There's a big buzz about primary care being a great thing; and there are a lot of people toting it as a lynchpin of financial reform. I believe this is true. But there is a condition that must be met for any of this true. It must be primary care done well. The idea of good primary care is an assumption that may not be valid for many PCP's. There are many good PCP's out there, and I believe they constitute the majority, but there are also those who have frustrated and discouraged patients. I think this is mostly due to a payment system that has discouraged everything that primary care should be, but as the discussion goes on there needs to be more than just warm bodies labeled as PCP's.
Here is what I see as the essentials for good primary care:
The days of doctor-god are over. The job of a doctor is not to decide things for patients, it is to give enough information so the patient can decide. If a doctor doesn't explain things well, patients will go elsewhere to get their information. This means that people should understand why they have tests ordered, what each medication is for, and what the plan is.
"A stitch in time saves nine." Do we really believe that disease prevention and holistic care is better than just treating problems when they come up? We had better, as our specialty rides on the idea of long-term relationship and disease management. A manager must plan, and a good PCP plans as well. This means that patients should not only know why a test is being ordered, but also what the next steps will be once the results come back. Patients also need to know when their next well care needs to be done.
It's called Primary Care for a reason. The idea is that the patient comes to get the attention of a medical professional, and that the patient is the center of that attention. Because of the "herd them through" mentality propagated by the fee-for-service payment system, the patient has become a consumable commodity for the physician. This is totally backwards to what it should be, and is not found in other high-end professions like law or accounting. This takes a fair amount of self-discipline and professionalism on the part of the doctor in the current climate, as it means caring enough for quality that profits can be sacrificed.
Caring comes in many flavors:
- Giving patients the time they need. Feeling rushed does a lot to undermine trust.
- Making sure their concerns are addressed. Doctors tend to address their own concerns first - and I suppose that's OK - but then stop once they are satisfied with an answer. Yet the patients, who are the paying party in this transaction, are left to worry. Good primary care is not satisfied until the customer is satisfied.
- Attention to detail - making sure the quality of medical care (including record-keeping) is high quality. This is true with any profession, but sloppiness is much easier to hide in medicine and so it often comes down to professionalism. Does the doctor take pride in his/her work?
A crucial aspect of a PCP's job is to make order out of confusion. Someone needs to gather disparate parts of the patient's care and put them all together. This takes a huge amount of discipline, as the natural instinct of a person is to move on once the minimum of work is done. Instead of just taking care of a person's stated problem, a PCP must step back and think, "is there anything else I am missing?". In a fee-for service world, this is very hard to do as "head count" is how we are paid. Stepping back and methodically going through things takes time, but it is a necessary thing for good care.
Another area of discipline is in the office itself. A PCP's office is the dumping ground of a huge amount of information, and somehow having a system that pushes back the chaos is necessary for good care. This takes much more than the physician; it takes a well-run office with a good staff. That means that a PCP must either manage well or possess the ability to give the management of the office to someone who can.
I could also call this "perceptiveness," as I am referring to a doctor's ability to understand and sympathize with others' situations. The view in the exam room is totally different from the doctor's chair, and docs need to be able to put themselves in the other chair. Most people don't want to go to the doctor's office, and when they do they feel very self-conscious. Understanding this and factoring this in to the care of the patient is a huge key to good care. This is important in both clinical and interpersonal aspects of being a PCP, because the people are coming to them have lives of their own. They have to live with symptoms, so telling them "everything is fine" is not always enough, but people may be too self-conscious to ask more.
It's also important to realize people are products of their environment. The terribly needy and self-abusive patient may have been molested as a child. The chronic smoker may have grown up with cigarettes in the house. The parent yelling at their child may have never seen what compassionate parenting looks like. It's very hard, but losing the reflex to look at some people as "losers" is really big. The reason docs have a hard time with this is that it feels like making excuses for unhealthy behavior. The fact that it's there for a reason doesn't make it OK, but assuming smoking cessation, losing weight, or being a better parent is an easy thing to do, will doom any attempt by the doctor to help.
Why is this important? For patients to get care, they need to set foot in the office. When a person feels ignored or judged when coming to the doctor, the likelihood of them getting the care they need is low.
It's a hard job being a PCP, and it's really easy to cut corners. The thing that keeps pushing me away from mediocrity is the belief I have in the importance of what I do. I put up with the struggle because I care. A sense of mission will push away temptations to cut corners, skimp on quality, or lose compassion. It's really easy to become jaded and cynical in the medical profession, but I do not understand how any PCP can be a cynic and still practice. The two seem to be utterly incompatible.
The end product of all of this is care that is patient focused, efficient, compassionate, and high-quality. Our system should promote that kind of care, and we should try to weed out any aspects to this system that push us away from this ideal.