“…an act, a habit, an institution, a law, gives birth not only to an effect, but to a series of effects. Of these effects, the first only is immediate; it manifests itself simultaneously with its cause—it is seen. The others unfold in succession—they are not seen: it is well for us, if they are foreseen…The one takes account of the visible effect; the other takes account both of the effects which are seen, and also of those which it is necessary to foresee. Now this difference is enormous, for it almost always happens that when the immediate consequence is favourable, the ultimate consequences are fatal, and the converse.” ~ Frederic Bastiat
Treating Pain in Primary Care
“If there is ever a case for patient-centered care, it is probably the chronic pain patient, especially the older chronic pain patient,” Vega suggests.
He recalled the case of a 72-year-old retiree with chronic degenerative disease of the spine. “She also had stage IV chronic kidney disease, hypertension, and diabetes, all fairly stable and well-controlled. It would be a huge mistake to put her on chronic anti-inflammatory drugs; acetaminophen doesn’t do enough, and she has trouble accessing physical therapy,” he explained. “What really sets her free is tramadol once a day, which she takes in the morning. And then she uses acetaminophen the rest of the day. When I last wrote her the usual prescription, the pharmacy denied it, saying she didn’t have a chronic condition and was at risk for overdose. They didn’t notify me and she went 10 days without therapy. She finally called me, asking why I had withheld her medicine, and I didn’t know what she was talking about.”
With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key. Surveys consistently demonstrate that patients prioritize both the interpersonal attributes of their providers and their individual relationships with providers above all else. Doctors also ascribe great value to relationships. Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”
For the sake of brevity, I am not going to show my math. Trust me, I’m a doctor! Here are the average panel sizes based on the assumptions above using 2012 census data.
FP/GP = 1,041 patients per doc
IM/IM-Peds = 464 patients per doc
Pediatrics = 552 patients per doc
Ob-Gyn = 642 patients per doc
Geriatrics = 1,237 patients per doc (this was tough to estimate, maybe way off)
Take a close look at the patient panel sizes. Yes, they are derived from raw data and don’t represent actual practices, but they do represent every single individual via census data that were represented in the categories that I used. Why are they so much lower than the “average” U.S. primary care doctor patient panel numbers we see quoted so often? The panel sizes would be larger if we count those with more than one doctor, but that would be a wild guess. But, that effect is dwarfed by the fact that I assumed every single American in the age/gender categories that I used has a personal physician, which we know is not the case. There is the issue of uneven distribution of doctors, with more in urban/suburban area compared to rural areas, tending to skew sampling surveys to higher panel sizes. The other sampling bias of surveys may be web presence of the practice. Again, these practices are easier to locate and contact; which might also account for why they have larger patient populations.
So it the physician shortage real? I don’t know. I do know access to supply is out of balance and we can do much better with some efficiency enhancers.
“Proactive Medicine” refers to medical services that focus heavily on engaging patients while they are healthy or early in the disease process, developing strong relationships, and providing early treatment or driving behavior change that prevents or delays serious illness.
Intensive primary care is important because 1) primary care impacts almost 100% of the population and 2) the benefits are big. Jorgensen reports that MDVIP has seen reductions of 80% plus in ER and hospital utilization and in hospital readmissions among a large group of Medicare patients that benefit from MDVIP’s particularly intensive primary care service.
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