Primary Care Physician as Care Maestro

When I blogged about your local drug store’s walk-in medical clinic, I promised some thoughts about a shift for primary care doctors and their role in healthcare.

To reiterate:  New options for patient care are evolving, and the primary care physician is being left by the wayside.  Beyond the walk-in drug store clinics mentioned above, newer “types” of healthcare titles have evolved — nurse practitioners and physician assistants, and these professions can legally and capably perform many of the functions of a PCP generalist.  In addition, some patients choose to see specialists on their own without referrals by a primary care physician. As a result of these and other reasons, PCPs are finding the sizes of their practices dwindling, or their time is spent doing more paperwork or phoning and less real patient care.   And because healthcare is about money (not health or care) — PCPs are leaving their practices, or choosing to specialize instead. 

Talk to med students and you’ll find very few who choose primary care as their field, often because they want to make more money than a generalist like a PCP makes.  With all the student loans and effort they put into their education, we certainly can’t fault them for their choices!

It seems to me, however, that PCPs have a major role to fill — and for the most part, it’s not being filled at all.  That role is of healthcare symphony leader, the maestro of our care.  In effect, the patient care coordinator.  Sort of an uber-advocate.

My own healthcare crisis is a good example of stories I hear all the time.  When I found a lump on my torso and went to my PCP (actually, his physician assistant) they immediately referred me to a surgeon.  The surgeon then referred me to the oncologist.  The second oncologist referred me to the National Institutes of Health.  When it was all over, and I had figured out I didn’t have cancer at all, my PCP called me and asked me to return to his office to tell him what had happened.

Who was my care maestro?  Me!  But I don’t know anything about medical anything!  I was just determined and angry and confused, and refused to believe that a cancer was going to kill me in six months!  There wasn’t anyone with any know-how helping me through the maze.  My care symphony was a cacophony of uncoordinated and highly dissonant notes. 

How different it might have been had I had access to someone who could have created harmony for my care.

Often, patients contact me with stories that have a similar vein.  They are frustrated because there is no one looking at the big picture.  There is no one who can help translate what a specialist has just told them.  There is no one who can take the test results they’ve gotten from a gastroenterologist to compare to the results they’ve been given by a cardiologist — or whatever other combination you want to throw in.  They are frustrated because they have no maestro — no one who is keeping their specialists playing on their same patient page.

Is this not the role of the generalist? The person who can look at the big picture, and coordinate the patient’s care?  The person who can be the gatekeeper, the liaison, the translator, the scheduler, the coordinator, the….

MAESTRO?

I realize this is the idea behind managed care.  Insurance companies will have us believe, and PCPs will buy-in, to the idea that this is what they are already doing.  And, again in my own experience, when it comes time for a check up, then yes, I think this is what happens.  As an over-50 patient, my PCP orders blood work, an EKG, a colonoscopy, a bone scan, a mammogram, and then she looks at the results and tells me to lose some weight. 

BUT — that’s not what I’m talking about.  I’m talking about what happens when a problem occurs.  When all is not well with test results.  When finding a diagnosis is a challenge.  When one doctor is telling a patient to get physical therapy and the next one is saying surgery is the only option.  When a man is told he has prostate cancer, but can’t choose between robotic or laproscopic and the only doctors providing advice are the ones who will make money from the procedures.

Who is the care maestro then?  No one — because there is no reimbursement for it.  The PCP makes no more money once the patient has been sent to the surgeon or the gastro or whoever the specialist is. 

There is a huge shortage of PCPs in this country.  We don’t have enough pediatricians or geriatricians or those doctors who generalize in order to help people.  They are like school teachers;  they realize they will be overutilized and under-rewarded, but choose their professions because that’s how they can establish relationships with their patients. 

Further, patients are getting more frustrated — and LESS healthy — because they can’t afford to establish those relationships — insurance won’t pay for it.  Is this not a detriment to patient safety?  Doesn’t this create sicker patients?

Doesn’t this all translate to MORE cost and LESS health?

It seems to me all these disparate aspects of care could come together to benefit us all?  What are your thoughts?

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