blood sugar, blood pressure, exercise and sleep. I’m sure there are more apps already available and even more in development. Feedback from all this data can be easily managed using artificial intelligence, leaving only the final decision making and personal touch in the hands of the medical provider. (More on why the personal touch is still necessary in a future post.)
PREVENTION AND DETECTION OF DISEASES
It doesn’t take a dozen years of professional education to tell people to get routine vaccinations, offer screening colonoscopies, or administer standardized questionnaires for anxiety, depression, alcohol, or domestic abuse or anything else that politicians and bureaucrats think we doctors should do.
My professional opinion is that this work is too routine to require a medical license, but could be performed safely by non-providers or even by computers with very rudimentary programming.
I also question the logic of bombarding patients with these things when they come in for a sick visit with a lot of concerns and questions they hope to have time to address. In fact, I wonder why these things aren’t done outside of the visit, through outreach through our patient portals, newsletters, phone calls, emails, or even paper letters.
What I do think is that these exams can and probably should be done under the umbrella of the patients’ primary care “medical home.” But I strongly oppose the erroneous assumption that this data collection is medical work. However, the doctor should be available during the course to manage positive results.
(In my EMR, the doctor has to approve even normal screening tests in a very cumbersome workflow as part of an office visit. Why not have a standing order and automated process to flag the provider only for scores above a certain value?)
Prevention and screening services to 331,000,000 citizens, one-on-one and face-to-face, for countless 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’s a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford it.
Hans Duvefelt is a doctor, author and creator of “A rural doctor writes”where this piece first appeared.
