Why Isn’t It Better?

REVERT TO FIRST PRINCIPLES TO MAKE IT BETTER Pepi Granat, MD

Nothing supplants the face-to-face relationship of a doctor and patient, just as there is no substitute for the nuclear family, a father, mother and children. Group homes will always be second best. Bigger is not better. Small and personal is good: one doctor, one patient, with specialists coming and going as needed.

The groupthink these days is “systems”, a way of avoiding individual responsibility and diffusing/defusing the pointed finger. This keeps lawyers at bay (a huge part of the problem of poor quality – remember autopsies? Remember real learning from our mistakes?), and creates business for makers and managers of “systems.”

We would welcome better systems, both in hospital and office, but they are not the main story. The computer is a tool. Universal EMRs (electronic medical records) will no more change what ails us than snowmobiles have improved Yellowstone. Sadly, more data, more quickly accessible could deter us from looking into the eyes of our patients, the most telling of all LCDs (liquid crystal displays).

Editorialist John H. Wasson, MD quotes an influential physician businessman (not clinician), whose righteous indignation over his own travails in the maze of medicine so impressed reporters of the Wall Street Journal and Boston Globe that his personal opinions have been given elevated status and circulation.

Complaining about his wife's poor treatment when she was lost medically and emotionally in the maze of a large, impersonal organization, he then -- from his lofty perch in his own large organization -- recommends that we all subject ourselves to even larger and more impersonal organizational schemes, in the name of efficiency, cost-saving and "quality".

Could not the reverse be true? We have become disconnected from our real doctors, our family/generalist physicians, by subspecialists doing not only their own jobs but preempting the generalists’ purview. The patient needs coordination of care, hiring and firing these very subspecialists by someone qualified to realize their performance close at hand. Insurance companies (“health plans”) and hospitals have wrested power away from all but the most tenacious personal physicians to develop systems that effectively disincentivize personal care. By excluding generalists who know the patient from the care of the sickest patients and interrupting continuity of care they take away the patient’s most important link and advocate. Our graduating residents are acculturated to accept fragmented care, handing their most vulnerable patients over to hospitalists. Perhaps it has been “systems” that have “done us in.”

Had that physician’s hapless wife been my patient, my name would have been on her hospital bracelet, from admission to discharge. I would have willingly taken responsibility for her total care, including negotiating the puzzling patchwork that is today's mega-hospital.

. The family doctors who know the patients should stay with the patient he/she knows, and even be called into ICUs as consultants to establish continuity, for any patients who have the misfortune of being taken care of by subspecialists only. As expert and indispensable as these specialists are, they are immersed in one field, depending on nurses -- who are wonderful but are not generalist physicians -- to be the equivalent of the generalist, spotting conditions outside the particular specialists' domain.

It is not the dearth of systems that is our problem, but of individuals imbued with concerted efforts to revert to the first principles of Medicine. The concept of small and personal assuages completely patients’ dissatisfactions, and leads to fewer errors, better communication and more real caring. That’s how to make things better, and that should be the future of Family Medicine.

Competing interests:   None declared