Primary care needs a new model of office practice
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7504.E358 (Published 09 June 2005) Cite this as: BMJ 2005;330:E358
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Bravo to the always thoughtful and innovative Dr. Scherger, and to the BMJUSA for discussing this critical issue. The approach articulated is probably the only reasonable path for the survival of primary care medicine - as running any faster on the volume treadmill is clearly not desired by patients or doctors. Here are a few other ideas to add to the concept: (1) eCare does not have to be asynchronous. In our current system, where paid care is in person, and email is something that some of us atune to (and others sign on intermittently) - asynchronicity seems to be a reasonable compromise. However, with a changed payment model, real-time eCare might be preferrable, with defined hours and conditions (much like technology companies and Internet ISPs have the ability for "real-time chat"). (2) In addition to the other components listed in the article, I believe that care coordination should be added. This aspect of primary care medicine, which was a regular part of our practice day before the pressures of managed care forced us to turn as much time as possible into "billable hours," is enabled by interconnected electronic healthcare - but like eCare, will not re-emerge without a changed payment model. I noted that another article in this issue of BMJUSA raised the question of the absence of the "the medical lead" and the negative impact on care when the medical lead was absent. (3) The % of eCare as opposed to in-person care may actually be quite high (particularly for PCPs and certain specialties). In my practice of general internal medicine - I have estimated that as much as 50% of the patients I see could be safely and more efficiently taken care of with eCare. In some specialty practices, such as endocrinology, that % may be even higher.
One question - Dr. Kamerow's editorial makes it clear that the roadblock to progress is the financing model (which I agree with); and Dr. Scherger quotes Don Berwick as saying the problem is one of a "lack of will and ambition." Are Drs Berwick and Scherger stating that the lack of "will and ambition" is that of payers, or of PCPs? I agree with Dr. Scherger that we are now all so busy that we don't have time to think about new models of care and practice redesign - but I also believe that we will learn to do things differently if a changed payment model were to emerge (after all - we all learned how to practice within the confines of managed care).
Competing interests: None declared
Competing interests: No competing interests
Editor:
Primary care can not be reduced to a brief office visit model of practice or to an alternative to hospital care or, in some context, to a health care model for low resources setting. Primary care attention is a philosophy where its heart is the individual, –not necessarily the sick person- their family and their community, where well educated, skilled and motivated actors –doctors, nurses, social workers, others professionals, etc- working together --in friendly connection with peoples and with the society-- have the appropriate technology to promote health, to prevent diseases and to treat patients. This model could receive the support of the new technologies such as Scherger is proposing (1) but never that new technologies will substitute the human warm that this special relationship need to operate adequately. I know that this is a lot work, sometime ungrateful, but it has been a challenger since Sculapio to the present time.
Dr. Scherger is calling us to change. I don’t sure how feasible and acceptable could be this “type of care” –electronic mediated- to US and UK citizens but as others calling from the North it is ignoring again that the world is more than a few set of richest countries. Africa and Latin America have together fewer computers and phone lines than US. However, I agree with Dr. Scherger: now is the time to radically change how primary care is delivered. Now and from the South is the time to extent the coverage of the primary care, to achieve better accessibility and quality of care. A new primary care for all can help us to reach a healthy nutrition, to stop the tobacco spread, to reduce the infant mortality, to eliminate some pre-historical diseases, to control HIV/AIDS pandemic, to prevent the coming epidemic of cardiovascular diseases. Primary care might be a success technology to accomplish the Millennium Goals (2) and to solve our debts with Alma Ata. (3) Several aspects of the Cuban practice which has been centered on primary care (31 000 family physician/68 000 medical doctors, total population = 11 million) , political prejudices apart, provide as realistic demonstrations of the value of that strategic approach. (4)
References: 1. Scherger JE. Primary care needs a new model of office practice. BMJ 2005; 330: 358-359 2. “Global Health Problems, Millennium Development Goals and the World Bank’s Role.” http://www.worldbank.org/oed/gppp/case_studies/health/global_health.html?goog=3099 (Accessed May 12, 2005). 3. “The Declaration of Alma Ata”. www.who.int/hpr/NPH/docs/declaration_almaata.pdf 4. Spiegel JM, Yassi A. Lessons from the margins of globalization: appreciating the Cuban health paradox. J Public Health Policy. 2004;25:85- 110.
Competing interests: None declared
Competing interests: No competing interests
Great Ideas, Tort Reform Necessary
Dear Editor,
Dr Scherger provides us with excellent insight about new models for office practice. Without such changes to traditional medical practice, it will be difficult to care for our patient’s needs – now and perhaps more so in the future. There is one aspect of American medical care that is relevant to pursuing any new models of care - the American tort system as it applies to medical malpractice.
The first thing I thought of when I read the article was ‘how will these changes impact my risk a law suits?’ and ‘will online care, team practice and self management of illness lead to greater liability?’ I am sorry to say that before I consider changes to my system of care, I must first consider liability issues, then consider patient benefits. I do not believe such sentiment is rare. It seems that any time two doctors talk for more than a few minutes the liability crisis and how it interferes with our delivery of quality care enters the conversation. Additionally, there is data to support that, at least here in Pennsylvania, many (92 %) physicians practice defensive medicine (1).
The way things stand now, I can not imagine trying to defend a lawsuit involving a case where there was no face to face patient encounter. I would be concerned with excessive liability if I were to implement some of Dr. Scherger’s suggestions. For example (this is my opinion and not supported by research that I know of), many patients that call their family doctors after hours are sent to the emergency department to be evaluated, often for relatively minor problems. Twenty years ago, many of these problems were handled over the phone. Now, fear of lawsuits sends our patients to the emergency department, adding to the cost and inconvenience, with little evidence that outcomes are improved. Would the situation be the same about Internet communications?
Changes to our health care delivery system are necessary and inevitable. But without realistic changes to the current tort system, needed improvements to our health care system will be met with resistance due to real or imagined fear of litigation resulting from those changes. In other words, without first changing the tort system, our patients may not get the opportunity to receive the better medical care they deserve.
1. Studdert DM, et al. Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment. JAMA. 2005;293:2609- 2617.
Thomas G. Phillips, MD Assistant Director The Washington Hospital Family Medicine Program
email: tphillips@washingtonhospital.org
Competing interests: None declared
Competing interests: No competing interests