The Myth of the Lone Physician: Toward a Collaborative Alternative

We appreciate the very thoughtful reflections on our essay (1-7) as they highlight vitally important issues we need to consider when transitioning toward a more collaborative paradigm: the importance of caring, compassion and continuity, the involvement of the patient as a member of the team, and the appropriate size of a functional team.

The alternative we proposed --Highly Functioning Health Care Team (HFHCT)--does not envision a new breed of family physicians who no longer concern themselves with 'bedside manner' or in developing caring, continuous relationships with patients and families. It seeks just the opposite. The realities of modern medical practice have increasingly placed family physicians in a vice which pressures them to perform an expansive range of tasks in a reduced visit time. In our experience, the existing paradigm leads family physicians, with great reluctance, to frequently sacrifice their 'bedside manner.' The HFHCT seeks to fully enact the fundamental principles of Family Medicine that are based in the biopsychosocial model and expressed in the relationship-centered clinical approach.

A unique aspect of our specialty is the ability to see patterns within and outside the skin, to think interactionally and to act in relationships The HFHCT does not position family physicians to abdicate continuity, compassion or intimate relationships with patients and families. In fact, by creating a team that authentically involves patients and their network with that of the health care professionals, we hope physicians can more clearly focus on the key relationships. The redistribution of responsibility and tasks throughout a team can free physicians to deal with complexities of the care-medical, psychosocial and interpersonal. They will have the bird's eye view and the skills to develop a caring relationship that can focus clinical encounters on the big questions that face patients and families that involve shared-decision making, managing life transitions, and dealing with suffering and illness.

In that sense, clinical training for medical students and family medicine residents cannot not include training in communication, compassion and team collaboration. These skills are intertwined. If all the HFHCT accomplishes is to facilitate family physicians in becoming more effective 15 minute, biomedical practitioners, then we have failed to realize what the biopsychosocial and relationship-centered care approach intended when our specialty was created. In fact, that is the reality that has become the default experience of the current situation for many family physicians who feel frustrated if they cannot retain their relational lens or overstretched if they do.

We proposed certain criteria for the new paradigm shift. Minimally, it represents a change from physician-centered to physician-led teams. The physician does not abdicate complete responsibility to others, but shares it appropriately. In addition, the HFHCT does not simply represent a team of health care professionals. It necessarily involves the creation of a new system that combines the patients' network (patient, family, supports) and the health care network. Patients and families will need to be welcomed and educated to participate as informed, empowered, and active members of the HFCHT. Arguably, shifting the expectations of the roles of patients and how we interact with them. Culturally, we appear to lag behind Europe which has an effective model and metaphor for such collaboration. (2)

In our essay, we recalled the story of Flight 1549's landing on the Hudson River to provide an example of a HFHCT. The recent tragedy of the sinking of the Costa Concordia cruise ship stands in stark contrast. While multiple reasons have emerged to explain the disaster and the degree of accountability of the captain and crew remain unclear, it appears that the passengers were not trained or prepared to deal with a potential emergency, as should have been done prior to leaving the dock; this lack of active involvement seems to have added to the confusion and chaos. (8) They could not participate as informed members of the team. Similarly, while many members of the physician led health care team must be trained in collaboration, the active participation of patients and families is a key element of the new paradigm.

Determining the "right size" of the team will need rigorous investigation and may well vary based on patient needs and available resources for any given practice. The current 1- to-1 physician- patient/family dyad seems too small, and arguably a large interdisciplinary team that struggles with continuity and accountability is no doubt too big. In our own experience, we have found a small team, the teamlet, which consists of the patient/family, physician and health coach to represent a manageable size. (9) These teamlets are subsets of a larger team that includes a circumscribed panel of patients, families and community supports along with interdisciplinary health care professionals (nursing, behavioral health, nutrition, pharmacists) who move in and out of involvement with the teamlet when clinically needed.

Rather than removing the heart of our specialty (our ability to develop caring, continuous, meaningful relationships with patients, families and colleagues), we hope that a shift to a collaborative alternative restores it where it has been lost, reinforces it where it has been under siege, and redeems it from an unworkable myth that has kept us from realizing the original promise of family medicine.

George W. Saba, PhD; Teresa J. Villela, MD; Ellen Chen, MD; Hali Hammer, MD and Thomas Bodenheimer, MD, MPH

References: 1. Saba GW, Villela TJ, Chen E, Hammer H, Bodenheimer T. The myth of the lone physician: toward a collaborative alternative. Ann Fam Med. 2012;10:169- 173. 2. Palkowski JJ. Cultural integration of a collaborative approach to patient care. Eletter, Ann of Fam Med, available @ http://www.annfammed.org/content/10/2/169.full/reply#annalsfm_el_24393.16 March 2012. 3. Moore LG. The myth of the lone physician: not dead yet. Eletter, Ann of Fam Med, available @ http://www.annfammed.org/content/10/2/169.full/reply#annalsfm_el_24393. 16 March 2012. 4. George AE. Three paradigms to deconstructing the myth of the lone physician. Eletter, Ann of Fam Med, available @ http://www.annfammed.org/content/10/2/169.full/reply#annalsfm_el_24393. 16 March 2012. 5. Palkowski JJ. Re: three paradigms to deconstructing the myth of the lone physician. Eletter, Ann of Fam Med. Available @ http://www.annfammed.org/content/10/2/169.full/reply#annalsfm_el_24393. 19 March 2012. 6. Chacko S. The essence of the family physician, Ann of Fam Med. Available @ http://www.annfammed.org/content/10/2/169.full/reply#annalsfm_el_24673. 6 April 2012. 7. Forrest B. Ideal team based care: working for the patient, not their insurance company, Ann of Fam Med. Available @ http://www.annfammed.org/content/10/2/169.full/reply#annalsfm_el_24699. 10 April 2012. 8. Bly L. Cruise ship passengers recount capsizing off Italy. USA Today. 16 January 2012. Available @ http://travel.usatoday.com/cruises/story/2012 -01-15/Prosecutor-says-captain-left-ship-early/52579406/1. 1 April 2012. 9. Bodenheimer T, Laing BY. The teamlet model of primary care. Ann Fam Med 2007;5:457-61.

Competing interests:   None declared

While I appreciate many of the insights offered in this article, many of the assumptions are based on practicing in the broken third party payer healthcare system. After seeing the problems and frustrations of primary care physicians in the "15 minute/paid for volume model" I decided 12 years ago to find away around some of the obstacles mentioned for patient care. Principally, the fundamental challenge are the time and overhead demands placed on primary care physicians by third party payers.

Physicians have to often see 12-15 patients per day just to cover their enormous overhead. What if instead of being dependent on volume of 99213s through the door each day, physicians could be paid for taking quality care of a population of patients. What if they could reduce their overhead from the national average of over 60% to around 25%. What if they could improve collections from a national average of around 65% up to around 99%.

What would happen is this: physicians could spend 30-45 minutes with each continuity patient, have time to fully educate the patient about treatment options and lifestyle changes, fill out patient assistance forms to overcome barriers to compliance, and improve quality of care dramatically-all while decreasing the patients out of pocket charges by 80%. (see Medical Economics May 2011 "Cutting Edge -Three's a Crowd")

Part of the Lone physician idea comes from the days of Doc Baker and Marcus Welby. I would argue that was a time of exceptional and well coordinated primary care. The difference was that third party payers did not so encumber the the care of the patient and divert the physicians time away from what they were trained for which is direct patient care. Direct primary care models, where patients or their employers pay directly for primary care rather than passing the payment through insurance is another way to achieve optimum quality, reduced cost, universal access, and complete price transparency. By not filing insurance, practices can save up to $250,00 per year per provider. There are no personnel costs for billing, coding, claims appeals, or filing. This means that all staff are focused on patient care only. In our office we have providers which consists of Nurse Practitioners and physicians. As a team we work very effectively together. The other staff serve as "patient care coordinators." They check patients in, handle referrals, scheduling, phone calls, compliance optimization, and accepting payment in full either at time of service or through online monthly payment options.

We are not concierge! Concierge practices charge a premium fee for premium service. We charge greatly reduced fees for premium service. This makes our model affordable for almost everyone. We have had homeless patients that could not qualify for Medicaid but could afford our $20 office visits (inclusive of labs, EKG, and other ancillaries). Our patients (or their employers) pay either a monthly fee of $25-39 per month or simply pay in full for their annual physical once per year to benefit from these low prices. So many would ask- how can we afford to practice this way? Well, by reducing our overhead by $250,000 (overhead associated with filing insurance) per year per provider we are simply passing those savings along to the patients and still having a net fee per patient that is significantly better than the average primary care physician.

It is possible to be a successful lone physician. It is possible to provide patient centered high touch care for these patients and not weaken the physician patient relationship which is at the core of good care. If we are honest with ourselves we will realize that many of the staff on the large teams involved in healthcare are mainly tasked with reimbursement issues. If we simplify that, then everyone on the team can share a common goal of taking care of the patient.

To Dr. Saba's point about Captain Sully, he did utilize his team effectively- but I do not think anyone would have wanted one of the crew members steering that plane instead of Captain Sully. My point is, I am starting to see models of care arise where the physician simply signs off on the work others are doing with patients to maximize profitability. The worst mistake we can make in health care would be to put the pilot in the back of the plane. That's not the type of team based care we need.

Competing interests:   Author is a consultant for physicians wanting to practice in a Direct Pay Model and has an ownership in forrestdirectpay.com, Direct Pay Health, and Physician Care Direct all subsidiaries of Innovadoc, LLC.

What is the essence of a family physician? This is the question we really need to ask ourselves. The focus of family practice is our relationship to our patients. We build a history and a future with them through health maintenance exams, sick visits, life changes, and a breadth of problems. Our main goal is to maintain continuity of care.

Allow me to quote from the article: The Domain of family Practice: Scope, Role, and Function by Dr Phillips and Dr Haynes. 'What if the initial interview had been conducted by a computer, the pap smears done by a mid-level practitioner year after year, the mental health concerns referred out to the 1-800-counseling service, the asthma carved out by a disease management program? What would remain as the foundation for the relationship? Where would the history have gone? What interaction would sustain the bond between doctor and patient? What kind of person would want to be that kind of family physician?'

Having a HFHCT to take care of aspects of preventive, acute, and chronic care so that family physicians can concentrate on 'more complex patients who need more of our time', is NOT what family medicine is about. We are the ones keeping a surveillance on our patients as they go through the different stages of life, and when they are on the perimeters of health, minor illnesses, or advanced disease. A family physician who is not involved in these stages of their patients health is no longer a family physician.

The HFHCT may be a great tool in assisting patient education and reinforcement of health goals set by the family physician, but it should never take the place or stand in the way of the patient's connection with their doctor.

The HFHCT may help increase the daily patient number and allow more appointment slots, but this would be at the cost of sacrificing the quality of the doctor-patient alliance.

Our goal is to enhance the framework of the classic patient- doctor relationship and to ensure continuity of care, for which the HFHCT may be a deterrent if not handled carefully.

1. The Keystone Papers: Formal Discussion Papers From Keystone III (Fam Med 2001;33(4):273-7.) 2. Heath I. The mystery of general practice. London: John Fry Trust, Nuffield Provincial Hospitals Trust, 1995.

Competing interests:   None declared

In reading Dr. George's response to the original article, I finally have read the three word phrase that was missing out of the original article and out of some program's medical educational approach to patient care. That phrase is and always shall be in the forefront of any approach to patient care and that is "bed-side manner". I am truly optimistic that this generation of new family physicians are learning that a sincere and naturally occuring care for crisp, intelligable communication and empathy with patients from any and all backgrounds is at the very soul of any practice.

Our population is ageing. The age difference between new family physicians and patients is widening and our population is more culturally diverse than ever before. In an effort to try to integrate some understanding of our many cultures into our practice and how those cultural differences may change the way we approach meeting a particular patient's intangable needs and how that patient's expectation of US may slightly differ DOES CALL for that 75% of learning time devoted to clinical experience in the 3rd and 4th year of medical education. Very well said, Dr. George.

Regardless of the model we use or the way we orchestrate our patient care team I feel that as long as the conductor directs his care plan with the patient sitting in the front row, we are bound to grow as physicians and have a finer tuned orchestral team as well. I had a professor once tell me that if we listen to a patient long enough, many times they will tell US what is wrong with them. I know it is perhaps an overly simplistic view, but think back over some of your patient interactions and cases. Perhaps...you can recollect just such an instance. See, some of you are smiling to yourselves already.

Competing interests:   None declared

As a fourth year medical student, I stand at the forefront of the pipeline of a burgeoning generation of family medicine physician leaders. At the current crossroads of health reform and systems development, I have had a unique opportunity to witness the modern realities of family practice in both the classroom and the clinic. The image and role has certainly shifted from the house-calling doctor with a black handbag to the integrated coordinator of patient care. Part of the perception of the family physician in this mythical light derives from the distant, and fond, memory of the solo-practitioner as the purveyor of infinite medical knowledge. Yet, we must be wary of abandoning this image with haste - as it could risk alienating or confusing our patient population. Further, we must recognize the transition from an era of family physicians as the sole purveyors of knowledge to that of mediative and intuitive interpreters of information for our patients.

I envision three separate paradigms that need to be addressed as we move toward successful highly functioning health care team (HFHCT). First and foremost, (1) patients must be brought along the journey, and must actively view the role of the family physician as team leader, facilitator, and communicator. Concurrently, (2) physicians must engage the transition and be adequately prepared to lead these future health care teams. To inspire a robust and skilled pipeline for the future workforce we must (3) generate incentive and interest for medical students and undergraduates in their perception of the reality of the role of family physicians.

I believe that as a medical student, I can best speak to the second and third paradigms. In both regards, moving future physicians to embrace the role of team leader can be best cultivated and enhanced through the response of medical educators. This next generation of physicians must be equipped to deal with an expanded skill set that goes beyond the approach to developing the traditional clinician. Fittingly, the recent 2010 update to the Flexner report highlights an 'individualization of the learning process" and calls for 75 percent clinical work and 25 percent nonclinical work during the formative training years of medical school.1 This coincides well with recent calls for enhancing interpersonal skills, teamwork, and communication in the medical school curriculum.2-4

How do we, as a profession, come to grips with cautiously deconstructing the myth, while continuing to incentivize the practice? I believe we must begin with an earnest effort to shift patient expectations, yet we must be resolute in our commitment and present in our compassion. We must continue to practice a delicate and humanistic bedside manner. For these offer an opportunity to transcend our fading mythos - a comforting hand, a warm heart, and the dedication and trust of a life-long family physician.

1 Cooke M, Irby DM, O'Brien BC (2010). Educating Physicians: A Call for Reform of Medical School and Residency. 1st ed. San Francisco: Jossey- Bass; p. 221.

2 Center for Creative Leadership (2010). Addressing the Leadership Gap in Healthcare: What's needed when it comes to leader talent?.

3 Smith, Stephen (2011). "A Recipe for Medical Schools to Produce Primary Care Physicians." The New England Journal of Medicine. 364(6), p 496.

4 Morse, Gardiner (2010). "Health care needs a new kind of hero: Interview with Atul Gawande" Harvard Business Review. 88(4), p 60.

Competing interests:   None declared

This is a nice piece describing the paradigm shift from the myth of the lone hero to that of the clinical care team. As the authors note there is good evidence supporting this shift as well as recognition that we are not certain of the effect of the full-on care team approach on patient experience of care and outcomes. An additional care team member added to a typical practice is likely to provide a net benefit to patients and the authors describe how this addition may be done well. But what happens to outcomes when the full cast come on-line? I suspect the complexity of the larger care team will be like sports teams: some are brilliant, others adequate, and some miserable. My concern regarding the size of the team stems in part from the rich literature supporting continuity of care. While the definition varies greatly in studies, there appears to be a salutary dose effect when continuity is defined by a personal relationship between patient and clinician. In fairness I am not certain if this personal continuity must be to a physician, but I suspect it is weakened when linking a person to a team. I fully support the model of physician as member of a care team - solo physicians today work within a complex web of individuals who help meet the needs of their patients. We must evolve from the ad hoc groupings to intentionally designed teams. The authors describe a thoughtful and coherent approach to team based care that is very likely to improve outcomes but we needn't sacrifice personal continuity when making this transition.

Competing interests:   None declared