Primary Care Dilemma: It’s Not What Wonks Think : It's How Patients Act

Between the idea
And the reality
Between the motion
And the act
Falls the Shadow

T.S. Eliot (1886-1965), The Wasteland (1922)

July 23, 2011 - I’ve heard critics express the idea a thousand times in a thousand ways.

The Idea

The idea goes like this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

The Shadow

The problem is between the idea and reality falls a shadow.
Patients aren’t listening. They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem.

Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care.

The Problem Comes Home

This problem came home to me yesterday. I accompanied a patient to visit her primary care doctor. When her primary care physician diagnosed late-onset type 2 diabetes, she informed him, “ Please refer me to an endocrinologist who specializes in diabetes.”

He replied, “But I can handle your situation perfectly well. I have all the resources and knowledge needed to manage your illness , including a nutritionist and a team of other providers, to handle your diabetes.”

“No, “ she said, “ I want to see an endocrinologist, inside or outside your system.” She was not concerned about the “fragmentation” of the system.

The Dilemma

Therein lies the dilemma – whether patients chose to be handled by “systems of care,” and funneled through a primary care generalist within the system or to go directly to a specialist of their own choosing.

This is not a trivial matter. It stands in the way of widespread establishment of Primary-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs). And it will be a point of dispute between primary care physicians, specialists, and patients. Many patients feel they are perfectly capable of choosing what doctors to go to.

Patients are often unaware of background arguments about primary care doctors working proactively to keep patients healthy, coordinating patient care, achieving measurable better outcomes, and focusing on “whole patient care,” rather than specialists addressing specific illnesses, offering life-style procedural salvations and one-on-one solutions.

In choosing doctors, patients still prefer to think for themselves, rather than having others think for them. If their decision involves “waste” for the system, so be it. One person's idea of waste may not be reality-based.