London Journal of Primary Care 2010;3:112–14
# 2010 Royal College of General Practitioners
Systems and Organisations
Healthcare needs personal doctors: a US perspective with British roots Larry A Green MD Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado Denver, USA
US healthcare is in a mess. In 2008, the US spent $7681 per person for healthcare, and annual national health spending reached $2.3 trillion.1 The US Central Intelligence Agency estimated in 2009 the value of all final goods and services produced within nations and rankordered nations by their Gross Domestic Product (GDP; purchasing power parity). Only China, Japan, India, and Germany had total, national GDP estimates exceeding the US estimated healthcare expenditures in 2008.2 The Commonwealth Fund’s 2010 report about US healthcare performance compared to other countries again confirmed underperformance of the US on most measures.3 Meanwhile, during the last decade the largest health insurance companies have seen increases in profits of some 250%, or 10 times the rate of inflation.4 The tragedy this higher cost, lower value system produces for families is revealed in estimates that the price of an average family healthcare insurance policy is expected to be half of an average family income by 2016.5 Herein lies an operational definition of unsustainability, and as economists are known to claim, ‘an unsustainable curve will not be sustained’. In an attempt to find a better way, a rash of practice innovation has broken out including urban and rural, independent and affiliated practices of all sorts, and especially in family medicine and general internal medicine. The current code words for this redesign work in primary care are the Patient Centred Medical Home (PCMH). The PCMH represents a great opportunity to lay a foundation of primary care across the US, and implementing the PCMH is hard work, requires a culture shift for practices, and takes time.6 Notable for its absence in PCMH pilots and reports is an explicit expectation that high performance healthcare systems need people to have their own doctor – a personal physician. The rhetoric properly emphasises systems and maintains that individual practitioners should know their jobs, follow evidencebased protocols, and work well with other fellow workers. But there is also an assumption that the clinicians are interchangeable so long as the replacement
has the right certificate or license. The implication is that when the workers in the system have done their job for the assigned duty hours, they are free to leave – and this leaving will not affect quality, costs, access, nor outcomes. Such thinking probably depends on a degree of organisation inherent in patients’ lives that underestimates how much of health and healthcare falls into a ‘disorderly’ category and relies on the need to have non-random responses to random events.7 Such thinking forgets that primary care is not a commodity, but a set of ongoing relationships. Ongoing relationships engender trust, and trust has a therapeutic effect quite different from disembodied voices or a rotary of strangers. For example, we know that some patients will change their medication only after Dr X says so; some decompensate when Dr X is away on holiday; some forego an MRI because they trust Dr X’s judgement after years of shared experience. Where, in progressive thinking about improving quality of care, fit the pleas from the public for a good doctor who will ‘just stick with me, even when I don’t have the right problem?’. In the US, such considerations are frequently dismissed as nostalgic yearnings by intransigent, stubborn doctors reluctant to change and the public’s ill-informed desire for old-fashioned docs whose time has come and gone. Such thinking overlooks what people need and want when they are sick, or fear becoming sick. Half a century ago in The Lancet, TF Fox, described a need for personal physicians.8 From this classic publication, the following summation was extracted and published again in 2007:9 The doctor we have in mind, then, is no longer a general practitioner and by no means always a family practitioner. His essential characteristic, surely, is that he is looking after people as people and not as problems. He is what our grandfathers called ‘my medical attendant’ or ‘my personal physician’; and his function is to meet what is really the primary medical need. A person in difficulties wants in the first place the help of another person on whom he can rely as a friend – someone with knowledge of what is
Health care needs personal doctors
feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for him, and, knowing how he lives, will keep things in proportion – protecting him, if need be, from the zealous specialist. The personal doctor is of no use unless he is good enough to justify his independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help his patients not because of the interesting medical problems they may present but because they are human beings in need of help.
The human need Fox described persists today. True, it often seems to be difficult to achieve in these high pressure, high turnover days of gut-wrenching, repeated change. But the current difficulties should not stop us asking questions about this core aspect of good healthcare systems. As Cooperider and others have claimed,10,11 inquiry is itself an intervention, with our questions influencing what we find, out of which the future is conceived. We seem to grow in the direction of the questions we ask. If we want healthcare to grow in the direction of highly personal and satisfying healthcare enabled by trusting relationships, we must ask questions about relationships and the role of personal doctors. So! What, in a modern context, do we expect from the personal doctor, when one of his/her patients receives care in another country consequent to an emergency or consequent to being a medical tourist? What do we expect of a personal physician when one of his/her patients is admitted to hospital or hospice, has a baby, adopts a baby, retires, grieves the loss of a life partner of some 50 years, attracts a 7th diagnosis requiring a 9th medication, drinks too much alcohol, is arrested? How will the personal physician use the internet and applications like Facetime, Skype, and other social networking technologies to achieve and sustain continuity, be comprehensive, be prompt, do ‘house calls’, obtain real time dermatology and radiology consults? What will be the responsibility of the personal physician for measurably improving the quality of his/her care and in measuring the health status of the population served? How will re-validation help the personal physician be a better personal physician? How many people can a personal physician tend with excellence? How will the balance be struck for the personal physician to thrive as an individual while honoring promises to patients? What alterations in medical education are necessary to enable personal doctoring? What is the effect of personal doctors on expenditures? How can a team or system provide personal doctoring?
113
It is not too late for leaders in primary care, general practice and family medicine, and public-minded leaders including medical subspecialists and patients, to ask together these kinds of questions and engage in a deep exploration of relationship-based healthcare and personal doctoring in a modern context. This type of doctoring is not a fantasy; it persists and is honored today despite current, perverse healthcare arrangements.12 In the current mess so many countries seem to find themselves in, such an exploration seems urgent. I contend that lower cost, high-quality healthcare systems require relationships between patients and their personal doctors and nurses. To achieve high value, sustainable healthcare for entire populations, nations need highly competent personal doctors. These personal doctors and nurses themselves need, and must earn, trusting relationships with particular individuals for whom they care and with whom they exchange and keep promises, over time. Many, if not most, people want and would welcome a personal doctor of their choosing. We need to work out how to provide such a doctor for them and agree as to what promises will be made – and kept. Who will call the meeting? CONFLICTS OF INTEREST
None. REFERENCES 1 Hartman M, Martin A, Nucciio O, Catlin A, and the National Health Expenditure Account Team. Health spending growth at historic low in 2008. Health Affairs 2010;29:147–55. 2 www.CIA.gov/library/publications/the-world-factbook/ rankorder/2001rank.html (accessed 9 September 2010). 3 Mirror, Mirror on the Wall: How the Performance of the US Health Care system Compares Internationally, 2010 Update. www.commonwealthfund.org/Content/ Publications/Fund-Reports/2010/Jun/Mirror-MirrorUpdate.aspx (accessed 9 September 2010). 4 Mills A, Engelhard CL, Tereskerz PM. Truth and consequences – insurance-premium rate regulation and the ACA. New England Journal of Medicine 2010;363:899– 901. 5 DeVoe JE, Dodoo MS, Phillips RL Jr, Green LA. Who will have health insurance in the year 2025? American Family Physician 2005;72(10):1989. 6 Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaen CR. Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home. Annals of Family Medicine 2010;8(suppl 1);s80–s90. 7 Ulanowicz RE. A Third Window: natural life beyond Newton and Darwin. West Conshohocken, PA: Templeton Press, 2009. 8 Fox TF. The personal doctor and his relation to the hospital. The Lancet 1960;2:743–60.
114
LA Green
9 Green LA, Jones SM, Fetter G Jr, Pugno PA. Preparing the personal physician for practice: changing family medicine residency training to enable new model practice. Academic Medicine 2007;82:1220–7. 10 Cooperrider DL and Avital M. Constructive Discourse and Human Organization: advances in appreciative inquiry. Oxford: Elsevier, 2004. 11 www.12manage.com/methods_cooperrider_appreciative_ inquiry.html (accessed 9 September 2010). 12 Phillips WR and Green LA. A public celebration of a personal doctor. Annals of Family Medicine 2010;8:362–5.
ADDRESS FOR CORRESPONDENCE
Larry A Green 12631 East 17th Avenue Room 3521 Aurora, CO 80045 USA Email: [email protected] Submitted 22 August 2010; comments to author 5 September 2010; revised 9 September; accepted for publication 14 September 2010.
Read and comment on this article online at www.londonjournalofprimary care.org.uk/
# 2010 Royal College of General Practitioners
Systems and Organisations
Healthcare needs personal doctors: a US perspective with British roots Larry A Green MD Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado Denver, USA
US healthcare is in a mess. In 2008, the US spent $7681 per person for healthcare, and annual national health spending reached $2.3 trillion.1 The US Central Intelligence Agency estimated in 2009 the value of all final goods and services produced within nations and rankordered nations by their Gross Domestic Product (GDP; purchasing power parity). Only China, Japan, India, and Germany had total, national GDP estimates exceeding the US estimated healthcare expenditures in 2008.2 The Commonwealth Fund’s 2010 report about US healthcare performance compared to other countries again confirmed underperformance of the US on most measures.3 Meanwhile, during the last decade the largest health insurance companies have seen increases in profits of some 250%, or 10 times the rate of inflation.4 The tragedy this higher cost, lower value system produces for families is revealed in estimates that the price of an average family healthcare insurance policy is expected to be half of an average family income by 2016.5 Herein lies an operational definition of unsustainability, and as economists are known to claim, ‘an unsustainable curve will not be sustained’. In an attempt to find a better way, a rash of practice innovation has broken out including urban and rural, independent and affiliated practices of all sorts, and especially in family medicine and general internal medicine. The current code words for this redesign work in primary care are the Patient Centred Medical Home (PCMH). The PCMH represents a great opportunity to lay a foundation of primary care across the US, and implementing the PCMH is hard work, requires a culture shift for practices, and takes time.6 Notable for its absence in PCMH pilots and reports is an explicit expectation that high performance healthcare systems need people to have their own doctor – a personal physician. The rhetoric properly emphasises systems and maintains that individual practitioners should know their jobs, follow evidencebased protocols, and work well with other fellow workers. But there is also an assumption that the clinicians are interchangeable so long as the replacement
has the right certificate or license. The implication is that when the workers in the system have done their job for the assigned duty hours, they are free to leave – and this leaving will not affect quality, costs, access, nor outcomes. Such thinking probably depends on a degree of organisation inherent in patients’ lives that underestimates how much of health and healthcare falls into a ‘disorderly’ category and relies on the need to have non-random responses to random events.7 Such thinking forgets that primary care is not a commodity, but a set of ongoing relationships. Ongoing relationships engender trust, and trust has a therapeutic effect quite different from disembodied voices or a rotary of strangers. For example, we know that some patients will change their medication only after Dr X says so; some decompensate when Dr X is away on holiday; some forego an MRI because they trust Dr X’s judgement after years of shared experience. Where, in progressive thinking about improving quality of care, fit the pleas from the public for a good doctor who will ‘just stick with me, even when I don’t have the right problem?’. In the US, such considerations are frequently dismissed as nostalgic yearnings by intransigent, stubborn doctors reluctant to change and the public’s ill-informed desire for old-fashioned docs whose time has come and gone. Such thinking overlooks what people need and want when they are sick, or fear becoming sick. Half a century ago in The Lancet, TF Fox, described a need for personal physicians.8 From this classic publication, the following summation was extracted and published again in 2007:9 The doctor we have in mind, then, is no longer a general practitioner and by no means always a family practitioner. His essential characteristic, surely, is that he is looking after people as people and not as problems. He is what our grandfathers called ‘my medical attendant’ or ‘my personal physician’; and his function is to meet what is really the primary medical need. A person in difficulties wants in the first place the help of another person on whom he can rely as a friend – someone with knowledge of what is
Health care needs personal doctors
feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for him, and, knowing how he lives, will keep things in proportion – protecting him, if need be, from the zealous specialist. The personal doctor is of no use unless he is good enough to justify his independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help his patients not because of the interesting medical problems they may present but because they are human beings in need of help.
The human need Fox described persists today. True, it often seems to be difficult to achieve in these high pressure, high turnover days of gut-wrenching, repeated change. But the current difficulties should not stop us asking questions about this core aspect of good healthcare systems. As Cooperider and others have claimed,10,11 inquiry is itself an intervention, with our questions influencing what we find, out of which the future is conceived. We seem to grow in the direction of the questions we ask. If we want healthcare to grow in the direction of highly personal and satisfying healthcare enabled by trusting relationships, we must ask questions about relationships and the role of personal doctors. So! What, in a modern context, do we expect from the personal doctor, when one of his/her patients receives care in another country consequent to an emergency or consequent to being a medical tourist? What do we expect of a personal physician when one of his/her patients is admitted to hospital or hospice, has a baby, adopts a baby, retires, grieves the loss of a life partner of some 50 years, attracts a 7th diagnosis requiring a 9th medication, drinks too much alcohol, is arrested? How will the personal physician use the internet and applications like Facetime, Skype, and other social networking technologies to achieve and sustain continuity, be comprehensive, be prompt, do ‘house calls’, obtain real time dermatology and radiology consults? What will be the responsibility of the personal physician for measurably improving the quality of his/her care and in measuring the health status of the population served? How will re-validation help the personal physician be a better personal physician? How many people can a personal physician tend with excellence? How will the balance be struck for the personal physician to thrive as an individual while honoring promises to patients? What alterations in medical education are necessary to enable personal doctoring? What is the effect of personal doctors on expenditures? How can a team or system provide personal doctoring?
113
It is not too late for leaders in primary care, general practice and family medicine, and public-minded leaders including medical subspecialists and patients, to ask together these kinds of questions and engage in a deep exploration of relationship-based healthcare and personal doctoring in a modern context. This type of doctoring is not a fantasy; it persists and is honored today despite current, perverse healthcare arrangements.12 In the current mess so many countries seem to find themselves in, such an exploration seems urgent. I contend that lower cost, high-quality healthcare systems require relationships between patients and their personal doctors and nurses. To achieve high value, sustainable healthcare for entire populations, nations need highly competent personal doctors. These personal doctors and nurses themselves need, and must earn, trusting relationships with particular individuals for whom they care and with whom they exchange and keep promises, over time. Many, if not most, people want and would welcome a personal doctor of their choosing. We need to work out how to provide such a doctor for them and agree as to what promises will be made – and kept. Who will call the meeting? CONFLICTS OF INTEREST
None. REFERENCES 1 Hartman M, Martin A, Nucciio O, Catlin A, and the National Health Expenditure Account Team. Health spending growth at historic low in 2008. Health Affairs 2010;29:147–55. 2 www.CIA.gov/library/publications/the-world-factbook/ rankorder/2001rank.html (accessed 9 September 2010). 3 Mirror, Mirror on the Wall: How the Performance of the US Health Care system Compares Internationally, 2010 Update. www.commonwealthfund.org/Content/ Publications/Fund-Reports/2010/Jun/Mirror-MirrorUpdate.aspx (accessed 9 September 2010). 4 Mills A, Engelhard CL, Tereskerz PM. Truth and consequences – insurance-premium rate regulation and the ACA. New England Journal of Medicine 2010;363:899– 901. 5 DeVoe JE, Dodoo MS, Phillips RL Jr, Green LA. Who will have health insurance in the year 2025? American Family Physician 2005;72(10):1989. 6 Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaen CR. Summary of the National Demonstration Project and Recommendations for the Patient-Centered Medical Home. Annals of Family Medicine 2010;8(suppl 1);s80–s90. 7 Ulanowicz RE. A Third Window: natural life beyond Newton and Darwin. West Conshohocken, PA: Templeton Press, 2009. 8 Fox TF. The personal doctor and his relation to the hospital. The Lancet 1960;2:743–60.
114
LA Green
9 Green LA, Jones SM, Fetter G Jr, Pugno PA. Preparing the personal physician for practice: changing family medicine residency training to enable new model practice. Academic Medicine 2007;82:1220–7. 10 Cooperrider DL and Avital M. Constructive Discourse and Human Organization: advances in appreciative inquiry. Oxford: Elsevier, 2004. 11 www.12manage.com/methods_cooperrider_appreciative_ inquiry.html (accessed 9 September 2010). 12 Phillips WR and Green LA. A public celebration of a personal doctor. Annals of Family Medicine 2010;8:362–5.
ADDRESS FOR CORRESPONDENCE
Larry A Green 12631 East 17th Avenue Room 3521 Aurora, CO 80045 USA Email: [email protected] Submitted 22 August 2010; comments to author 5 September 2010; revised 9 September; accepted for publication 14 September 2010.
Read and comment on this article online at www.londonjournalofprimary care.org.uk/
