Wednesday, February 19, 2014

How Many Health Professionals Does It Take To See a Patient in a Primary Care Office?

Two heads are better than one.

John Heywood (1497-1580),  Proverbs (1546)

Medicine is, or should be, a confidential one-on-one relationship between patient and physician.

A  belief of many physicians

How many?

It depends on how you define “health professional.”


Do you define a  health professional  as  the primary care physician?

Then the answer may be one, as Doctor Gordon Moore, a primary care physician,  explained in a 2002 article “ Going Solo: One Doc, One Room, One Year Later, American Academy of Family  Medicine, March 2002).  In his article,  Moore  carefully pointed out, it also takes  a trusty computer with broad band access to the Internet.

The answer could still be one,  if you accept the premise of  doctors practicing  “retainer medicine,” aka, direct pay or concierge, medicine.  These physicians believe in a one-on-one doctor-patient relationship with 24/7 access,  patients being seen on the day they call, longer face-to-face visits,  and pay either at the time of care delivery or on the basis of a monthly or yearly retainer fee.

Many More

Then  the answer  may be many more if you  practice as part of an integrated team at Kaiser Permanente, as set forth by Doctor David Lawrence,  former chairman and CEO of  Kaiser, in his excellent book, From Chaos to Care: The Promise of Team-Based Care (Perseus Publishing, 2002).  

The Kaiser Team

 In his book, Lawrence  listed these members of  a team  delivering  integrated care to preven manage and treat disease.

·         Doctor, the leader

·         Nurse care manager, the glue of the team

·         Other physicians , e.g, for the patient with diabetes, a cardiologist, a nephrologist, an ophthalmologist, an endocrinologist, even a surgeon

·         Other professionals, - nutritionists, pharmacists, social workers, health educators, nurse practitioners,  physician assistants

·         Alternative Providers -   Chiropractors, Osteopathic physicians, Yoga and acupuncture specialists, and managers for stress, chronic painl sports-injuries, and addiction

Doctor Lawrence  presents a compelling case that his approach works better with better outcomes than the traditional one-on-one relationship of patients to doctors.  And it works better if all of this takes place under one corporate roof with clear information exchanges between the various team members. His underlying message is: it’s the system, not the individual doctor or the individual patient who drive the health care bus.

Cambridge Health Alliance Team

In a similar vein of health care integration,  in yesterday’s Wall Street Journal,  Laura Landro,  gives this  list of  health providers on the health care team with their duties at Union Square Family Health Center in Somerville, Massachusetts one of 15 primary care centers  of Cambridge Health  Care Alliance affiliated with Harvard Medical School  (“The Team Can See You Now”,  February 18, Wall Street Journal).  The article’s subheading tells the story, “Why Visit One Doctor When Some Offices Offer a Medical Entourage?  Physician Shortage Drives Trend.”

Team Members and Duties

Landro says team members and their duties include:

·         Doctor – Supervises medial team, diagnoses patties, peformsm procedures, prescribes medications.

·         Social worker – Assists patient with needs like transportation  and financial assistance  , connects patient to behavior  health services for depression.

·         Physician Assistant – Handles routine consultations,  manages lab results, point person when doctor isn’t available. 

·         Pharmacist – Advises  Patients  on how to take drugs  correctly and possible side effects and interactions, adjust dosages, and helps manage chronic pain.

·         Medical Assistant – Takes patients’ vital signs, prepares them to see doctor, takes blood for lab tests, tracks follow-up appointments.

·         Registered   Nurses – Performs triage and directs some patient visits like prenatal counseling.  Helps patient adopt healthier life styles.

The Team –Based Idea

The idea behind team-based care is to allow team members to  practice at the highest level allowed by their training and license.  Team-based care is not without dissenters.  Many doctors resist it.  A  majority of patients, according to a study by a California Blue Shield study, prefer to be seen  first and in some cases, only by a doctor.   But 94% of patients participating in team-based care said they liked it, and 81% said they were willing to try it. 

For larger integrated health organizations,  like Kaiser and Health Partners in Boston and in many academic centers,  team-based care is how medicine is practiced now.   For independent physicians in private practice, team-care is less desirable, and they prefer other options relying more on their personal skills and training.    

What we are witnessing is the evolution of a two-tier medical system, with one tier being handled by  organizations and the other by personal physicians.

Tweet:  Medical practice is evolving into a two tiers – one system consisting of team-based care, the other of personal physicians practicing independently.

No comments: