In medical school we learn about the effect of increased volume on cardiac output. For non-physician readers, the curve shows an increase in function up to a certain point and then function starts decreasing. Physicians are aware of the descending limb of the Starling curve.
As I was thinking about patient volume the other day with regards to the Starling curve. I believe that this curve which shows improvement up to a certain volume, and then worsening likely also describes the relationship of a physician’s patient volume.
We need to care for adequate numbers of patients to maintain our skills. As we see more patients, we gain from that experience. However, at some point we see too many patients. When we have too many patients to care for, we are no longer efficient or complete.
I fear that the insurance companies are driving many primary care physicians towards the descending limb of the Starling curve. We need to better understand the proper volume to provide the highest quality care.
We have rules for interns and residents. They have limits, because the Residency Review Commission understands the Starling curve. I believe we need to better understand the implications of this concept for practicing physicians. I hope some researchers can figure out how to address the concept. High quality care requires it.
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4 Responses to The Starling curve and patient volume
Abby
March 5th, 2005 at 9:45 am
This is (unfortunately) a very good way to look at it. It’s also clearly happening in other areas besides primary care. If you look at the info from the US Renal Data System, the # of ESRD patients has grown, and is projected to continue growing, at a very scary rate. Dialysis is unbelievably regulated, and it’s getting worse and worse. The documentation you have to produce to get paid for dialysis treatments is approaching critical mass-you spend more time writing notes than you do seeing the patients! Makes me glad that I’m based in the hospital. I still have notes to do, but the mass isn’t as great (not like facing 35 chairs full of patients 4 times a day!), and I actually get to talk to my patients! (BTW, I’m an NP in a very large university hospital, working with patients in dialysis and pheresis. Very interesting job!)
Tom Wigton
March 5th, 2005 at 10:18 am
Wonderful analogy. I meet with my Chariman this week to address exactly this issue. The pressure to see more patients just does not end, especially in our “academic” practice, (which is busier than any local private practice group). As a high risk obstetrician, I am very concerned that the quality of our care does decrease as our patient volume increases beyond a point. But how to measure outcomes (and of course which outcomes) to answer the question you pose above is very difficult.
Spinoff55
March 5th, 2005 at 11:23 am
There is an answer… it’s called Consumer-directed healthcare; commoditize the patient-physician relationship to such a degree that the physician is only called upon to pronounce the patient’s death. Call me cynical, but that’s the real destiny for managed healthcare.
DB’s Medical Rants » The future of medicine
March 7th, 2005 at 9:39 am
[...] ere I given the power. In many ways, Saturday I summarized a major concept of this blog – The Starling curve and patient volume. In this rant, I postulated [...]