Provider Accountability Meets Patient Choice

The health care system overall - and community health centers and family practices are no exception – have been constructed on a very paternalistic model.  We pretend we know what is best for our patients and make a system of comprehensive care that requires continuity, appointments to be kept, and patients to obey our orders for preventive care.  And we are increasing being evaluated and paid on our ability get our patients to comply with all of the preventive and chronic care imperatives that are determined to be today's best practices.

While we are evolving this system, patients are choosing to go to other models of care for urgent issues, camp physicals, immunizations, as well as for simple problems.  They seek problem focused, convenient, rapid throughput visits without being engaged in discussions driven by our advice about other issues and our response to EHR-driven reminders.  

We have to pay attention to what is happening now that new immediate care options are available more and more to our patients and we have to figure out where our comprehensive care model fits in.  I don’t have the answer to this yet but we have been talking about it a lot in our management team meetings.

Imagine that your life is in disorder and its three days before school starts, you forgot to get your child’s immunization updated and need a school physical form filled out.  Our health centers see this as a disruption in our appointment system and have difficulty  accommodating this type of visit in an efficient manner.  

Our patients, however,  can now go to any of a dozen local sources of immediate care and get this done.  I think we need to be able to figure out a way to keep our patients with us, while still allowing them to have a short visit if they need it, to accommodate their last-minute issues (haven’t we all had them at one time or another?) and still maintain them in our practice.   If we stick with our old model of requiring people to get care the way we think it should be done and remain oblivious to their chosen care model and the proliferation of places where they can get it respected, then we are truly in trouble.

The real issue now is that accountability for quality will still lie with their primary care provider team, yet our patients will have more and more choices for more convenient care in between their main chronic illness visits.  How we will adjust our practices to deal with that?

Sexism Effects Clinical Decision-Making as Well

In repsonse to my last two blog posts, a number of readers responded that women, not just people of color, experience bias and disrespect in the health care system. This brought to mind a study done over 20 years ago by a brilliant colleague of mine, Dr. Jonathan N. Tobin. His 1987 Study published in the July 1 issue of the Annals of Internal Medicine (Volume 107, pp 19-25) revealed that there was substantial "Sex Bias in Considering Coronary Bypass Surgery".

The abstract of that study reads in part:
" In a study of 390 patients consecutively referred for nuclear exercise testing, abnormal results found in 31% of the women and in 64% of the men affected physicians' decisions to recommend catheterization in men only; 4% of the women with abnormal radionuclide scans were referred for catheterization compared with 40% of the men (p < 0.001). This 10:1 ratio was independent of age."

Gender bias, racial bias, bias against obese individuals, bias against those who speak a language other than English - all affect the care that patients recieve in the health care system. And they have secondary effects as well - as some of the commentors on my previous blogs pointed out - they make one loathe to go to the doctor at all. And with no medical visit, the odds are that people neglect needed preventive care and comprehensive care for chronic conditions. Can this problem be helped through training? Perhaps. But we have a very long way to go. And tragically - for decades since the Tobin article was published, there is little evidence that we have made any substantial progress.