Sunday, November 30, 2008

Innovation in Primary Care.... NOT

Much like the earnest gecko hunter of those Geico commercials, a reporter has been dispatched from the New England Journal to observe ‘innovative’ primary care physicians in their natural habitat. According to this intrepid correspondent, there are creative docs out there who are field testing ways to see fewer patients, work-smarter-not-harder and avoid burn-out.

And just what are these precocious practitioners of the Plains, these daunting docs of Dubuque, trying out? According to this safari jacketed writer, the ingredients for physician innovativeness consist of downjobbing routine stuff to the nurses, being savvy schedulers, using group visits, email and telephony. See, this may free up time for precious moments of physician-patient intimacy sprinkled with some real medical stuff, like worrying about potassium levels.

This is insight from the New England Journal? Maybe among Boston's Brahmins. The rest of us know the nurse-physician dyad has been the bedrock of well functioning outpatient clinics for decades. Not only have nurses plowed the road for the physicians in high performing clinics, they know better than anyone else that in primary care, quick one-on-one '12 minute' visits are ultimately more remunerative and that complex time consuming issues can be referred away.

Group visits, e-mail and telephony are not ‘all that’ either. The DMCB suspects these remain pretty much confined to very large physician practices, which seems to be the favored hiking range of the Journal’s academic writers anyway. As for the other 90% of primary care that has been missed by this reporting, these docs have probably calculated that adding to or substituting lots of patient visits with lots of phone calls and emails is a losing hand in a zero sum game. They also know that group visits are not a slam dunk either, especially in smaller practices with limited square feet.

Nonetheless, even this faux field report couldn’t help but spot the recruiting struggles of the large primary care practices. And it begs the question: if large group practices, nurse teaming, scheduling know-how, remote care communications and group visits are all that cool, then why are young physicians not flocking to innovation/large group practices so admired by the New England Journal?

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