Thursday, April 14, 2016

Primary Pediatrics Laboratory #2

Readers have responded to my proposal for a Primary Pediatrics Laboratory.
#1 Some have pointed out that the proposal needs to meet the objection that it ignores the needs of the general population and might be seen as promoting a double (or even more levels) standard of care.
#2 Others have wondered if we should be looking for ways to test better methods and increasing use of midlevel practitioners as a way of stretching scarce resources of money and personnel.
Answer to objection #1: Building the ideal in a model practice is just that, building an ideal. It's not a prescription for a whole system. You put all your money and effort into building the Warriors, and then the rest of the basketball world can look on with wonder, and emulate as possible. The Warriors inspire, and they instruct. Laws then support a fair distribution of resources. Building the Warriors doesn't hurt, rather it helps the school teams and summer leagues around the nation.
Answer to objection #2: the PPL is kind of a mind bender, or paradigm shifter.  We are so used to operating under budget constraints and being good citizens in primary care.  Think like a procedural specialist where the money just rolls in -- think fine art and walnut paneling of our cardiology colleagues instead.  They are used to thinking in exactly the opposite way we think.
Imagine if cost were no object -- no object.  Where the task was to go higher and higher in every way.  Think different.  Does anyone think about cost when designing a new, better aortic valve?  Etc.  Think about primary care being the Cadillac,  What would you do?
In fact, in an academic center where money could be abundant, could you achieve the highest quality care possible?  No one really tries.  Primary care tries tries this and that, but not the whole ball of wax.  But it is possible to do so.  The barrier is simply our way of thinking.
Benefactors generally think of the traditional -- more top heart surgery, more that sort of stuff, more really deluxe hospitals.  Benefactors want to see kids in their beds getting better because of something their money bought.  But benefactors also think of fixing education in primary care terms, so it is possible that they could look at things differently.  What they need is a proselytizer.  I haven't seen that pediatric primary care proselytizer; the world is looking for that leader.
Think of the Peter Bent Brigham Hospital and the recent scandal of treating a Middle Eastern prince differently as they rent out several rooms on the top floor.  What if, instead of attracting royalty for specialty services, someplace like the Brigham hoped to construct the same quality service for primary care, no costs too high, no patient/clinician ratio too low?  What could one do?  I can think of lots of things.
Someone will want to be that leader. I wonder where it will be.

Budd Shenkin

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