Tuesday, February 28, 2012

Too Many Docs in the Kitchen? Careful Redundancy or Unnecessary Overcomplication?

I have just had the privilege of sitting in on a Patient Centered Medical Home meeting for the family medicine practice with which I am currently rotating. As I sat around with 16 health providers over the course of a 90 minute conference, two conflicting thoughts struck me:

1) Isn't it GREAT that we are able to have this coalescence for the good of patient care?
2) Is it really beneficial to have all these people in on the conversation?

I quickly did the rough mental math on 16 providers spending 90 minutes in a conference. It is certainly costly, and it additionally takes away from what could be a full 24 hours of one-on-one patient care.

The goal of this particular meeting was to analyze and discuss patients that are on the high end of the cost curve - those that are outliers in terms of readmission rates, ER visits, and other concerns of overutilization. From a cost-reduction and care standpoint, this was likely a productive meeting. Less than a dozen patients were targeted and discussed over the course of the 90 minute session. For those patients, the value for the extra time and concern for there care is immeasurable.

Simultaneously, I believe there was another current at work here - the adherence to the vision of the team-oriented approach in the Medical Home model. Bringing these providers together in one room allowed for a team-oriented discussion. However, at the same time, I witnessed a majority of bored faces, yawns, and disinterest. One person spoke at a time and, it seemed, the rest were more or less varyingly engaged.

Yet the box was checked. The meeting was held. But was the value and vision of the PCMH met?

Bringing 16 providers into a room sounds great. Then, why not make it 20, or 30, or 50 at a time? At what point do we sacrifice the general good of overarching patient care, to take the time to "check the box".

These are just some thoughts that crept through my mind over the course of this afternoon. My only intention in my criticism is in the opportunity for self-reflection and advancement. Ultimately, I am certain this model is far superior to the isolated islands of care of yesteryear, most prominently for the dozen or so patients discussed.

Are we truly moving forward or are we just taking baby steps while posturing?


  1. It doesn't matter what the media tells us, truth is there are too many doctors, period. But very few good trained physicians. With all this "primary care shortage talk" which is grossly miscalculated (and has more obscure objectives which menas an overpopulation of doctors that will benefit hospitals, pharmaceutical companies and big medical groups while bringing family physicians income down). We have to remember that there are over 460 family medicine residencies in the country!!!! more than anywhere in the world. The answer is never more doctors. The answer is training BETTER doctors which grow more incompetent every generation, and it shows in health care related mortality rates and a growing malpractice index. It is madness for the country to think we need more doctors, lets train the ones we already have!

  2. I completely agree. Access to care is the name of the game with the so called "shortage". There is no shortage. Family medicine residencies are pumping over 10,000 new family docs every single year (not to mention that family medicine residencies are a very lucrative business to hospitals, faculty and especially program directors alike, which is kind of a taboo subject to the AAFP and its members) And the primary care force is not only comprised with family docs. You got the internists, pediatricians and not to mention the mid level providers. The primary care work force in the United States is fine when it comes to numbers, in fact there are just too many. I don't feel its going to be long before medical schools in the country need a moratorium since our health care system is going bankrupt. (look at countries like Malasya where a five year moratorium has been approved to relieve the pressure that the overpopulation of doctors was causing on an already bankrupt system!)What we need to do is offer better incentives to get docs to the rural communities in need. And, why not?, make it a requirement for graduation from a residency to work a certain period of time in a rural community, a lot of countries do this and are very successful at providing rural care. A glut of doctors is not an answer. And don't even get me started on the multi billion dollar industry that medical schools are in the U.S. which includes the dubious Caribbean schools!

  3. I am glad to consider the above thoughts, but I feel compeled to respond in kind. Though, I think the issue of physician shortage isn't exactly what I was focused on in my original peice. That said:

    1) How will the primary care workforce look when tens of millions of new patients are added to the health care system in 2014?

    2) True. We may not be dealing with a shortage issue, as much as a distribution issue. I would refer you to the Robert Graham Center's studies on this:

    "Policy-makers should consider improvements that refocus HPSA designation and resource allocation (e.g., offering grants or loans to physicians who locate to shortage areas; reducing physician-to-population thresholds to better reflect true need; focusing more resources where the ratios are worst; finding criteria that are more reflective of access to care than physician counts"


  4. We can divide physician workforce issues into 3 areas:
    1) supply
    2) distribution
    3) scope of practice

    I would argue (and data supports) that we have problems in each of these areas. In brief:
    1) If you take a look at COGME's 20th report, http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/index.html, you can see that there does in fact exist a problem in the supply of primary care doctors.
    2) Rural problems have already been addressed above. We also have to consider urban underserved areas.
    3) Scope is another issue that has not been focused on much. The problem is that each primary care doctor is doing less and less in their scope of practice. I would refer you to the upcoming JABFM series that would look at the fact that family physicians are doing less care of children and care of women.

  5. "Are we truly moving forward or are we just taking baby steps while posturing?"

    Maybe or maybe not. The only question for me either if we are moving forward or taking baby steps is; Is it effective?

    Peny@lab coat