Tuesday, June 10, 2008

What is the Role of Physicians as Leaders in Disease Management (and the Medical Home)?

So, a physician and a psychologist are in a local watering hole, and the bartender tells them a local disease management company is looking for a Chief Medical Officer. Both want the job. Who should get it?

Readers of the Disease Management Care Blog may think selecting the physician is a no-brainer, but don’t be so sure. The DMCB wonders if the key ingredient of success in the management of chronic illness for persons with chronic illness is ‘self efficacy,’ defined as the level of confidence about achieving a desired level of performance. After all, once patients are outside their physician’s office, it’s up to them to meet the hour by hour, day by day challenges of their condition. In the case of disease management, the patient’s confidence in optimal use of a peak-flow meter, avoiding an emergency room visit or asking the physician the right questions lays at the core of quality and cost. Sound psychological? Sure does.

In addition to self efficacy, a prevailing theory of disease management is ‘readiness to change.’ Described in the Transtheoretical Model of Behavior Change, the point is that assessing patients’ willingness to alter life-choices is a critical 1st step in the delivery of illness-changing interventions. Sound psychological? Yup.

Once self efficacy, readiness to change and countless other approaches to molding patient behavior is reconciled, who is best equipped to assess the integrity and impact of the patient outreach programs themselves? Think physicians are taught about this in medical school or residency programs? Not so sure about that.

And how about analyzing the outcomes? The DMCB has run into many qualified statisticians with backgrounds in psychology. Maybe it has to do with all those mazes, questionnaires and measures of physiologic responses from their days in post-graduate training programs, but these social scientists seem to have a special affinity for t-tests, regression equations and minimizing sources of bias.

On the other hand, the DMCB has met many physician-Chief Medical Officers of disease management organizations, the majority of whom appreciate the psychological dimensions of their business and have the extra added bonus of knowing the difference between an A1c and an ACE. Most seem to have backgrounds in primary care medicine, which seems to attract persons with an innate interest in reconciling the medical and psychological. The DMCB thinks they are more the latter than the former.

Which raises another point. The Medical Home is predicated on the physician leadership of a team of health care providers who provide the full spectrum of participatory support and clinical services for persons with chronic illness. As you may have gathered from the watering hole scenario above, the DMCB thinks docs who embrace the non-medical dimensions of self-care are not as common as we’d like: they’ve all become disease management medical directors or are in bars debating things with psychologists. As the Medical Home continues to evolve, it will be interesting to see how this potential Achilles Heel plays out.

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