Re-designing the practice of Medicine

The traditional model of medical practice, where a solo physician controls the management decisions of his or her patients, is slowly yielding to a more collaborative and patient-centered model.  Or is it?

The general practice of medicine in the United States tends to be an individualistic and physician-oriented endeavor. Nationwide trends, however, are seeking to redesign the clinical practice into one that is patient-centered and comprised of multidisciplinary teams. A field study of three different primary care practices – a solo practice, a certified patient-centered medical home, and an academic multi-specialty practice – serves to illustrate that the redesign of medical practices is still in its infancy.

The current study utilized an ethnographic approach to describe these three distinct types of internal medicine practices. For each practice type, researchers sought to understand the roles, routines, and experiences of various members of the health care team including physicians and support staff. In total, the study sample consisted of five physicians, nineteen professional and administrative staff, and nine patients.

Over one-third of physicians practice in a solo or two-person practice. This style of practice is typified by one or two physicians, one or two nurses, and a receptionist and/or an office manager. Nearly one-half of physicians practice in a group setting (which includes HMOs) or a medical school or public faculty arrangement.

Over the past 10 years, health policy experts and quality advocates have pushed for primary care physicians to practice in defined patient-centered medical homes (PCMHs). As defined by the National Committee for Quality Assurance, PCMHs are a medical practice model where each patient has an ongoing relationship with a personal physician who leads a team that shares responsibility for patient care.

When comparing these different practice types, researchers noted more similarities than differences. Regardless of practice type, most team members practiced in separate silos. Physicians tended to work in a “frantic bubble” of activity, seeing patients in continuous one-on-one interactions scheduled every fifteen minutes. Physicians felt isolated and rarely collaborated with other staff.

The experience of professional staff was more relaxed; staff often assisted and covered for one another. Their experiences were much more collaborative and flexible.

Patient experiences were often marked by unpredictable and consuming waits. Conclusions to office visits were ill-defined and led to confusion for many patients.

The study revealed that the practice of medicine currently is devoid of adequate time and teamwork. Physicians scramble to work in a manner that limits thought, reflection, and collaboration. Staff feel disempowered to collaborate with clinicians. Patients are left in limbo. Office schedules and routines revolve around physicians and not patients.

Commentary
Health policy experts believe that the movement from traditional solo practice designs to group practice and ultimately to the patient centered medical homes will empower patients in the healthcare system. Current observations suggest similar experiences for all the above practice types, casting doubt on the PCMH model.

Realistically, the PCMH model is merely a reiteration of what all primary care physicians should be doing anyway: fostering a personal patient-physician relationship, serving the needs of patients at all hours, and appropriate referral to specialists and support services needed by each patient. PCMH certification appears to identify primary care practices that are doing what they should be doing anyway. What our healthcare system needs to consider is how to best integrate (1) alternative sites of care such as retail clinics and (2) alternative clinicians such as physician assistants and nurse practitioners.

Could integrated systems, like Geisinger, sprout across the nation to offer continuity, convenience, and specialty care? Not without the free flow of patient information.

Medicine (and privacy hawks) must take a lesson from the banking industry. Credit cards and ATMs permit secure access to financial information, releasing consumers from their bank’s schedule. A universal medical record – accessible by physician offices, retail clinics, hospitals, and patients themselves – will facilitate a patient centered approach to health care delivery.

Chesluk BJ and Holmboe ES. “How teams work–or don’t–in primary care: a field study on internal medicine practices.” Health Affairs. 2010; 29 (5):874-9.

by
Cedric K. Dark, MD, MPH