Monday, July 21, 2008

Patient Centered Medical Care and Disease Management Both Let Doctors Be... Doctors

The Disease Management Care Blog doesn’t remember too much about its 7 years of medical school or residency (thank goodness) but it remembers when it left Preventastan and crossed into Acuteastan. It was close to midnight and one of my fellow interns was drawing up a gram of Solumedrol for an I.V. ‘push’ dose for an unfortunate with Lupus nephritis. I thought, how cool.

It is difficult to overestimate the mostly good and sometimes bad influence of medical training on attitude, values and career choices. One of the most pervasive outcomes of med school and residency however, is the enculturation of young trainees toward an acute care focus. We become addicted to the thrill of spotting a diagnosis and tailoring a successful treatment. That’s not necessarily bad: physicians are needed first and foremost to care for sick patients. After many rewarding years of helping patients in extremis, prevention - the art and science of non-events - is, well, so boring.

This contrast between chronic care ennui and acute care excitement has gone unexamined as one cause of the widespread lapses in health care quality. But the DMCB thinks it is out there.

By ‘prevention,’ the DMCB includes not only the avoidance of disease but the complications of established chronic disease. Getting docs to enter Preventastan is hard work. There have been unsuccessful efforts to advance prevention with quality improvement (QI), the electronic medical/health record and pay for performance (P4P). There is literature that suggests these interventions have a spotty record in changing the approach of hardened professionals. They are openly skeptical about QI, willing to ignore electronic on-screen prompts and resist P4P.

The DMCB appreciates there are other forces at play. Physicians lack time, trust in the system, training, incentives and support. On the other hand, when physicians really want to effect change, it appears they have the means to do so.

This is why the DMCB likes the Patient Centered Medical Home (PCMH) and Disease Management (DM). Both approaches explicitly recognize the physician doesn’t need to be personally responsible for preventive care. PCMH delegates chronic care to members of the clinic’s team while DM outsources it to remote nurses. Some combination of both probably works best.

What’s more both PCMH and CM approaches can be helped by quality improvement, rely on the electronic record and can generate payment for performance.

And finally, both let doctors be …. doctors.

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