Saturday, November 29, 2008

Still thankful...

I trust you've all seen it by now: Physicians' Foundation Survey via CNN

Horror of horrors, Half of all primary care doctors (in survey) would leave medicine! For a specialty trying to prove our mettle in the world of evidence-based medicine (and being leaders in the field in many respects), I've heard very little from the rank-and-file disputing the media coverage of this completely misleading and unscientific survey. The response rate was a whopping 4%. Not any selection bias there; of course not. And I'm sure none of the completely unpublished survey questions were in any way leading. (For a different take on the state of primary care that was published about the same time, but again without methodology or listed references: see Getting More: compensation survey shows more income, less pain in primary care.)

I noticed that one of the quoted respondents was noted to be a survivor of the managed care revolution. Again, selection bias likely came into play with that generation of generalists preferentially answering the survey due to their continued angst over the changes forced upon them. They have good reason to be disillusioned. Reading Shannon Brownlee's Overtreated helped me realize what that change really meant for doctors used to getting patients through personal referrals and keeping them for life. They knew these people and their families, and they were trusted by both patients and insurers to make the right decisions for their patients.

The main problem with that system was that doctors were often not making the best decisions for their patients. In our technology and liability laden culture, doctors were signing on to fancy imaging and interventional technology as fast as it came, protecting themselves from liability fears by overtesting, and semi-unconsciously churning out prescriptions for whatever brand-name newfangled medicine the pharmacy reps were stocking in their sample closet. Evidence-based-medicine was not commonplace terminology, much less patient-oriented evidence or point-of-care decision aides. (And how could they be? Remember your first email program from 1994, how it wouldn't even backspace? Google wasn't invented until 2001. You doctors of my generation, just try to find an up-to-date, evidence based answer for a foreground clinical question in that 1986 Harrison's in under a minute. Go on, try it....)

As Brownlee so well explains, costs were rising with abandon under the venerated system that trusted physicians and patients to make sound decisions based on individual cases and incremental learning. Some would argue the cost only represented the great strides in technology and research that were making U.S. health care great, except that all the data showed that health outcomes were not getting better, and in some cases were worse. What's more, other countries with equal access to research and technology were not burning up health care dollars so fast. Neither were the few U.S. health maintenance organizations. They had better than average outcomes with much lower costs. With a focus on primary care and prevention, and cost-control measures coordinated by a central management that had the vantage point of seeing trends and results in aggregate, it could be done.

So it's no wonder insurance companies decided they could be that central management for all their doctors, even though they never had such a relationship with them before. Of course, since the change was initiated by people who cared about money above all, it's no wonder we got the "managed" part with very little in the "health" department. (Notice how the name changed from having "health maintenance" as the focus to having management at the focus? Not good...). In the end, outcomes got no better, and the patient rebellion thwarted the cost-control as well. But we've somehow been left with all the same paperwork, rules, and restrictions. And now we have payment based on Relative Value Units that undervalue chronic disease management, mental health, and any type of counseling.

I have been left with this legacy as well, so I sympathize with the disgruntled doctors from the survey. But what is evidence-based medicine if not the ability to learn from our mistakes? We so want to take surveys like this one to policymakers to back up our whining and legitimize our complaints, but what do we really want? Do we want fee-for-service back? Do we want everything to go back magically to the way it was in 1988 and pretend that costs won't keep skyrocketing or that people can and should pay cash or deductibles for primary care, even though the average American makes under $50,000 (1*) and mean office-based visit charges per person per year are over $1400 (2**)? We often say we want better payment for chronic care and care management, which would help, but only if we actually earn it by doing a better job.

The article suggests that we want more money so that we can attract more students to primary care, which is exactly where this type of survey shoots itself in the foot. Do we think anyone will want to be a primary care doctor after reading this dismal complaining? If our goal is to keep food on our own tables, let's say that. If our goal is to convince policymakers to help us reform insurance and delivery mechanisms, let's go to them with real research that means something to patients. If our goal is to recruit smart, thoughtful, well-rounded and innovative people into primary care, let's forget these crazy surveys and shout out the great challenges and rewards of being family doctors. Let's tell them not what we're upset about, but our hundreds of ideas to fix this broken system. Let's tell them how exciting it is to be at the forefront of medicine at a time in which we have learned from the managed care mistakes, have evidence-based medicine actually becoming a reality, and have a growing power to influence the return of health care to what is truly best for the patients and the country as a whole. For all of you who spent precious time returning that survey, please remember, there really are undergraduate and medical students out there interested in primary care who are watching you. They may be the next great hearts and minds who have the potential to turn this system around; don't let them become Botox technicians because of what you say.

I had Thanksgiving dinner this week with church friends who taught me a Latino aphorism: "Lo mejor es que malo esta poniendo." It means, "the best thing is how bad it's getting." Perhaps it's human nature, perhaps vested interests, perhaps just inertia, but it is true that we often have to let situations get desperate before we become motivated enough to tear down the old ways and rebuild with something better. Primary care is at that verge for real this time. And I, for one, am thankful. I am thankful that:
I have a job that encourages me to form lasting relationships with many people; that
being a family physician forces me to use both sides of my brain and exercise my heart; that
my days average more delicious variety and interesting challenges than mundane frustrations; that
the field for research in primary care is ripe with possibilities, that
I do live and work in the age of Google; that
the crumbling of the health care system and the downturn in the economy may serve to awaken us to the realities of poverty, disparities, irresponsible use of resources, and the very un-patient-centeredness of our current approach to health, and that
we have a significant opportunity to turn each of those problems around.

But we have to start telling the story right. We have to start with why we're thankful to be family doctors, and then work for our patients in the system the way we always did for them in the clinic.

Source 1: *Median household income $50,740, nonfamily household $30,909 in 2007. US">Census update

Source 2: **mean/median office-based charges/person/year 2005 when "0" category taken out of calculations: $1474, $430, respectively. MEPS 2005

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