The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.
Paul Starr, The Social Transformation of American Medicine, 1984
How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.
But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.
The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.Continue reading…
The New York Times recently published an article titled the Family Can’t Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and “doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat…larger practices tend to be less intimate”
As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service. How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing. Of course, there was a price. His life was focused solely around medicine which was the norm of his generation. Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.
The New York Times article and many patients typically confuse high quality care with bedside manner. Not surprising. In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:
The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments
The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient. This is bedside manner. The last two items relate to whether a patient can be seen quickly and easily when care is needed.Continue reading…