American College of Physicians: Internal Medicine — Doctors for Adults ®

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Best patient care gets lost amid the health care delivery system

From the February ACP Internist, copyright 2010 by the American College of Physicians

By Joseph W. Stubbs, FACP

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

—Hippocratic Oath, seventh paragraph, written in the 5th century B.C.

When I walked in the examining room to see Ms. Jason (not her real name), I knew immediately by the look in her daughter’s eyes that things were not going well.

Ms. Jason, a 78-year-old woman with moderately advanced dementia, had a habit of getting up at 2 a.m. or 3 a.m. every day to “get ready for work, clean the house, or prepare for guests’ arrival.” If any in the family attempted to dispute her perceived reality or suggest that she ought to return to her bed, they were greeted by her well-honed ire and castigations.

Despite multiple medication trials, nothing seemed to help her stay asleep. Her daughter’s visible exhaustion and resignation told me the family was close to admitting defeat and considering nursing home placement for Ms. Jason. As a last resort, because she loved music and had long sung in the church choir, I made the seemingly preposterous proposal (even to me, though I was desperate) of playing gospel music in her room at night. It worked! Sleep at last for everyone.

Sadly, our patient stories are becoming fragmented sentences and dangling modifiers in the climate of our current health care delivery system. Real stories require time with patients that is lacking in the proverbial hamster-wheel reality of present-day primary care practice. When one of my healthy, young patients with no prior conditions came to the office and said that she did not feel well, and perhaps needed a referral to a specialist, I had to hold back the existential cry of “What am I here for?”

Am I a specialist in primary adult care or am I a transfer-station specialist with subspecialty skills in third-party hassles and barriers? Perhaps the extra reimbursement promised to general internists by the Physician Quality Reporting Initiative should consist of the referral rate per hour, the number of prior authorizations completed per day or the daily quota of Durable Medical Equipment forms signed. Regrettably, I feel these sometimes are more accurate indicators of the quality of my work as an internist than an A1c level or a mammogram.

But even such standard quality indicators do not truly reflect the quality and value derived from primary care. They are like those inconsequential pieces of a 10,000-piece jigsaw puzzle. If lost, they would never affect the big picture, yet they require so much of one’s time to find their place. How does one develop a true quality indicator for trust, empathy and compassion?

Those of us who live primary care on a daily basis know stories like that of Ms. Jason that substantiate our value to patients and make for a meaningful professional career. We intuitively understand the value we bring to our patients and to society in providing first-contact, continuous, comprehensive and coordinated care. Yet we are left too often feeling that our contribution has been relegated to a dark corner of a room full of new specialty treatments and technology, rather than made the centerpiece it deserves to be.

Still, we cannot just sit back and passively hope that others will suddenly sympathize with our plight and reward us with more equitable reimbursement and an upgrade on the ladder of medical prestige. In this age of accountability, we are being challenged to provide more accessible, equitable, efficient and effective care for the population of patients we serve. We cannot meet this challenge by sitting in the doctors’ lounge and decrying our fate. We must move forward to incorporate the capabilities of health information technology and team-based practice and to reengineer our focus from a provider-centered practice to one that is patient-centered.

Health care reform may soon be more than legalese occupying thousands of sheets of paper floating through Congress. If it becomes a reality, then a true opportunity will emerge for sorely needed practice transformations. Like crocuses breaking through the snow-covered grounds, let us hope that in this season of reform, the pilot testing of patient-centered medical homes, comparative effectiveness research and new payment methodologies will emerge and offer us sprouts of new hope that will blossom into this 21st-century vision of primary care. In our rush to the future, however, let us hold to the enduring principle of the past that it is a patient, not a disease, that we treat. That principle makes for good stories and a good life.

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