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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Powerlessness, Frustration, and Control -- So what do we do now?
Changing the identity of family medicine
Family Physician Morale in Practice -- Large Groups
Local vs. central control: one issue that might influence powerlessness.
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David W. Price, MD, Broomfield, CO Director of Education and Clinician Researcher, Colorado Permanente Medical Group, Denver, CO
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Dr. Gask's article on the frustrations experienced by Family Physicians working in one Group Model HMO reinforced the need, in my view, for us to get beyond the increasingly unsustainable "one doctor, one patient, one exam room" method of patient care. She points out the opportunities that newer models of care, such as group visits (1), may provide for enhancing physician as well as team satisfaction (not to mention patient satisfaction). Participating in some of these teams, as are being increasingly implemented on our medical group, provides an opportunity for family physicians to remain involved in management of patients while sharing care responsibility, and developing new skills or expertise in different model of care in clinical conditions of interest. Berwick (2) and others have written extensively about the need to make small, incremental, rapid cycle changes in health care delivery. Enlightened leadership of group model HMOs have encouraged (and should be encouraging) family physicians and other team members and colleagues to attempt small and repeated "Plan-Do-Study-Act" cycles. Such empowerment can enhance the family physician's sense of autonomy, while at the same time being consistent with necessary efforts to improve quality, cost- effectiveness, and patient satisfaction. References: 1. Beck A. Scott J. Williams P. Robertson B. Jackson D. Gade G. Cowan P. A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic. Journ American Geriatrics Society. 1997;45(5):543-9. 2. Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med 1998;128:651-656. Competing interests: None declared |
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Bonnie Sibbald, Manchester, England Professor of Health Services Research, University of Manchester
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Gask draws attention to a challenge faced by family physicians in the UK, Netherlands, Canada, Australia and many other countries apart from the United States - namely the changing ‘skill mix’ of the primary care team. Solo family physicians are slowly being exchanged for large multi- disciplinary teams. Nurse practitioners, clinical nurse specialists and physician assistants increasingly substitute for family doctors in the care of minor illness and the routine management of stable chronic diseases. Family doctors are increasingly required to focus on patients with ‘complex’ health problems and co-morbidities. The factors driving such change are many and complex. However central to the process is the belief is that large, multi-disciplinary primary care teams will enhance the quality of care, constrain costs, and make best use of limited human resources. Quality improvements are sought through specialisation within larger teams. Cost savings are sought through economies of scale and scope, and by shifting care from expensive to cheaper health care professionals. Better use of scarce human resources is sought through the breakdown disciplinary boundaries which prevent professionals being deployed where their skills can best be utilised. But are these benefits achieved or achievable in practice? The evidence base for change is generally not robust and has lagged behind the transformation of primary care.1 Most importantly, little attention is given to the unintended effects of changing ‘skill mix’. These include the increased difficulty of coordinating patient care within ever larger teams, loss of continuity of care with the patient’s preferred practitioner, and a devaluation of the ‘generalist’ skills of the family physician. The latter is particularly worrying because having a generalist physician as the usual point of first contact in the health care system is thought to be key to delivering high quality care at low cost.2 Gask points out that health care managers need to attend more closer to the concerns of their family physicians. In particular, she argues managers need to value the generalist skills of family doctors more highly than they do. I agree – not simply because this will benefit the well being of family doctors but also because it is in the best interests of health care system more generally. 1. Sibbald B, Shen J, McBride A. Changing the skill-mix of the health care workforce. Journal of Health Services Research and Policy 2004 (9) Suppl 1: 28-38. 2. Starfield, B. (1992) Primary Care. Concept, Evolution and Policy. (Oxford, Oxford University Press) Competing interests: None declared |
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Joseph E. Scherger, San Diego, CA. USA Clinical Professor, Department of Family and Preventive Medicine, University of California, San Dieg
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Linda Gask provides an inside look into the morale among experienced family physicians working in a large group model HMO. While there is some contentment and a variety coping skills, the overall tone is negative with respect to professional satisfaction with their role. Physician autonomy is a traditional value among physicians, and a sense of control over one's practice is much less in a large group with fixed schedules and policies. This article studied family physicians with 10-30 years of practice experience and a mean of 15 years in the HMO, which is quite a stable physician group. Young physicians recently out of training are in some ways a new generation, and may have a different attitude about the importance of control and physician autonomy. A group of younger physicians might make for an interesting comparison study. Since managed care became prominent in the early 1990s, my anecdotal observation has been that family physicians in large stable HMOs like Kaiser Permanente and Group Health Cooperative of Puget Sound seem happier in their work setting compared with those in smaller private practices. The hassles seemed less, and there was more professional time devoted to clinical practice rather than paperwork. This article compels me to think about another study comparing such populations. Finally, I wonder whether there may be an improvement of the professionalism for family physicians in large groups in the near future? Do airline pilots of large airlines feel a similar lack of control? I suspect not, although the controls on their work may be greater than among physicians today. This study calls for a greater focus on the long term professionalism of physicians in practice. The new tools of information technology and quality improvement methods of team empowerment may help. Patients want personal physicians who are happy with their work. Competing interests: None declared |
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Macaran A. Baird, Minneapolis, MN, USA Professor and Head, DFMCH, Univ. of MN
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Dr. Gask's study reflects the informal reality I have experienced in a variety of leadership and practice roles in large group practices, including a staff model HMO, over the past 20 years. I think this article will "ring true" for many physicians but not just those within staff model HMO's but for physicians in any large practice that has centralized a variety of key practice functions such as scheduling, quality initiatives, staffing decisions and phone support for more comprehensive management of patients with chronic illnesses. Perhaps we have learned much about how to reduce random and irrational variations in practice via centralizing certain hourly or minute-by-minute decisions to the benefit of patients previously vulnerable to the consequences of ideosyncratic, possibly low quality, practice by individual physicians. However, this study points out some of what has been lost. The analogy that comes to mind is only partially applicable, but consider what would happen in the airline industry if we had not centralized and automated some functions such as scheduling, pricing and perhaps pilot and staff training. However, individual pilots and crews flying within the airplane still control the actual aircraft (with computer and ground level support). Even the autopilot can be over- ridden by the pilot and crew as deemed appropriate by those actually in the cockpit. Similarly, some decisions and functions in primary medical care may be more efficiently managed from a distant centralized office or unknown care management nurse but the efficiency or value is only gained if the "local physicians' and team members'" input is retained sufficiently to allow for "rational variation" as determined by moment-to-moment realities. The negative impacts described in this study are possibly as related to the size of a practice as to the organization model of 'group model HMO" vs. "private pratice" groups. An interesting follow-up study might evaluate what, if any, differences are found if primary care physicians make the strategic management decisions vs. "others" less connected to the ground level practice realities of caring for patients in the manner valued by those acting seeing the patients. Secondly, we could assess size of practice as a variable. A sense of powerlessness in any workforce seems to be one of our era's pervasively negative cultural themes. Highly effective primary medical care must address this issue successfully in order to fullfill our potentially vibrant future role in improving the health of our patients and communities. . Competing interests: None declared |
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