Sunday, August 29, 2010

Primary Care - My KALW Interview

It wasn’t the prospect of a hanging that did it in my case. For me, my mind was concentrated by my being interviewed for KALW by a very intelligent journalist on the subject of primary care. I’ve always said, if you can’t explain something so that an intelligent layman can understand it, you probably don’t understand it enough yourself. I don’t know how it will be for the listeners, but for me it was a very good educational experience. It clarified my thinking.

Being me, I found the interview an opportunity to disagree with all three of the other interviewees for this project, all of whom I know and like: Tom Bodenheimer, MD, of UCSF internal medicine; Kevin Grumbach, MD, of UCSF family practice, and Richard Scheffler, PhD, of UCB School of Public Health. Interestingly, I found myself to the traditional Right of the two academic docs, and skeptical of Richard’s traditional economics view of medical care, although let me say, not dismissive of any of them. They are all smart and thoughtful and worthy on all levels.

Tom has published great articles on the plight of primary care, and accurately focused on money as the biggest problem. Some people say primary care is too difficult to do, not professionally rewarding enough as compared to specialities, etc. Tom doesn’t buy this and neither do I, and neither does Kevin for that matter. For a person-oriented physician, noth other specialty provides the long term relationships of primary care. But faced with the prospect of primary care for $120-$190K a year, vs. anesthesiology for $600K a year – is this a choice? Not to mention cardiology, ENT, ortho, various surgical specialties, etc. You don’t have to be an economist to figure this one out. But my interviewer said, do primary care doctors need more money, or as Tom Bodenheimer says, are the primaries getting enough, it’s the specialists that need to get less, so the choice of a medical student is less economically based?

Time to disagree with Tom. I’m reminded of one of Martin Amis’s books on Russia, when the young people are parading around saying, No One Should Be Rich! An old lady says, I remember when we said, No One Should Be Poor!

Tom (and Kevin) represents a strand of medicine that I call the missionary strand. We do have a priestly role, but I personally have no desire to wear a hair shirt, and neither do most doctors. I don’t ask for poverty, I ask for an even playing field. It’s true that doctors in the US make more than in other countries, but that’s not true of primary care docs. If all doctors were to make less money, medicine would be less attractive to the elite, and I’m for as many smart and aggressive and entrepreneurial and progressive and inventive minds as possible in medicine. Economics works.

My interviewer said, but given more money, would the doctors just bank it? I said, to some extent, but then what we see now is primary care doctors with insufficient resources to bulk up the office with nurses and other personnel – we train the staff, then they leave for hospitals and specialists offices, where the money is. We are asked to be a medical home, calling patients on the phone to see how they are doing, and directing patients and spending more and more resources for patients, but to do this we need more money to spend. It has to stop all going to hospitals and specialists – but I guess I’ve mentioned that.

Would primaries do that, spend some money on the practice as well as bank some of it? They would if there were a fair market. Patients appreciate these aspects of care, they aren’t hidden as are some aspects of quality. So patients would choose to visit the doctors who had beefed up their offices with the enhanced payments they receive. In this case, the market would work.

Kevin says that hankering for the past security of your friendly neighborhood doctor is passé. He says that much of primary care can be accomplished by midlevels (nurse practitioners and physicians’ assistants), nurses, and others, so we should husband our physician resources and save money and be more efficient by having independent nurse clinics and much more clinical work done by others than doctors. I disagree.

First of all, the problem of medical cost does not stem from primary care, it stems from the money pit of hospitals and specialist services, and IMHO it is more a price problem than a volume problem. So you’re going to fix a money problem occurring elsewhere by economizing in primary care? I think this is a very poor solution. Since I tend to be sometimes belligerent, I say – Don’t give in to those schmucks!

At Bayside we have NP’s and PA’s and we love and respect them, definitely. My own step-daughter often chooses to go to a PA for her own care. But our PA’s often go over to our lead FP MD and ask him questions, seek assistance and direction, etc. They are not doctors, and they don’t think they are.

What is it that makes me value a doctor so much? Is it because I am one? I don’t think so. Mid-levels do well on measurable quality parameters, but quality assessment is still rather rudimentary. The deeper considerations a doctor makes, the questing after difficult diagnoses, the balancing of judgment calls – doctors weren’t highly selected and highly trained for nothing.

Kevin is right that we need to beef up our offices with personnel other than physicians – the medical home is a good and important concept. But he needs to be a little less enthusiastic in calling for a substituting for primary care doctors and economizing. In our country we should be able to afford primary care doctors, and we should be able to afford a first-class primary care system.

Kevin also seems to represent a potent line of thought that the Obama Administration has mindlessly adopted – that we need to have larger systems of care – Kaisers and other large entities – and primary care needs to get out of the communities and into the large organizations. I couldn’t disagree more. The local doctor’s office is personal, and the best doctors in these offices care for their patients, and moreover, care about their patients in a way that an employee of a large organization just won’t. Sorry, they won’t. And anything that a primary can do in a large organization with quality enhancement, we can do in our local offices. I personally think the offices need to be larger than just one office, but the best offices can do it even with three or four docs. They just can.

An example of caring: my friend Bob Shimizu is a long time pediatrician at Lamorinda Pediatrics in Lafayette. He recently cut back his hours markedly and feels much more relaxed. I asked him what the big difference was. He said, “The worrying. I would get so worried about some of my patients. That was really getting me down.” Worrying outside the office. Caring about his patients, not just caring for his patients. Think that’s happening at Kaiser? Betcha not.

Richard had not yet been interviewed so whom I couldn’t comment on what he had said. But I had read his interesting book, Is There a Doctor in the House, and my interviewer was sharp enough to anticipate some of what he would say –do you agree with Scheffler that it is all right to have to wait to see a doctor?

My answer is no. In this respect, medicine is not like other goods and services. It is OK to wait for cable installation, but it is not OK to wait to be evaluated for sudden feelings of weakness and arm pain that could be musculo-skeletal, or could be heart. Urgent care and ER care are not substitutes for good primary care by your own doctor whom you know, and who care about you and you know cares about you, and who is good and competent, and you know is good and competent. There is no substitute, and waiting is not OK. As I said, I like and respect Richard, but his strength is also his weakness, which is that he is an economist. Waiting might be fine in economics because it is cost sparing, but add into early detection the issue of patient anxiety, and you have to be better staffed than what is envisioned by economics. Plus, it’s all because of the horrendous rents paid to monopolistic systems of care at the hospital and specialist levels that we even contemplate savings in primary care, which is so inexpensive by comparison.

I loved being under the pressure of this interview, but typical of me, I found a way to disagree with everyone else on the panel. But hey – I still think I’m right. Don’t you?

Budd Shenkin

1 comment:

  1. The Kevinist point of view, currently enjoying wide popularity, doesn't seem even internally consistent, in that it advocates for a) independent nurse clinics but also b) huge physician groups.

    Huh? We're going to let the midlevels be small and independent practitioners, with *less* oversight, but physicians must form huge coalescing entities to be "efficient"?