Friday, November 24, 2006

Testing the Limits

If surgery training, with its brutality, inculcates a saving sense of limitations, of knowing when you're about to get in over your head, family practice training does the opposite. That's what I thought a few years ago, and the reason I thought so was that at the time, it was true. Things have changed, and so has my opinion. But there was a period in my practice when I believed the worse thing you could do was choose as your doctor a family practitioner. And that was AFTER I'd happily and with no subsequent regrets chosen as my doctor -- and that of my wife and son -- a family practitioner.

It was a perfect storm: the confluence of the concept of the "gatekeeper," and the idea that specialists were overvalued, and the shift in emphasis of medical schools toward cranking out more primary care doctors. A darker view would be that it was the fruition of the belief by all the various healthcare payors that the more you pit doctors against one another, the easier it is to get them to work harder for less money. But I digress.

During my training, the only contact I'd had with family practice docs was at the county hospital, which provided them a residency program. It was only in the emergency department that we intersected: they had no role nor spent any time on the surgical service, which seemed fine. Why would they need to? In the ED, as interns we were the same: grab the next chart and deal with the problem at hand, among those of the countless souls waiting for help. Sore throat, vomiting, belly-ache, discharges and drips. See and sort. We were all pretty much interchangeable at that level, but I noticed all the male FPs had beards, and liked to spend too much time (given the seemingly self-fertilizing piles of charts waiting) convincing drunks they should stop drinking. Surgeons -- by decree -- were clean-shaven, and we tended to focus on turning the crank as fast as possible. After internship, my dealings with medical types were entirely with practitioners of the fields involved in internal medicine. Family practice folk were, I must have assumed, office docs.

Before arriving in my current location, I spent five years in a small clinic in Oregon. Adjacent to my office was that of the family practice doc who became my friend and my doc. He was about my age, but because of the shorter length of his training and having escaped military service (unlike me) he'd been in practice for several years. He had broad knowledge of adult and pediatric medicine, giving excellent and devoted care to his patients, and referring to specialists when any sort of procedure or complex hospitalization was required. So did his three compatriots. It so happened that the hospital had rules prohibiting FPs from doing any operations, and even from admitting to the ICU/CCU. I'd understood they were adopted not without acrimony; but my clinic-mates never expressed a desire to be doing more than they were. They liked to assist on the operations I did on their patients; that was about it.

I joined a much larger clinic when I moved. Initially, we were a FP-free zone. Unlike the smaller clinic in Oregon, this clinic had figured out that multi-specialty groups couldn't survive forever without a broad primary care base, for the simple reason that docs who weren't in a clinic preferred to refer patients to specialists who were also not so aligned. In the years prior to my arrival, and for the first few after, the expansion of primary care had been in the form of general internists, pediatricians, and OB/GYNs. But family practice had developed momentum in the public arena: caring for the "whole patient" had a certain logic to it. Why leave your kidneys here, your heart there, and your gallbladder god-knows-where? Those specialists: all they care about is a few organs and a lot of dollars. So our leaders told us that in addition to having opened walk-in clinics, extended hours to seven days a week, emphasizing access, we needed to hire family doctors, because that's what the demographic studies were saying. It was controversial.

Being a relative newbie, I didn't speak up much; plus, my prior experience with family practice had been positive. Probably overly snooty, it was the general reaction that the clinic had promoted itself on the basis of specialty care and expertise, and that hiring family practice would be a downgrade. Would they be allowed to deliver babies, the OBs wanted to know. How would we survive, asked the internists? Still a work in progress, turf-wise, the family practice department was brought to life. In the long run, it's worked out great: the clinic is one of the most successful doctor-run ones in the country, still growing at a staggering rate, and thriving. When I came there were about thirty-five docs; now there are around two hundred fifty. It's gone from one main office and one satellite, to around ten satellites, all happily staffed with FPs among the internists, pedipods, and OB/GYNs. It has two MRIs, at least two CT scanners, a comprehensive lab, its own nucular medicine department, two surgical centers, fully electronic medical records, patients up the wazoo. But the family practice idea didn't start entirely well.

Let's take a moment to set the scene: this was all happening at the time of early focus on the skyrocketing costs of healthcare. (It should be obvious that there are still no really comprehensive solutions; in one guise or another, it's still just about cutting payments to doctors and hospitals.) But for a while the hot idea was that of primary care doctor as gate-keeper, with or without pre-paid care. Not only the insurers, but the companies that paid the premiums bought the concept; and it's not without a certain purity of logic. Left to their own devices, specialists will do what they do, unrestrained (certainly not by conscience, ethics, or a sense of propriety. Surely not.) Put the primary care doctor -- clearly the only one in the equation who truly has the patients' best interest at heart! -- in charge of deciding when a specialist is necessary and what procedures that specialist is authorized to do. Clean, and tidy. Economical. And if you really want to see an end to unnecessary care, give all the money to the primary care doc, pre-paid based on how many patients he/she has, and make that doc pay for the specialist care out of that stash. Perfect. My clinic, in another overly snooty bit of self-delusion, figured if anyone knew how to monitor and control costs and to deliver highly efficient care, it was us. We bought the pre-paid, gate-keeper run model, hooker, line-item, and stinker. Nor did it occur to us that if we were going to entrust that responsibility (not to mention the huge pressure and implicit conflict-of-interest) to people, they ought to have some preparation and experience in the matter. Which gets us back to the training issue.

My first clue came with the first call. Within weeks of hiring a couple of family practice doctors (fresh out of training, shiny as a new penny) I got a call from one, asking if I did pediatric hernia repairs. I did. At which hospital? At a surgery center, outpatient. Well, I'd like to refer you a baby, and I need to be there to assist. Uh, I generally don't need or use an assistant for a pedi-hernia; you're welcome to be there, but I really wouldn't want there to be a charge for an assist. Well, I think the family would feel better if I were there...

OK, not a real big deal. But my thought was, this isn't exactly good ol' Doc Jones who delivered three generations of the same family on the kitchen table. This person has been in town all of three weeks, and can't possibly have the sort of relationship with the family from which that sort of comfort derives. So it's got to be the training: you, they must be told, are the only thing standing between your patient and mayhem. No specialist (certainly no pea-brained, slash and cut, think-with-his-wallet surgeon, fergodsakes) will ever have the patient's interest at heart the way you do. Maybe I'm a little paranoid. Maybe even more then than now. But I wondered about the larger implications: if, after three weeks out of the oven, this doc believes he has the rapport, the knowledge, the TRAINING to run interference between his patient and me, what other delusions might he have? And where might it lead? I'd had five more years of training than he, and more than five years in practice. Maybe he was the most brilliant guy on the planet, or maybe those FP residencies had actually found a way to fill brains to the max with all the info in all the specialties -- as opposed to mine, which took three times the years to fill me up with only one specialty, and left me needing a little time in the world to feel competent. Was I making too much of it? It was just a request to be there, after all. But it seemed to bespeak a mindset: whereas I'd had grinding, lengthy, browbeating, comprehensive, non-stop 24/7 training that left me able to do very complex operations and evaluations but still wondering if I knew a damn thing, these guys had had a few weeks each in several specialties and were evidently told they knew everything. Was I wrong? We'll see....


Anonymous said...

That is the best picture I have ever seen....brings to mind some hospital administrators and JCAHO people I have known

MedStudentGod (MSG) said...

The thought of FP's as red eyed, hooded, forboding gatekeepers brought a grin to my face. I think a lot of patients would actually think of the OR in that fashion since it can be very nerve-wracking to enter that atmosphere.

Good topic. I can't wait to read some more and see what others have to say.

Anonymous said...

Follow the money. Back then, we could get $1000 or more for a hernia repair, and the assistant could get as much as 25%. Not bad for 30 minutes of semiskilled work as an assistant. Today, we're lucky to get $400-500, and assistant fees are typically 16%. The FP can do better staying in the office. And she does.

Anonymous said...

Aha! I can see that you've mastered the skill of "cliff hanging" your readers, Dr. Schwab! :o)

Waiting to see the rest of it ...

Anonymous said...

Dammit, I hate when you do that... :P

The Spanish have a saying:
"Aprendiz de todo, maestro de nada." (Student of everything, master(teacher) of nothing.)

Applies loosely to FP docs, methinks, but it does take a different person to be OK with handing off on all sides as part of their job description. Sure they take care of lots of things in-house, but I could never be the person who, when the tough gets going and things get complicated, the handoff is the standard play.

It's like when you've tried to open a jar for 3 minutes, give up, and then a friend opens it on the first try with fresh hands, thanks to your efforts. No way I could deal with that day after day.


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