It has been said that primary care in the United States faces the worst of times and the best of times.1 Why the worst of times? Primary care was catapulted into prominence by the advent of health maintenance organisations; many of such organisations' 80 million patients were required to gain permission from their primary care physician to access laboratory, radiology, and specialty services. Because the number of people enrolled in health maintenance organisations is declining, more patients are free to move around the healthcare system. The United States may revert to its previous dispersed system of care, in which patients enter the specialty-dominated system through a variety of doors rather than through a single primary care entrance.
When health maintenance organisations moved primary care to a central position in health care, they expected primary care physicians to do far more for their patients than before,2 yet they paid little more, if at all, for these additional tasks. Primary care physicians were looking more and more like the “hamsters on a treadmill” described in an article in the BMJ.3 In California, the proportion of primary care physicians very satisfied with their work dropped from 48% in 1991 to 36% in 1996.4 In the past few years, medical students have become less interested in making a career in primary care because of the long hours, high stress, and relatively low reimbursement of generalist physicians.5
Summary points
Primary care in the United States is facing difficult times: doctors are overworked and dissatisfied with it, and medical students are not very interested in it
Primary care is unable to deliver everything expected of it and offers neither timely access to acute care nor state of the art chronic care
A redesign of the primary care sector that addresses these problems is gaining acceptance in the United States
The redesign envisages the development of clinical teams, open access scheduling, implementation of a new model of management of chronic care, training patients to manage chronic conditions themselves, and group medical visits
The problems go beyond primary care's insecure role in the US health system: primary care is not serving patients satisfactorily. Fewer than half of patients with hypertension, diabetes, atrial fibrillation, and hyperlipidaemia—diagnoses chiefly handled at the primary care level—are well managed.6–9 Many patients also have difficulty obtaining an appointment with their primary care practice. From 1997 to 2001, the proportion of people reporting inability to obtain a timely appointment rose from 23% to 33%.10
Clearly, primary care clinicians are unable to handle everything piled on to their plates. Thus, the worst of times. Why, then, the best of times? One proposition explaining the work of great artists holds that suffering breeds creativity—Beethoven and Van Gogh are cited as examples. Although the situation of US primary care physicians cannot be called “suffering,” the proposition could be reformulated as follows: as primary care physicians have seen their problems mount and satisfaction fall, they have begun to create innovations in primary care practice (innovations that are sometimes more advanced in the United Kingdom). Examples of these innovations are: functioning primary care teams, open access scheduling, the chronic care model, collaborative physician-patient interaction, group medical visits, and the paperless electronic office. The potential for these innovations to improve primary care practice creates the “best of times.”
Behind each specific innovation lies a global vision of primary care practice in the 21st century. Donald Berwick of the Institute for Healthcare Improvement, one architect of the new vision, explains: “We are carrying the 19th century clinical office into the 21st century world. It's time to retire it.”5 What is the vision of primary care practice in the 21st century?
Primary care teams
Physicians working alone cannot solve the problems of untimely access and inadequate management of chronic care, but with a team approach, everything changes. A patient care team is a group of diverse clinicians who participate in the care of a defined group of patients and communicate with each other regularly. Team care often means the doctor delegates routine tasks to other team members.11
In a few US primary care practices such teams are functioning well. In some cases, each team might have one primary care physician, two non-physician clinicians (nurse practitioners or physician assistants), three nursing staff (nurses or medical assistants), and a receptionist. The team is responsible for a panel of 5000 patients. In larger sites, a health educator, physical therapist, and pharmacist would work with several teams. The physician might see only 10 (rather than 25-30) patients each day, focusing on those with complex problems and spending 30 minutes rather than the typical 18 minutes per patient. Patients attending with routine acute problems are handled by the non-physician clinicians, and nursing, health education, or mid-level caregivers are responsible for planned follow up of those with chronic conditions. The physician would spend considerable time consulting with and training other team members.
Advanced access
A new model of appointment scheduling, called advanced access or same day scheduling, is being used at a number of primary care practices in both the United States and the United Kingdom. In its most simple form, it means that if a doctor can see 25 patients a day but it takes patients three weeks to get an appointment, could the doctor not care for 25 patients a day but see them the same day they call? On average, the number of visits would not change, but access would go up and patients' frustration go down. When doctors practising under this new model start work each morning, about half of their appointment slots are open. Patients calling in are offered an appointment the same day.12 As both urgent and routine problems are seen the same day, there is no need for nursing triage, freeing up nursing staff for other tasks and reducing the need to interrupt the physician.
The chronic care model
Management of chronic illness can be improved through a set of innovations known as the chronic care model, which incorporates several essential components of primary care practice.13 Self management support includes training patients in problem solving and goal setting. Decision support consists of making evidence based knowledge available to all physicians through clinical practice guidelines and physician education. Delivery system redesign refers to the understanding that the structure of medical practice must be altered; it includes creating practice teams with a clear division of labour, separating the management of chronic conditions from acute care by using planned visits, and case management of patients at high risk. Clinical information systems involve reminders to primary care teams to comply with practice guidelines; feedback to physicians, showing how each is performing in managing chronic illnesses; and registers for planning individual patient care and conducting population based care.
A new area of research—evidence based management—examines which components of the chronic care model actually improve clinical process and patient outcomes. Studies suggest that planned visits to patients with chronic conditions and case management of high risk patients (two components of redesign of delivery systems) and reminder systems for clinicians (a component of clinical information systems) improve doctors' performance and, at times, patients' outcomes.14,15
Clinical outcomes probably improve more when several components of the chronic care model are used together.16 A number of primary care practices, led by healthcare organisations such as Kaiser-Permanente and Group Health Cooperative of Puget Sound, and community health centres for patients with low incomes are implementing components of the chronic care model.
Collaborative care
The 21st century primary care practice envisages a patient-physician partnership with collaborative goal setting. A recent study found that in about three quarters of primary care visits physicians issue instructions to patients, such as “change your diet, take more exercise, and take your pills.”17 This model often fails to encourage healthy behaviours and leads physicians to blame patients for being “non-compliant” with doctors' orders.18
Under the collaborative model, both patients and physicians define the problems that require solution, though their definitions may coincide or diverge. For example, a physician may define the problem of a diabetic patient as a raised glycated haemoglobin concentration, while the patient defines her problem as extreme anxiety caring for her husband with Alzheimer's dementia. Failure to tackle the problem that the patient sees will frustrate the physician's efforts to solve the problem of poor glycaemic control.19 One tool of collaborative care is the setting of goals through action plans agreed between physician and patient—a typical action plan might be to walk for 15 minutes three times a week. In the example of the diabetic patient caring for a demented spouse, the action plan might involve ways of relieving the patient from her caregiving responsibilities rather than simply trying to improve glycaemic control. Action plans should be realistic, giving the patient a strong chance of success. Some research has found that collaborative care with action plans can improve outcomes in asthma, diabetes, arthritis, and other chronic conditions.19
Group medical visits
Several US experiments in which patients see their physicians in groups rather than singly are under way. This innovation, which has spread to numerous US primary care sites, began near Denver, Colorado, when John Scott, a Kaiser-Permanente primary care physician, gave his elderly patients the option of seeing him in groups. The groups are not simply patient education sessions; they include direct patient care. In John Scott's cooperative healthcare clinic model, 15-20 elderly patients with a variety of acute and chronic medical problems come together monthly to see their doctor, who goes around the room performing those elements of the history and physical examinations that do not require privacy and carrying out diagnostic and treatment plans for each patient. Other patients in the room listen to the interactions and may contribute ideas based on their own experience. In a randomised controlled trial, the group patients made fewer visits to emergency departments and to specialists, cost less, stayed healthier, and were more satisfied with their care.20
A second kind of group comprises patients with the same diagnosis. A trial of such single diagnosis groups, conducted for patients with diabetes, found that glycated haemoglobin values of patients in groups fell by 1.3% compared with 0.2% in control subjects. Group members used outpatient and inpatient facilities less and felt more satisfied with their care.14
A third category of group medical visit is the “drop-in group medical appointment” (DIGMA) for patients with simple acute rather than chronic conditions. The purpose is to improve timely access to care, since in this way a doctor can see 15-20 patients in 90 minutes. By adding capacity to primary care practices, these group sessions can become an adjunct to open access scheduling. These sessions are not appropriate for patients with more complex and time-consuming problems.
Information technology
The ideal 21st century primary care practice would be virtually paperless—a goal to which the United Kingdom is currently nearer than is the United States. While such a digital world has great appeal, only a tiny fraction of US primary care sites have an electronic medical record, and relatively few use email and the internet to interact with patients. Studies of the electronic medical record show that it may improve quality of care but it makes extra demands on physicians' time.21,22 A controlled trial involving electronic registers and reminders for the care of 13 000 diabetic patients found that most physicians did not use the computerised systems available to them because they took too much time.23
Importance of teams in primary care
None of the innovations being introduced into the United States works well without the formation of primary care teams. The chronic care model relies on medical assistants checking reminder systems and making sure that patients receive the chronic and preventive services they need. When physicians no longer have to carry out these routine chronic care tasks, they have more open appointment slots, allowing advanced access scheduling to function smoothly. Nurses or health educators, rather than physicians, can work with patients on healthy behaviour change, using action plans. Group medical visits are best with teams of physicians and nurses. When patients are able to communicate by email or the internet, staff other than doctors can handle many simple requests, thereby sparing physicians' time. Without teams, most of these innovations would be unsustainable because they add to the huge workload of primary care physicians. With teams, physicians can spend more time training and supervising team members and less time seeing patients with uncomplicated problems singly. The creation of teams is the key element in primary care redesign that allows other innovations to succeed.
Conclusion
Primary care physicians in the United States who are stressed and dissatisfied may glance at a list of supposedly helpful innovations and exclaim: “Making those changes will just add to my work.” Without managerial support, they are right. For that reason, innovation is commoner in large health systems with administrative leadership. To help physicians jump off the treadmill, innovations must improve quality of care or access to it while reducing doctors' workloads and not endangering the financial viability of primary care.
Supplementary Material
Footnotes
This is the last in a series of four articles edited by Andrew Bindman and Azeem Majeed
Funding: Robert Wood Johnson Foundation.
Competing interests: None declared.
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