Physicians writing on KevinMD about the primary care shortage, the fifteen-minute visit, panel size, what primary care is paid against procedural specialties, continuity, and the administrative load that has grown around the work. Four maintained records draw on this archive: Primary care: what physicians say, in their own words, Direct primary care: what physicians say, in their own words, Prior authorization: what physicians say, in their own words, and Scope of practice: what physicians, nurse practitioners, and PAs say, in their own words.
If you listen to the pundits, the future of medicine is big: big medicine, big data. And indeed the healthcare policy of our nation is couched in the promise of what is to come. Many dictates of the accountable care act focus on the ability to aggregate and consume a variety of inputs. ICD-10, EMRs, and meaningful use all tie nicely into a beautiful computational orgy.
Big data, however, has it drawbacks. One wonders if in …
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Do we want big medicine or good medicine?
Several years ago I cut my hand badly on a broken glass and required surgery to reattach a tendon. For a few weeks after the operation, I attended regular sessions in a physical therapy department devoted to people with hand injuries. There were no closed curtains in the large therapy room — we bared only our hands, after all. As I had my fingers warmed, splinted, or stretched, I observed …
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Education that occurs among patients in a group
As Americans we spend more money on healthcare per capita than any other nation in the world. We have the latest medical innovations and for decades have been able to provide cutting edge therapy without regard to cost. However, as a profession, doctors are not doing nearly enough when it comes to prevention of disease. Certainly, costs will be reduced if we are able to prevent chronic illness and associated …
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The powerful effects of culture and lifestyle on health
This past weekend I spent time relearning some life lessons.
On Saturday, I picked up a couple screens from the hardware store to reinstall them after they were nearly destroyed by our neighborhood bear. The bear seems to think she will find the birdfeeder that used to hang nearby, so she stands on our deck and leans on whatever is nearby (our screened porch) while she looks for it. Then she heads …
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Overcoming the resistance to same day appointments
The following column was published on May 29th, 2013 in the New York Times’ Room for Debate blog, which asked the question, “Is Obamacare too complicated to succeed?”
Is the Affordable Care Act complicated? Of course it is. Even one of its architects concedes that it is phenomenally complex. Why? To pass, it had to be contorted to satisfy a number of special interest groups.
As its major reforms are implemented …
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Complicated Obamacare clears a very low bar
Racial disparities in health and healthcare are a persistent and troubling problem for the U.S. Despite substantial policy efforts to the contrary, racial and ethnic minorities, especially African-Americans, often receive a lower quality of care and have worse outcomes. The key questions, of course, are why do these disparities exist, and what might we do about them?
Over the past decade, two primary theories have emerged to explain disparities and propose …
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Addressing racial disparities in health care
Clear communication from doctors, nurses, hospitals and clinics is essential for patients to manage their health care effectively. But creating easily understood materials isn’t simple. Many health workers don’t realize when they’re using technical terms, and many non-medical people have problems reading and understanding scientific and mathematical concepts.
Fortunately, several web sites offer helpful advice about how to create patient-friendly educational print materials. Two of the most useful are the National …
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How to create clear patient education materials
Medical care in the U.S. over-promises and under delivers. It costs about twice as much as in most other developed countries, but compared to them manages to produce only mediocre health outcomes. The profit motive has resulted in badly misallocated resources — too much testing and treatment for people who don’t need it and lousy access for many who do.
The impact of advances in medical science on the delivery of …
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Confronting the reality of uncertainty in medicine
My patient and I had spent most of the 45-minute appointment discussing the challenges of living with diabetes and some ways that he could begin changing his eating and exercise habits. I started to wrap up the visit and asked him, “Which of these changes can I follow up with you about next week?”
He looked at me incredulously and said, “You are supposed to tell me what to do: I’m …
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The patient is the center of the medical home
A paper in JAMA Surgery noted that patient satisfaction ratings have very little to do with the quality of care provided by a hospital. The study analyzed data from 31 hospitals that participated in patient satisfaction surveys, the CMS Surgical Care Improvement Project (SCIP), and employee safety attitudes questionnaires. They found that patient satisfaction did not correlate at all with the rates of hospital compliance with SCIP process measures nor …
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A doctor guilty of fraud has great patient satisfaction scores
Twelve years ago, in its landmark study Crossing the Quality Chasm, the Institute of Medicine (IOM) found that “the health care industry is plagued with overutilization of services, underutilization of services, and errors in health care practice.” In simple English, the IOM reported that health care was riddled with overuse, underuse and misuse of medical services.
The IOM also defined quality health care as “the degree to which health services for …
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Some patients are receiving too little care
In 2006, as I was starting my geriatrics fellowship, we started renovating our home.
This took almost two years from start to finish. It was a long, arduous, expensive, and often stressful process. And this experience ended up profoundly influencing my philosophy as a primary care physician, and my approach to practicing medicine.
To this day, I’ve had minimal experiences as a primary care …
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What being a primary care patient has to do with home renovation
As a practicing primary care doctor, I very much believe that better care is when patients are engaged and share decision making with their doctor. Though in the past doctors treated patients in a paternalistic manner, my generation of doctors has been taught to uphold a balanced doctor-patient relationship and partnership. This change in balance of power has accelerated with the ease and availability of information via the internet. More …
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Why shared decision making is difficult in practice
Family physicians told us they are more comfortable with uncertainty than the “ologists.” For a little history, the Future of Family Medicine project published in 2004 identified this mental attribute as an important defining skill of family physicians.
This ability manifests itself across the entire spectrum of family medicine.
An example is reassuring a young mother that her infant with a fever will probably be fine – and ordering no …
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Family physicians are more comfortable with uncertainty
Walgreens, the country’s largest drugstore chain, announced that its 330+ Take Care Clinics will be the first retail store clinics to both diagnose and manage chronic conditions like asthma, diabetes, high blood pressure, and high cholesterol. The nurse practitioners (NPs) and physician assistants (PAs) who staff these clinics will provide an entry point into treatment for some of these conditions, setting Walgreens apart from competitors like Target and CVS whose …
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Chronic care at Walgreens: Should we see how this plays out?
Have you heard that soon most primary care in the U.S. will be delivered by teams?
Yep. Team-based care is one of the characteristics of the patient-centered medical home, a way of organizing the care of patients that allows primary care clinicians to see more patients in a day while at the same time delivering better care. This move toward team-based care started long before health care reform and was embedded …
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What will health care teams mean for patients?
My friend Anne loves her primary care doctor.
“He is a really good guy,” She recently told me. You can just tell. You can hear his big booming laugh in the waiting room, the examination room, the bathroom. You don’t even mind waiting for him when his last appointment runs over because you know that he will give you his undivided attention when you’re with him. And you know that if …
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How the purpose of primary care is defeated
It feels dangerous to write this, but … my practice seems to be working.
But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from …
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The early success of a new practice model
