DB's Medical Rants: Perversions of meaning

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July 21, 2002

Perversions of meaning

This Sunday I will focus on three phrases that, in my opinion, should mean something different than administrators and subspecialists think. To do this, I must go against the Dictionary.

Primary Care -The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.

While I do little primary care at this time (I mostly attend on the inpatient internal medicine service), I have done many years of primary care internal medicine. I like the first contact concept - always have. I object to the phrase "before referral elsewhere ...". The implication bothers me. Reading this definition implies the dreaded gatekeeper concept. Why not consider primary care physicians as the anchor or the orchestra conductor. The good primary care physician provides continuity, accessibility, and complex care. He/she works to prevent disease as well as provide ongoing care for many medical problems. Primary care requires diagnostic acumen. Most important, the excellent primary care physician knows his/her management and diagnostic limits. Knowing when to refer, and to whom requires skill. Primary care medicine is very difficult, we should recognize that and reward that skill.

Managed Care - Any arrangement for health care in which an organization, such as an HMO, another type of doctor-hospital network, or an insurance company, acts an intermediate between the person seeking care and the physician.

As Frank Zappa captured in his classic Valley Girl (sung by his daughter), "gag me with a spoon". The managed care ideal has the primary care physician managing overall patient care. Under the original model, the first contact physician really functioned as an orchestra conductor. One could manage multiple complex problems, obtaining subspecialty help on an as needed basis. Where is the physician in that definition? Where is the patient? They exist on either side of the organization. Why would anyone think that such arrangements should lead to better care? They are business deals, where the organization controls the care. Given that we have limited health care dollars, we may need to ration some care. That is an easy intellectual concept which many European countries accept. Few in the United States believe that their health care choices should have limits. These organizations make the decisions and try to have the physicians "take the heat". The tide has turned - I first noticed while watching the movie As Good As It Gets. Hopefully, we will soon see the end of the managed care era. Until then, consider this from today's New York Times Health Care Appeals Are No Snap

Productivity 1. The quality of being productive. 2. Economics. The rate at which goods or services are produced especially output per unit of labor.

I like the first definition as it could refer to medical practice. I hate the economic definition. When I think of a productive physicians, I must consider quality. Has the patient had questions asked and answered? Are all pertinent issues addressed? Is prevention up to date? Is the patient receiving high quality care? The second definition just counts our patient visits, much like making widgets. But we aren't making widgets. I understand the drive to see more patients per session. It comes from how we are paid. Lawyers learned long ago to charge for their actual time. Maybe that would be a better model for medicine. Given the middlemen (the insurance companies), we probably won't see that revolution. Maybe that is why I keep wondering if retainer medicine may be a superior model.

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on July 21, 2002 04:43 AM | TrackBack

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