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Voyage of care: A sustainable future for primary care
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My life has been a tapestry of rich and royal hue An everlasting vision of the ever-changing view A wondrous, woven magic in bits of blue and gold A tapestry to feel and see, impossible to hold. As I watched in sorrow, there suddenly appeared A figure gray and ghostly beneath a flowing beard In times of deepest darkness, I’ve seen him dressed in black Now my tapestry’s unraveling — he’s come to take me back He’s come to take me back. — Carole King, “Tapestry,” 1971
Who’ll tell your future, I can’t tell my past, Who’ll tell your future, I can’t tell my past. — Canned Heat, “Future Blues,” 1970
Today as I walk through my garden of dreams I’m alone in the sweet used-to-be My past and my present are one and the same And the future holds nothing for me. — Willie Nelson, “Wonderful Future,” 1972
Over the last few columns, I have looked at the soul of the practice of medicine in an effort to make the case that our profession’s past offers a model for the future; one that is both sustainable and able to buttress the harsh winds of change we all feel on a daily basis. This month, I continue to look at pediatric practice — with my heart in the past and an eye to the future — in an attempt to weave a tapestry rich in meaning and wonder, and able to reflect a possible vibrant future for pediatric practice; a tapestry able to reflect Carole King’s dark force with a sagacious light generated by the past.
The penultimate question
Will the healing tradition that is a thousand generations old, the Athenian model, survive? Or will the large and wasteful 21st century service industry that is rapidly being commodified, in which physicians become full-time equivalents or a portion of a full-time equivalent and work (the Oslerian word that defines being a physician) is redefined as “shift work.” A world where our leaders are managers, not teachers nor mentors, and our exam rooms suffer from third-party invasions and often our patients never feel our hands?
The challenge as I see it is to base the future on retaining the classical healing ideal and providing a safe, sustainable and longitudinal care model to guarantee the well-being of all children and not simply to reduce inefficiency. Professionalism, dating to Hippocrates, is crucial to the task. An educational structure committed to the well-being of our patients and our practitioners, and not solely the boardroom, is also critical.
The practical practitioner’s answer, of course, is to survive financially in the process; this is our true vulnerability. In private practice, we have little in reserve to handle the risks we now face. Our joy is in caring for real patients not managing the actuarial risk of populations. While fee-for-service payments have jeopardized health care costs, this is not the fault of pediatrics. Embarking on outcome-based reimbursements place our practices at the mercy of distant financial departments and the mystical creations of health care economists.
A nuanced social contract
Professionalism is central to the current and future of medicine just as it has been for centuries and is grounded in the social contract between the medical profession and society. It also holds the key to the future of primary care. The critical elements of this contract reflect the granting of a monopoly over the use of a body of scientific knowledge, along with significant autonomy in the practice of medicine both to act in the best interest of the patient and to self-regulate education, training and standards of care. This monopoly comes with the understanding that, in exchange, the profession guarantees competence, integrity, morality, service and altruism. The existence of that social contract depends on the existence of a community, and the contract is always in flux, dynamically negotiated.
As physicians, our tension in this ongoing negotiation with the wider society often appears to involve the expectation of prestige and financial rewards, thus leaving out the true elements of the contract. For society, the exclusivity of the monopoly — the requirement of service for the public good and the degrees of autonomy — defines its tension with the profession. As community grapples with “unity and freedom,” it often forgets the delicate balance substituting more freedom (eg, granting of status to alternative care providers) for the ultimate community good of unity and, ultimately, wellness.
With the growing influence of both the government and corporations in the health care system, the relationship, and thus the negotiation, is even more complex. In pediatrics, however, the negotiated terms are not difficult to delineate: patient focus and public good. Pediatrics has always stood for these twins.
We are lucky in pediatrics that our professional organizations have always been patient-focused. The mission of the AAP is the well-being of children. The American Board of Pediatrics, our certifying board, represents the public good side of the equation and has repeatedly focused on discussions of professionalism as it applies to pediatrics since the 1970s. The privilege of self-regulation requires an absolute obligation to guarantee the competence of its members: continuous improvement and excellence in care underpinning the science and practice of medicine.
On the horizon
But who is going to provide primary care in the future? This question will define a most critical challenge to those of us who currently practice general medicine. It will drive the debate over primary care and complicate issues of medical education and training, secondary and specialty care, and the nature of health care reform. Integral to this discussion is the societal respect given to physician practitioners of primary care. If, as many august bodies have declared, primary care can be independently delivered by nurses, naturopaths, chiropractors and others — the likelihood of the permanence of the existing social context of physician-directed primary care practice is small.
Once lost, the past is forgotten, but even more troubling the future is made more treacherous. I will try to tell you your past, explain your present, and unlike Willie Nelson give you a future to embrace.
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- 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.