Ideal Medical Practices

GP waiting time target scrapped: eliminating delays for care has "no clinical justification"...???

via news.bbc.co.uk

A very interesting bureaucratic move in the National Health Service. The source of this problem is likely multi-factorial and quite complex, but I have to point out some flaws in perception if not policy.

The NHS is getting pushback from their GPs (primary care workforce; equivalent to U.S. Family Physicians, primary care Internists, Pediatricians).  The GPs have too much demand for patient care.  They worry that truly needy patients will end up with delayed appointments due to a national policy that everyone is seen within 48 hours of appointment request.

What's the solution?  Add delays to the system.  Hmmm.

The logic goes like this:  some patients are needy, others not so much.  We (health care professionals) can tell what is 'urgent' and what can wait.  Patients can't tell, they all think that their own stuff is urgent and we can't trust them.  Given a fixed limit on time and resources, we can take time away from actual patient care to spend time and resources instead on sorting patient demand.  This will make sure we have the right folks seen on time. 

This 'mother-may-I' approach turns nurses and doctors into high-priced schedulers, deflects professional time away from actual patient care into administrative work.  In the U.S. we've seen this approach lead to increased use of the emergency room, increased rates of hospitalization, increased cost of care, decreased satisfaction (both professional and public).  So much for 'no clinical justification.'

Adding waits and delays into health care systems is bad for the health of the population served and is bad policy.  Better to understand the root cause of supply/demand miss-match and right the problem. 

What Makes for a ‘Top’ Medical School: the disconnect between medical schools and national priorities

“So doctor,” she said as I pulled my stethoscope out to listen to her heart, “where did you go to medical school?”

via www.nytimes.com

Terrific piece by Pauline Chen describing the stark disconnect between our national health care workforce needs and what our medical schools produce.

Our nation desperately needs a larger and more effective primary care workforce.  This need is driven by the decades of research linking high performing health systems to good primary care.  People who have more access to good primary care (easy access, good relationship, comprehensive services, care coordination) are less apt to end up the hospital or emergency department - an outcome we can all agree is in our personal as well as collective best interest. 

Even better, people who receive good primary care are more apt to have preventive care needs met and those with chronic conditions are more likely to have those conditions under better control.  Adding to the benefits: people with good primary care are less likely to miss days from school or work and their total costs of care are lower.

Populations served by high concentrations of intensivists/proceduralists/specialists have increased cost with no demonstrable (and sometimes worse) overall outcome improvement.*

U.S. medical schools are pumping out ever increasing proportions of intensivist/proceduralist/specialist that our country does not need while the pipeline of primary care dries up.

One root cause of this problem is the way the NIH funds medical schools.  Inside the industry, medical school rank is a pissing contest to see who gets the biggest NIH check.  The bulk of NIH funding goes to highly specialized research while very little supports the core issue plaguing our nation today: ineffective, over stretched, over burdened primary care unable to meet the needs of America. (And I suspect almost nothing is spend to study how to better support solo and small practices that still make up the majority of practices in the U.S.)

Our national culture equates dollars with value.  The low dollar flow to primary care research implies low value and predicts the culture of medical school faculty who systematically belittle primary care as a career choice and berate those who admit an interest in primary care.** An expressed interest in primary care can turn the back-to-back specialty rotations of third and fourth year of medical school into a prolonged hazing incident.

Nothing short of a major funding shift will change this culture.  The occasional rotation with a PCP, the extra lecture or two from a community primary care physician, the extra residency slots for primary care are all nice but all fail to address the root cause: money.

It is time to stop this misadventure in funding that supports systematic bias against our urgent needs as a nation.  Washington must send a clear signal that the status quo is unacceptable with a major shift in funding to support research in effective primary care.  This federal signal would force medical schools to stop considering primary care orphan step-child of medicine and consider its rightful place as the foundation of a high performing health system.

* Starfield, B:  Threads and Yarns: Weaving the Tapestry of Co-morbidity Ann Fam Med 2006;4:101-103

See also the Dartmouth Atlas

** Hauer KE, Durning SJ, Kernan WN; et al. Factors associated with medical students' career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.

Putting the meaning back in 'meaningful use': lessons from the AAFP's National Demonstration Project

The evaluation of patient outcomes in the American Academy of Family Medicine's National Demonstration Project (a.k.a. 'TransforMED' project) is written up by Jaen et al in the Annals of Family Medicine supplement here.

This projected included a terrific evaluation team that really dug into a broad swath of data to understand the impact on patients.  They measured patient experience of care with the core attributes of primary care: access, relationship, care coordination & comprehensiveness of services, as well as a number of indicators of chronic disease management.

I want to point out a very common misconception in the office practice communities:  "Doing Open Access" is meaningless unless your patients report that their access has improved.  The industry standard of "number of days to third available appointment" with "future fill rates" are proxy measures.  They mean nothing if the patients in the practice report that their access has gotten no better.

After learning from the masters (Murray & Tantau) and implementing advanced access in my own practice, I have helped many achieve dramatic improvements in access and was one of the IHI faculty teaching this intervention to hundreds of practices from around the U.S.  There are a hundred ways to make the proxy data look good but accomplish nothing meaningful from a patient's perspective.

"We can see you today but you won't be able to see your regular PCP" is a fail because we trash one pillar of primary care to support another.

Making "Number of days to third available" go to zero by essentially cooking the schedule books is a fail.

Access success is not achieved when "sure we can see you today" is coupled with "But we run out of appointments by 11AM."

It is possible to truly improve access and to know with confidence that the improvement is real.  The way is to ask the patients in the practice to report on their experience with access.  Patients are the ultimate arbiter of access success/failure.  Populations of people who have good access are less likely to skip needed appointments, are more likely to follow up with their chronic condition follow-up appointments, are less likely to end up in the emergency room and are less likely to be hospitalized.

Patient experience of care with access is hard wired to meaningful outcomes as noted above.

Our industry has lost sight of the meaning of our work when we credit ourselves with success for things that have no meaningful impact on the lives and health of those we serve.

The AAFP's NDP/TransforMED project has demonstrated that their high cost/low relative value approach is not a path likely to lead our nation to the kind of robust primary care we need so that we can become a high performing health system.  At this point any large purchaser of health care or agency that funds improvement & innovation ought to be surveying the field for other paths, ones lined up with meaningful improvements in patient experience of care measures linked to important outcomes.

Is the 'medical home' concept a pointless journey down a list of technical box-checking?

The articles in this supplement demonstrate that it is possible for highly motivated, largely independent practices³ to implement most of the predominantly technological components of the PCMH.⁴ This implementation results in improved indicators of chronic disease care as assessed from medical records, but at the cost of reducing the quality of key attributes of primary care as rated by patients, at least over the 26 months of the NDP.^4,6

via www.annfammed.org

The journey is likely not pointless.  It is a good thing to improve 'indicators of chronic disease care as assessed from medical records,' especially if there is a link between better numbers in medical records and outcomes that patients really care about like better functionality and fewer hospitalizations.  It is also very important to try new things and see what we can learn about improving our currently not-so-good outcomes.

The troubling nature of this work as pointed out in this editorial in the Annals of Family Medicine supplement on Medical Home is that the experts on measuring health care quality in practice seem to be off track, in pursuit of small bits of chart data while missing the big picture.

When patients say that their access to care is no better, that the relationship with their PCP is no better, that comprehensiveness of care and care coordination are not better, we have failed to improve on the fundamental attributes of primary care.  Troubling in this journal is the indication that in fact these attributes got worse during the study.

As these attributes predict a high performing health system, I don't think it is too soon to predict that this whole bandwagon of micro-measurement & blizzard of reporting and data mining will amount to very little except to create and support ever-growing bureaucracies of measurement, data mining, and reporting.

In fact, as predicted by many PCPs and others working in the front lines of care, much of this top-down labor intensive overly bureaucratic approach to improvement is not only stifling, it seems almost gamed to support large organizations at the expense of solo and small practices.  The current approach is overly complex, burdensome, and largely tangential to the real work we do that helps people.

Adding a set of patient experience metrics to the current burdensome tangential approach is nice, but doesn't solve the underlying problem of focus on too many things, diverting attention from what is important, distracting us from work we should be doing for our patients instead of jumping through hoops for external reporting requirements. Measurement is good and just, but let's focus on the right work and the right amount of measurement.  Things have gone way too far.

Our nation would be well served if it would take one small step to support truly innovative approaches to primary care - approaches that work even in solo and small practice and demonstrate and improvement not only in chart reviewed data but in patient experience of care and most importantly lead to results that patients would stand up for: reduced hospitalization and emergency room utilization.

We need pilots of other approaches, approaches not run through massive bureaucracies or expensive consultancies but accessible through simple on line support that honors adult learning theory and the exigencies of practice in the front lines.  Give volunteer practices a lifeline - some breathing room to get off the hamster wheel and a simple set of resources that open their eyes to how they perform on the key metrics of primary care: access, relationship, comprehensiveness, coordination.  Track hospital and ED use for preventable conditions.  Simple, clean, actionable, accountable, and totally lined up with effective primary care and the outcomes we all want.

The burgeoning recognition of effective primary care as the foundation of high performing health systems deserves or wholehearted support. Mindless pursuit of minutia and further diversion of front line time and resources to chase data rainbows does not.  Let us pursue meaningful data, let us pursue improved patient experience of care especially as it is linked to the very outcomes we want and need: improved meaningful outcomes like fewer people landing in the hospital due to preventable illness and complications.

The Human Side of Doctor-Patient Relations - as if this shouldn't be there all the time?

Soon-to-graduate medical students, from left to right, Ronald Zviti, Shriji Patel, Marisa Earley and Nakul Raykar, met with cardiac patient Albert Naples on May 25 at the University of Medicine and Dentistry of New Jersey as part of a program that pairs medical students with dying patients; Mr. Naples died two days later.

via www.nytimes.com

Ok, first off let me say that this is a good program and I want it to succeed and expand. Medical students paired with people in the hospital who are dying and have no one to be with them.

The bit that gets me is that we've gotten so caught up in the gizmos and technology of health care that we forget the core of what we do is in the interaction.  We've stripped dignity and respect out of our profession by labeling patients as "non compliant" as opposed to taking the time to truly listen and better understand why a person might choose not to follow the course prescribed by their physician.

We are so infatuated with procedures, imaging, and pharmaceuticals - for which I am professionally and personally indebted but let's get some perspective going here folks!  Relationship is the vehicle of our work and often trumps other interventions we deploy.  Patients who respect their physician are more likely to have a colorectal cancer exam (a nasty but valuable intervention).  Patients are more likely to respect a physician who they say listens to them and treats them with respect (by not keeping them waiting too long, for instance).

This is a great program UMDNJ, keep it up.  Let's see more programs like it across the country, but for goodness sake, let's figure out how to get a beleaguered health care workforce off  the hamster wheel so that our natural inclination to interact with and support our patients can have unfettered reign.