The Disappearing Family Doctor - Is It a Bad Thing?

The New York Times recently published an article titled the Family Can't Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and "doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat...larger practices tend to be less intimate"

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given?  My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary.  One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening.   Those most likely to do the wrong test after a positive stool screening test?  Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice. 

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care.  I've worked at Kaiser Permanente (KP) in Northern California since 2000, a "larger practice".  The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka's.  Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient's lab work, imaging studies, and medications 24/7.  Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices.  Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor's appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let's not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors' offices as automatically dooming doctor-patient relationships to becoming more impersonal.  The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them.  Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor.  To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all. 

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices.  It offers no evidence if the quality of care delivered is as good.  Let's not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing.  It may not be up to the challenges of the 21st century.

Does America Want Apple or Android for Health Care?

The future direction of American health care is unclear.  Certainly the cost trend as it exists is unsustainable with health care costs being a major concern of the private sector, the government, and individuals.  How does the nation manage costs while ensuring high quality medical care, access, and service?  Proposals include increasing competition among insurers, providers, and hospitals to drive down prices or giving more financial responsibility to patients via higher deductibles and co-pays with the belief that they will demand price transparency, shop around for the best price, and as a result slow health care costs.

What if both ideas are wrong?

While it is possible these plans might work, I cannot help but notice the similarities in the challenges for patients in navigating the health care system and consumers figuring out how to purchase and use technology.  Walk into your neighborhood electronics store.   Individuals are overwhelmed with the number of product choices, manufacturers, differences in technical specifications and features.  In the majority of situations, consumers are unsure of what they are purchasing.  They want something that just works, whether surfing the internet, making home movies, or being connected with loved ones.  The gap in knowledge between an expert and a consumer is great and often unintentional and unapparent.

Two Different World Views - Apple or Android?

Within the technology world, there are two groups of thought.  The first group offers technology in a closed system, like Apple, where the focus has been on just making things work.  There are a limited number of product types and designs.  For example, its current smartphone, the iPhone 4 comes in only two types.  Aside from the base memory of 16 GB or 32 GB and two different prices, the phones are otherwise identical in features with the same apps, cameras, and ability to record video.  Although the specifications are available for anyone to see, the focus is rarely on the technical elements of the products themselves and more on what they can do for you.  Walk into any Apple retail store and the products are situated by function.   Staff ask not how much computing horsepower, storage space, or CPU speed one needs, but what one plans on using the smartphone or computer for.

In contrast, Google's sponsored Android platform, which runs smartphones from a variety of manufacturers gives consumers maximal choice.  Companies like Motorola, Samsung, HTC, and LG offer a variety of combinations of styles, features, and ironically even different software versions at various price points.  Verizon and AT&T wireless offer no less than 10 different Android based smartphones.  The amount of choice and options could be intimidating.  While potentially an Android smartphone could be cheaper than a comparable Apple iPhone, people often fail to account for all of the time and energy spent on researching, thinking, and also potential worry and buyer's remorse that the right choice was made.  The time and energy spent does cost, either monetarily or emotionally.

Which one would you choose?  A system which just works, gets the job done, and has been designed to fulfill most of your needs?  Or alternatively, a different system which provides more choice, more options, and in many cases, requires more time to research and become an expert to make the best decision?

Choice - Competition - Let the Consumer Do the Integration

If you look at proposals and trends in health care, it appears many are advocating for Android. 
To manage costs, consumer driven health care, where patients have more financial responsibility via the addition of deductibles and higher co-pays are felt to be the answer.  The patient is the party accountable to having the right tests done, finding the right doctors, reviewing and maintaining their medical chart using personal health records, and shopping around for the best price when it comes to imaging and other procedures.  After all, who has the most motivation to make the best choice but the individual who's life depends on it?

Increasingly there is research that shows people are decreasing health care costs.  Unfortunately it is not the behavior of avoiding expensive excessive care (opting to see a primary care doctor rather than the emergency room for non-emergent evaluation) but skipping preventive tests, prescription medications, follow-up evaluations to treat chronic conditions at the early stage to prevent future complications.   If true, the implications of these small inconsequential choices by patients could be problematic years later.

Also similar to Android philosophy, others argue for more competition.  With the consolidation of insurers and in some case providers and hospitals over the years, understandably many are concerned that prices are driven higher through monopoly power.  Instead, the belief is that having many insurers, providers, and hospital networks will improve health care as they compete for patients on areas of service, quality, and access.  The market will reward those who are best in providing all three.  With the large number of competitors, groups will be unable to have pricing power and therefore costs will be managed.

Providing patients plenty of choices is proposed as the key to fixing the health care crisis.  Perhaps this is the reason for the creation of insurance exchanges in the recent health care reform legislation.  Patients will have the opportunity be to select health insurance plans which are not tied to their place of employment.  Let them figure out which insurance plan is the best.  Have them figure out which doctors take their insurance and are the best.  They can select from their menu of different hospitals and determine the best one for their needs.

Health Care Integrates So Patients Don't Have To

Is there another way?  Would patients prefer a different system which is integrated and seamless and where patients can focus on simply getting better and not spending time and energy trying to figure out where to go and who to select?

One example might be where I work, at Kaiser Permanente in Northern California, a vertically integrated organization with health plan, hospitals, and doctors working together to provide care that is convenient, simple, and personal for our members.  Dr. Atul Gawande in his June 2009 New Yorker piece, the Cost Conundrum noted places like Grand Junction, Colorado, were able to provide high quality care at lower costs when doctors worked together.  Other organizations which were physician led and accountable also had similar outcomes.

Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Perhaps this is the reason for the creation of Accountable Care Organizations in the health care reform legislation.  Whether the legislation and regulations can foster and replicate similar organizations and outcomes remains to be seen.  What I can tell you is that within my organization, doctors, nurses, and support staff are working hard to improve how care is delivered to our members much the same way I suspect software engineers and designers at Apple focus on their technology to make it intuitive and so it just works.

Why a Patient Choose Kaiser Permanente

Perhaps there is no illustration better of the potential of American health care than the words from a patient.

Here's why I chose Kaiser for my medical needs at age 25:

    1.    I liked their Web site.
    2.    It was easy to set up appointments over the phone and via the Internet.
    3.    They have a 24-hour Advice Nurse phone line which is helpful if your parent is not "just a phone call away".
    4.    Through the Web site you can choose a primary care physician and OB/GYN by location, gender, and bio. If you don't like your choice you can always change it later.
    5.    You can email non-urgent messages to your doctor through the Web site and your doctor has to respond within 48-hours.
    6.    The Kaiser Web site will send you an email when test results are available online.

At age 29, here's why I know Kaiser was the best decision I ever made:

    1.    When I was brought to the Kaiser emergency room after my first seizure the staff was able to retrieve my complete medical history, which aids staff in making decisions about my care ... even when I'm unconscious.
    2.    After scans revealed I had a tumor in my brain, the head of neurology came down to see me and had me admitted to the hospital that night.
    3.    My newly acquired neurologist arranged for my transport to the neurosurgery center for the Sacramento region.
    4.    Once I got there I worked with Kaiser's neurological equivalent to Dr. House, except this doctor was way nicer.
    5.    My neurologist, neuro-surgeon, oncologist, neuro-oncologist, OB/GYN, primary care practitioner, orthopedic doctor, and physical therapist are all informed about my medical status.
    6.    I never have to seek, or wait for, a referral. If a new specialist is needed for my care I get to see him/her as soon as I'm able to get a ride.
    7.    I can get lab work done at any Kaiser facility and the test results are sent electronically to the requesting doctor within minutes/hours (or a few days if it's analysis of brain tissue).
    8.    Kaiser specialists network with peers from other medical institutions and often seek second and third opinions for you. They'll even tell you who disagreed with them and why. If you want to get the second opinion yourself they are respectful of your decision and make sure you get all required materials to make this happen (e.g., charts, scans).
    9.    After my most recent brain surgery, my tissue was analyzed by pathologists in Sacramento and Oakland, then sent to Kaiser in Redwood City, who sent it along to UCLA.
    10.    While my friends and I did a lot of our own research, Kaiser made it easy for us to get treatment. We never had to figure it out all by ourselves and my doctors/nurse practitioners answered every question I had ... even the silly questions.

The future of American health care is unclear.  Do Americans what Apple or Android for health care?

Let's let them decide.

The Rise of Desktop Medicine -- Wrong Terminology, But Right Thing to Do

A recent NY Times article, the Rise of Desktop Medicine, highlighted the use of technology in accessing information (desktop medicine) and how doctors were spending less time with patients (bedside medicine).  Many doctors were concerned about the change and longed for the old days.  Yet, the reality is that with more medical knowledge, doctors must retrieve information from clinical trials, calculate risk of heart attack or osteoporosis, rather than rely on intuition, particularly when data exists.

My biggest problem with this article really was with the term desktop medicine.  I don't like it.  Certainly over the past few decades, our understanding of certain illnesses has become more precise, the interventions and treatments more clear, and therapies more evidence based (precision medicine).  Other illnesses, however, still continue to be more challenging and determining the correct course of action less clear (cognitive or intuitive medicine). 

Precision medicine, a term used by Harvard Business School Professor Clayton Christensen, has simply occurred at the same time computers and the ability to rapidly access information developed.  Imagine if medical science knowledge had evolved but that there was no infrastructure or technology available to retrieve information like clinical trial outcomes quickly.  Doctors would still be treating patients based on intuition rather than science completely oblivious to the latest knowledge.  Research has shown it takes 17 years before outcomes from research studies become commonly practiced in the community.

No desktop medicine isn't the right term to describe the phenomenon in medicine.  It implies doctors are simply indentured servants to computers and technology.  Nothing could be further from the truth.  Generations ago, doctors had few tools and treatments.  When people developed pneumonia, we could do nothing but wait and hope because antibiotics were not discovered yet.  We simply comforted individuals and families.  Many people died.

Today we have more tools, more treatments, and a better understanding of many, but not all illnesses.  To say this additional knowledge and the ability to retrieve this information somehow erodes the doctor patient relationship is incorrect.  We can still be caring and use our technology to access information to make the care of the patient in front of us more precise and personalized than ever before.

No, the terms desktop medicine and bedside medicine are incorrect because they provide the wrong type of connotation.  The former term implies cold and impersonal.  The latter term suggests humanity and comfort.  Better terms with less emotional attachment would be precision medicine and intuitive or cognitive medicine.

I'm a big fan of the art of medicine and bedside manner.   I also love how my computer allows me to make care more convenient and more personal. 

The next generation of doctors must be experts at both bedside manner and using the vast knowledge of medical science to make care precise in areas we have good understanding.  For illnesses where we don't, we still do what we did generations ago, comfort and heal. 

No computer will ever replace that.