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October 25, 2010


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L Gordon Moore

Certainly we need a supportive environment for primary care to come back from the brink and thrive. Income and workload equity are part of a supportive environment as well as the tools and time to do our work well.

Regarding practice size:
There are people very happy with giving and receiving care in large institutional settings with very high quality of care. Group Health Cooperative of WA is one example. There are others who would not like to work in or receive care from such settings.
Quality and satisfaction are possible in many practice settings.

Regarding working in teams:
Whatever our own practice configuration we are all working with others. There is very good evidence supporting multidisciplinary team work for patients with diabetes, depression, almost any chronic condition you can name. Even if you work with no staff you and your patients benefit from input from others in the health system. The concept of high functioning teams applies science to the function of the team. This makes it possible to work with others in ways better than average and to achieve better than average goals: quality, satisfaction, capacity.

By defending the benefits of teams I dont mean to say that solo practices have to hire a bunch of people, Im saying that we can learn how to better interact with others in the health system to benefit our patients and our practices.

Coordination of care is one of the fundamental tenets of primary care. We are responsible for the administrative work of coordinating. The current payment and policy environment punish us for engaging in this work, but if it were funded we would be able to afford the time and team to do it well.

Robert Watkins

"It is theoretically possible to have a highly coordinated and thus effective clinical team delivering great and satisfying care"

But do we know that this is what patients want? And do we know that working as a team leader, spending less time in direct patient care, will attract more med students into primary care?
The PCMH really seems more centered around administrators and bureaucrats than patients.

"The pressure for team stems from concerns over primary care workforce shortage"

Yes, and this is one of my concerns about the whole PCMH concept. It seems to be a distraction from really addressing the factors (low pay and difficult working conditions) that are the cause of the PCP shortage.


L Gordon Moore

For the most part the principles of PCMH make sense to me. I too am concerned that large panel size runs the risk of more disconnected impersonal care leading to worsening experience of care (see Nutting et al
Annals of Family Medicine 8:S33-S44 (2010)doi: 10.1370/afm.1119).

It is theoretically possible to have a highly coordinated and thus effective clinical team delivering great and satisfying care to a large panel of patients, though I fear many teams will fail to adopt the necessary attributes that lead to high performance. The pressure for team stems from concerns over primary care workforce shortage as well as the recognition that our work always involves others.

Let the panel size float, let us provide care for as many as we can well manage and let us stretch to expand that number in response to our nations need for more primary care, but let us also know when to stop that expansion: when it eats into the quality and care our patients deserve.

Robert Watkins

I'm surprised you cite the PCMH as a model for good primary care. Though people frequently forget it, the PCMH model assumes that the physician has a larger patient panel, spends less time with each patient, and spends more time surpervising members of the "team" who actually interact with the patient. Seems like the exact antithesis of good primary care to me.


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