In my own practice and working with others I've been exploring answers to the question "What does it take to be a PCP in the US delivering great care while having an enjoyable and fulfilling professional career?"
The good news is that we have a pretty good idea of what it takes, the bad news is that in almost every practice we have to get the doc off the hamster wheel where productivity has trumped health care. When we push volume of services beyond the capacity to fulfill our professional obligations we end up with ethically unsound practice and a compromised and unhappy work force.
The problem with getting the PCPs off the hamster wheel is that this exacerbates the primary care shortage in the US [of course the shortage is due to miserable professional working conditions, but that's another post].
Some folks think that it is unethical for a physician to reduce their panel size. I think it is unethical to continue to deliver inadequate care to an overly large panel of patients; but I don't believe that we're stuck having to choose between two mutually exclusive options.
Our salvation is recognizing we have options - this is not an all-or-nothing choice. As I mentioned in my previous post we can get at the root cause of primary care shortage by creating practices capable of delivering great care while having an enjoyable and fulfilling professional career. We will see the ranks of primary care swell with new physicians, but this will take time.
What to do in the meantime?
Consider reducing demand for primary care services and/or increasing primary care supply through investment in high functioning multidisciplinary care teams. Some examples:
Is it necessary in every circumstance for a person to have a face-to-face visit with an MD to obtain a vaccine? We could offer vaccines as a community resource through pharmacies, schools, etc. This would take a substantial amount of work out of the PCP office, allowing them to care for more people.
I know that no solution is without difficulty - I'm just suggesting that "face to face with MD" need not be the only solution tested.
Is it necessary in every circumstance for a person to have a face-to-face visit with an MD to explore physiotherapy for musculoskeletal problems? How about health coaching to improve self management of chronic conditions and improving lifestyle? These ideas (tested and published) reduce the demand for face-to-face time with MD.
[I can hear a whole lot of physicians getting into "But what about nightmare scenario X!" thinking. Hold on a second guys - I don't discount 'nightmare scenario X' but let's agree that it is not always necessary to have a face-to-face visit with MD and go from there.]
Some smart health care delivery models offer direct access to non-MD services for those needs that do not require an MD, thus decompressing the bottleneck of primary care. This approach can powerfully shift the demand for PCP and could potentially extinguish the primary care shortage.
What's in the way of solving the primary care shortage?
- Health care policy and payment that dictates face-to-face visit with MD as the source of $$$
- Doctors afraid that if other do some of the work their profession will be irrevocably eroded
- Work force skill deficits on how to do this well (exp high functioning care team)
So before folks out there start sharpening knives to carve up the audacious innovators who choose to get off the hamster wheel and deliver great care, consider your real willingness to explore the full slate of options.
The real issue is that physicians and medical practices have been discouraged from innovating and providing more efficient care by the third-party payment system. The behemoth institutions of government and insurance corporation have held back the advancement of primary care for the past 3+ decades. Direct-model practices are the only ones attempting to actually reduce the cost of health care where it matters - at the point of delivery.
Posted by: WR Neuhofel | December 08, 2009 at 06:22 PM