The Battle Continues

The stage is set for major health policy reform, but there is no clear solution in sight. Part of the problem is that there is no one issue that explains all of the failings of America’s health care system: it is described as a “systems problem” exacerbated by malpractice litigation, decreasing health insurance coverage, decreased incentives for physicians to enter primary care, increased utilization of emergency resources, and many other factors. Having completed my Family Medicine (primary care) and Internal Medicine (hospitalist medicine) clerkships, I’m more aware now of the considerable ideological differences between primary care physicians and specialists. For example, the way physicians handle scientific evidence varies greatly. Many physicians in academic centers and hospitals are willing to change their practice of medicine based on a single, well-designed ground-breaking study. However, primary care physicians are much more conservative in their changes: while it may seem that they are “outdated,” they ideally focus on making changes based on a broad base of evidence (many studies over several years) to minimize costs and maximize effectiveness. In other words, PCPs don’t care as much about “expert opinions” and new discoveries and instead focus on what appears to be repeatedly proven truths.

There are great merits to both schools of thought, and American medicine benefits from having this dichotomy. It is clear that there is a problem with primary care in this country, and most people consider it to be a shortage of primary care physicians. However, I’m discouraged by the proposals that varies policymakers, physicians, and others make in an effort to solve this problem. For example, some propose increasing primary care payments at the expense of specialist payments. While this seems honorable to reassert the value of “cognitive” specialties (e.g. medical care based on actually knowing your patients and individualizing their care rather than medical care based on delivering specific treatments), it doesn’t seem sensible to “lower” the value of specialist care: after all, it’s the specialists that drive discovery and research (developing new and better treatments, discovering new knowledge on how to better treat diseases, etc.). Furthermore, there’s a shortage of specialists in many areas of the country (i.e. distribution is an issue). Others propose requiring medical graduates to do a year or two of primary care before starting their residencies. This proposal makes very little sense to me: what happened to the notion of “continuity of care?” It would not necessarily help patients to inject a fresh supply of young and inexperienced medical graduates into communities only to have them leave a year or two later (after seeing their patients maybe 3-5 times). Lastly, the AAMC is requesting medical schools to increase their enrollment of students by as much as 30% with hopes that this will increase the total number of physicians that can enter primary care specialties and practice in underserved areas. While this will likely help to some degree, this doesn’t change the incentives contributing to the current problems.

Some people seem to be bothered by President Obama’s focus on health information technology as an initial centerpiece of health care reform during his term, but this I do not see this as a fault. If anything, health information technology is low-hanging fruit: the lack of interoperability between electronic medical record systems and the continued reliance on paper documentation is a frustratingly backwater problem (e.g. reliance on fax machines, errors made based on poor handwriting, time wasted in documentation, etc.). There are many hospitals and communities in which electronic systems are very functional and useful, while there are also many others where it has been poorly implemented. Laying the groundwork for a more functional, national intranet makes sense with respect to reducing the long-term costs of overutilization: much the way medicine is practiced (e.g. ordering tests and interventions) revolves around finding information (that may already be available in older records and is not volunteered or remembered by the patient). While eventually all of the other issues will need to be addressed, I don’t think it is a problem starting with a relatively more straightforward issue.

  1. The different types of technology adopters you describe is reminiscent of those categories described in Gordon Moore’s book on the life cycle of technology companies, Crossing the Chasm.

    He talks about how early adopters will quickly adopt new technologies because they are looking for immediate major benefits and are to some extent interested in technology for its own sake. Unfortunately, these early adopters are not the folks who make up the bulk of a market–you want to attract the so-called “early majority” who really care about their domain of expertise, more than technology, but who ARE willing to adopt it once they see evidence of other members of the early majority using that technology to good effect. (Reaching the early majority is called crossing the chasm, and if your companies doesn’t do it, your company will probably die.) Anyway, it sounds like the same distinction that you describe.

    By the way, I wonder about this–“It would not necessarily help patients to inject a fresh supply of young and inexperienced medical graduates into communities only to have them leave a year or two later” I definitely see where you are coming from. This seems like a way of trapping medical students into primary care about making them comfortable in a position they didn’t set out to get, and decide to stay due to inertia.

    Interesting point about medical records being a way of reducing tests by finding information that has already been collected. Is that a hypothesis, or is that something you have seen frequently happen?

  2. Apollo said:

    About finding information: that’s a problem I’ve seen with majority of my patients. In my primary care clerkship, we spent a lot of time tracking down tests done during some hospital stay, and during my Internal Medicine clerkship, we kept trying to have the PCPs for our patients fax over medical records. Many times patients did not know their diagnoses for chronic conditions or the names or doses of the medications they were taking.

    Furthermore, even in the hospital on a single ward it is a pain: we (medical students, residents, attendings, nurses, etc) waste so much time just trying to track down the one chart for the patient we’re looking for because dozens of people use that same chart each day. All of the hospitals I work in have hybrid systems (paper-based charts with limited electronic documentation for lab values, imaging studies, etc.), and we spend more time just trying to farm information out of the computer and from the charts than we spend in the patient rooms.

  3. Thanks, I enjoyed reading your post. Its nice to see someone writing something worth reading. Take care.

    – Jack

  4. mar said:

    I will be starting medical school this fall, but have been working for the past half year in medical records for a large cardiology practice. I cannot explain how much time, effort and resources are wasted in having paper medical records. The endless printing, faxing, signing, and movement of paper and charts is horrible- not to mention the countless hours spent trying on just trying to FIND the notes, studies, and charts in and between offices. It really is sad. Hopefully, whatever reform in healthcare actually takes place, making medical records electronic is a big part of it.

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