Super doc and real health reform.

World War II was over, and the nation was full of general practitioners who thought they could, and frequently tried to, do it all. Only 50 years and 50 new specialties later, the general practitioner, now called family practitioner or general internist and trained for three or more years past the MD or DO, is thought to be able to do nothing well and is compensated accordingly.

To add insult to injury, the general practitioner is now also called "primary care provider," gatekeeper, triage physician, and other even more confounding terms. Dignity has been lost, and incomes, as well as kudos, go to the artists of flexible tubing, laser attachments, and computerized miracle images and to parts replacement surgeons. Fragmentation is king of the medical profession. Continuing, concerned, and accessible care is more difficult to find. What happens to patients before and after the miracle procedures is often forgotten or neglected and is always poorly compensated. The good news is that the "primary care" physician can still write prescriptions for most things, although the profusion of pharmaceuticals confounds the mind and overwhelms the analytic capacity for possible interaction of even the latest supercomputer at the National Institutes of Health.

Amazingly, the payers of claims. our insurance industry, after 40 years of analysis. discover that "thinking," costs less than "doing" and makes a thrust toward enticing more insureds toward the primary care physician in order to spend less on claims and to keep a reater share of premiums as profits. This is all accomplished while- compensating, the primary care physician only a farthing and flooding him or her with a blizzard of paper and phone calls. The process is designed to control, diminish, or even eliminate as many procedures and consultations as possible. And that we now call "gatekeeping." Some insured products, having recognized the value of avoidance of care, offer the PCP as much as an extra dollar per month to do the necessary phone calls and paper handling. This intended "bonanza" for the PCP becomes the object of unmitigated nausea and disgust of those so enriched and even the extra dollar per month does not relieve the symptoms.

Now comes a truth long forgotten. The patient in all of us seeks the physician healer and rarely succeeds. The cry long uttered but rarely listened to, "My doctor doesn't listen to me and seems not to care," comes to the forefront of patient/consumer complaints, and admiration for the profession dwindles year after vear. All is blamed on the greed of physicians, and even the miracle workers don't get much respect except for the momentary notoriety of headlines announcing, that the liver of a baboon has been successfully transplanted to a human or some other "breakthrough.

Revelation that Will Lead to Resolution

Recognizing, the value of the central physician in restraining, spending, we might take the opportunity to redefine the role, augment the education/training, and even elevate the importance of the PCP. A more descriptive designation for that physician is personal medical director or personal physician. That change should result in a change from the present relationship to a direct contract between the patient/consumer and his or her chosen physician. Full responsibility for care of that individual would lie with the personal physician. The full spectrum of needs - emotional, supportive, and physical medicine - would rest on that physician. This change anticipates that the personal physician understands the needs of the patient as a whole individual. Only then can appropriate resources be called into action effectively and without delay.

Understanding the responsibility and therefore the authority of the personal physician should recast this role and bring specialized medical resources into a more responsive approach. What is best for the patient would become paramount, and the team leader, the recast personal physician, would assume full responsibility for all of the care the patient requires now and in the future. Good patient relations, good patient care planning, a dedicated team of specialists, and a spread of care options, if properly managed, will result in maximum efficiency, greater value for health care costs, and probably lowering, or control of costs. We can begin to use our creativity in utilizing our resources for the best care of the individuals who really matter and to whom our profession can rededicate itself.

How to Create and Sustain This New

Super Doc

Traditional training for family practice or internal medicine or pediatrics does not completely prepare these physicians for the enlarged role. Certainly, the consequences of medical behavior on the economics of health care need to be clearly understood. The real crisis in the costs of medical care must be understood. The opportunity exists to participate in the onslaught of change, or to be washed away by inaction.

The super doc must be versed in social interaction and in the need for establishing a trusting relationship with patients. The healing power of that trust has now been fully recognized as a powerful tool for physicians. It can retum our profession to its prior luster as a healing profession. What could be more powerful in this new era of change than the recreation of a powerful personal and professional bond? It even makes economic sense, and that seems to be at the fore of our national concern

A program for maintaining continual knowledge of medical process for the super doc should be developed. It goes as follows. Each personal (PCP) physician would dedicate about 10 percent of his or her working hours for professional enhancement. It would be didactic and organized along well-organized topics. A PCP would spend three hands-on hours per a week with a specialist (cardiology, pulmonology, neurology, etc.), working with that specialist and seeing live patients, both inpatient and outpatient. Rotations would occur at two-four-month intervals from one specialist to another, from one service to another, local, near, or distant. Representatives of physician groups, hospitals, and teaching centers would come together and plan the programs. The programs would have to be meaningful to the professional, easy to obtain, pleasant to participate in, and worthy of the time allocated by the physicians. Can you imagine what could happen if specialists spent three hours a week with internists or family practitioners seeing patients? Might this not be revolutionary in bringing physicians closer together and in closing the chasm of fragmentation we have experienced in the past 50 years.

Placing the personal physician in the proper position of relevance and respect might begin to create a redistribution of medical income more favorable to the personal physician, eliminate a major reason new physicians have chosen more lucrative specialties, and create a shift in interest toward the primary care arena.

Enhancements that Will Lead to

Effectiveness

The practicing PCP is overwhelmed with the complexities of conducting both a loaded practice and the business side of medicine. The complexities are greater at the PCP level than in most specialties and are driven by the volume and the variety inherent in dealing with totality of care. Movement to consolidation, grouping, centralized management, and shared information systems are major changes that are essential if effectiveness of the PCP is to be achieved.

Further, teaming the PCP with a new breed of well-trained and dedicated physician assistants and nurse practitioners will give the PCP more time to concentrate on the more difficult cases and to be relieved of the mundane. This will go a long way toward relieving boredom and tedium in the profession.

Having achieved this remarkable transformation to the new super doc, we can focus on properly designing a spectrum of medical care that is both curing and caring. The new medicine will probably also be highly effective in containing waste and diminishing costs.

A large array of social, econo professional issues will have to be confronted and resolved before ptimary care physicians can take their logical place as leaders in the health care delivery system. Linkages wdl have to be forged between ptimary care physiciang and specialists and between primary care physicians and nonphysician providers of primary care. Key to successful resolution of the current dilemma is ensuring that primary care P%ysicians are compensated at afair kvelfor their skills. It is the dispari'y in physician incomes that lies at the heart of the problem, according to the author.