Is it a season for optimism or despair in primary care?

Issue: August 2013

ByWilliam T. Gerson, MD

Winter, spring, summer or fall/All you got to do is call/And I’ll be  — “You’ve Got a Friend,” Carole King, 1971

So long summer time/You got the power, you got the faith, you got the El Camino, you got the night, you got the day, I got the ole dark cloud/Sun is going to shine again/Sun is going to shine again  — “Sun’s Gonna Shine,” Steve Martin and Edie Brickell, 2013

While Carole King had a friend in mind for her lyrics, I would like to think that they reflect the office availability of the general pediatrician in any season. Summer can bring new residents or drought (sometimes both). Fall represents harvest plenty, while for others a sense of melancholy. As for winter, all I can say is that if you live in Vermont, you love it. And while spring is a time for hopeful new beginnings, it can also bring tornadoes and floods. How about pediatric general practice and its future for any time of the year? I am thinking that the sun’s gonna shine.

William T. Gerson

In my recent columns, I have discussed the uncertainties and challenges of primary care as we move forward in health care reform in this county. I hope many of you have read the latest wide-ranging AAP policy statement on the optimal pediatric health care model. The AAP affirms the position that a pediatrician (generalist or specialist) should serve as the leader of the pediatric health care team based on the pediatrician’s unique ability to manage, coordinate and supervise the entire spectrum of pediatric care, diagnosis through all stages of treatment and in all practice settings. The AAP supports limitations on the scope of practice of non-physician clinicians. It opposes legislation that expands their scope of practice, including independent practice, hospital admitting privileges and independent prescriptive authority.

In a carefully written document that focuses on the safety and quality of health care to all infants, children and adolescents, the AAP details the differences in education and training of pediatricians, their unique skills and ongoing assessment of their competencies and calls on pediatricians to advocate at all levels and in all forums for the optimal care for pediatric patients.

As I have stated before, we need to voice our expertise in identifying opportunities and advocating for the well-being of our patient population. This AAP statement is clear and strong. It needs to be complemented by an equally vigorous and comprehensive rededication to practice ideals.

Opportunities to move forward

There are significant opportunities as we move forward in health care reform, and in this process I see some similarities to the slow food movement. In that model, the original focus on taste and quality seemed narrow and elitist to many observers, but evolved into an organic synthesis of better quality food for everyone and an improved social contract. Parallels between not only quality but production, consumption and waste as it applies to food can be applied to health care. Just as globally we produce food for billions while billions remain hungry, in this country we produce health care for millions while millions remain without access to affordable care, not to mention troubling issues of quality and waste. More production of health care, just like that of food, does not mean less waste or higher quality care. We need to nurture our practice of medicine so that the abundance of harvest reflects an improved wellness of our patients.

Improving wellness

Primary care is not simply the health care maintenance of well patients and the careful and timely care of the acutely ill. If we truly want to improve the wellness of our patients and lay claim to the social delegation of primacy in primary care, we must redesign our practices to focus on the global well-being of our patients and commit to a process that integrates maintenance of certification into safety and quality of care. Pediatric care might just be the central to all reform.

Neal Halfon, MD, and Patrick H. Conway, MD, describe the opportunities and challenges of a lifelong health system in an editorial in a recent New England Journal of Medicine. Flowing from the very reasonable premise that a health system’s goals should be to optimize health and minimize disease burden over the life span both for individuals and the population, the authors explore the opportunities available in the new environment of the Affordable Care Act, as we no longer focus on immediate outcomes and the consequences of a payment and incentive system geared toward a short-term horizon matched with an annual (for some monthly) enrollment cycle for insurance coverage. Insurers, mostly Medicaid and Medicare but also accountable care organizations, will face the prospect of insuring patients for decades, not years, and sometimes for a lifetime.

Incentives for enhancing health trajectories and longitudinal integration of services and the awareness that many chronic conditions affecting adults originate in the exposures, experiences and behaviors of early life, even in utero may be transformative — not only for medicine but also perhaps for society as a whole. As Americans, a fixation on the short term not only infects medical care but has altered our relationship with democracy, capitalism and our social contracts. We need to reinvest in a vigorous debate about our shared future. As pediatricians, we should not only pay attention, we should lead the debate.

References:

AAP Committee on Pediatric Workforce. Pediatrics. 2013;131:1211-1216.

References:

William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email:  William.Gerson@uvm.edu.

Disclosure: Gerson reports no relevant financial disclosures.