“England and America are two great nations separated by a common language.”
-attributed to both Winston Churchill and George Bernard Shaw
In 1965 I spent the summer of my third year in medical school at the General Practice Teaching Unit of the Royal Infirmary in Edinburgh, Scotland because I wanted to learn more about the National Health Service (NHS). My impression then was that both the U.K. and U.S. medical care systems were evolving toward the same end result from very different directions. (1) That viewpoint has been reaffirmed by recent events. Both countries have embarked this past year on significant health care reform. Both countries are seeking to reduce costs, improve quality, become more patient-centered, and invest in health information technology (HIT). In both countries the majority of patients are highly satisfied with the NHS or Medicare and are vigilant about not giving up any of its benefits.
Both health care reform acts are being criticized for being too timid, or too bold, or too incremental, or too radical. The U.K. plan is being attacked by some as a disastrous turn toward privatization while the U.S. plan is “another step toward socialism”, i.e. very little change in the tenor since 1965. Vocal U.K. critics on the left decry the proposed move away from regulation (NHS) toward competition and market-place economics while the vocal U.S. critics on the right warn against more regulation and movement away from reliance on competition and market-place forces.
Increased Primary Care Support
The basic foundation of the NHS has always been General Practice physicians (GPs) who have no hospital privileges and refer all patients needing hospitalization to full-time hospital specialists (Consultants). (2) In 1965, and in 1996, such a separation of outpatient and inpatient medical practice was threatening to community physicians in the U.S. (3) Today it is difficult to recruit primary care physicians (and some specialists) to a community unless the hospital has hospitalists to care for inpatients. The community-based internist in U.S. is now more like the GP in U.K. then ever before, and that is not a bad thing.
The most common question first year medical students ask me is how do they become efficient at taking a patient history. Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?
When can they stop asking about the review of systems, a list of questions asked about each organ system? A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?
Patients lie and don’t even know it. It’s not that they mean to. In fact, they are trying to be helpful when giving a history of their symptoms. Medical students concerns about taking a fast history reflects two things. First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past. Second, more importantly, is their fascination and desire to get started on real medicine — what are the diagnoses, treatments, and tests that must be learned to be a good doctor.
In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening. Taking a good history is the essential part of being a good doctor.
Here are two examples of patients who I saw during the winter. The practice is busy this time of year. I’m often running late. Like many encounters, I’ve never met these patients before. In many ways, it can feel like an urgent care practice. Which patient is lying? Can you tell?
Twenty years ago, IMS Health got the idea to purchase prescription records from pharmacies, license physician information from the AMA’s Physician Masterfile, and link the two databases so as to create something new and different: prescriber-level data (PLD).
It was a brilliant idea. Almost immediately, pharmaceutical and device companies, government analysts and public health officials began lining up to buy raw PLD and/or the reports that IMS created from it.
And with good reason. By applying statistical tools to analyze PLD (a technique known in the vernacular as “Data Mining”) IMS and the purchasers of its data could obtain fresh insight into many topics of interest. These include prescribing pattern variations across regions, where and when influenza outbreaks occur, how physicians respond to these outbreaks and hundreds of others. Drug makers found PLD information to be particularly helpful. With it, they could refine marketing pitches and improve sales force efficiency, among other things.
Since those early days, the scope of the data compiled by IMS and other PLD providers has expanded to a point where it is truly breathtaking. The AMA Masterfile includes current and historical data on 880,000 physicians. IMS and similar companies collect information on more than 70% of all prescriptions filled in the US. SDI Health, another PLD provider, has billing information from 100% of inpatient and outpatient activity at 500 hospitals dating back to 2002. Their databases are large enough to detect national trends and withstand the most exquisite stratification analyses. Furthermore, PLD providers have perfected ways to exclude information from their databases that could be used to identify patients, so the data comply with HIPAA and other privacy-protecting laws.
I have been a strong proponent of the creation of a National Health Record (NHR), but will it increase the quality of care for each citizen? Without 100 percent compliance by all healthcare providers the establishment of the NHR will bear little fruit for its expense. Proponents of a NHR site the achievements of the VHA. VHA patients include highly mobile active and inactive soldiers. Ubiquitous methods for viewing clinical data are critical, however Joe Outpatient doesn’t move around in this manner nor does he stray far from the facilities where he receives care.