Saturday, May 8, 2010

Primary Care and "Small e" Ethics

In teaching ethics I like to distinguish between "large E" and "small e" ethics. "Large E" situations involve relatively rare but highly dramatic clinical questions like whether to turn off the respirator for someone without a family or an advance directive. "Small e" situations involve everyday matters like returning telephone calls that often go under the radar and don't get considered in ethics discussions.

Dr. Richard Baron's important article "What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice" shows just how important small e ethics can be. Baron's five physician "Greenhouse Internists" primary care practice used its electronic medical record to track their activities in 2008. Physicians averaged 18.1 visits per day, but also dealt with 23.7 telephone calls (80% handled directly), 16.8 email messages, 19.5 laboratory reports, 11.1 imagining reports, and 13.9 consultation reports. In addition to prescriptions written during appointments they averaged 12.1 further prescriptions as well.

A fee for service system pays only for direct patient contact. Greenhouse Internists derives 35% of its revenue through capitation, more than a typical small practice would. This has helped the practice invest in efficiency-heightening infrastructure, like its electronic record system and its website.

The U.S. health policy community has been wringing its hands for decades over the precipitous decline of primary care and the concomitant rise in (a) costs and (b) public dissatisfaction with the health system. There's nothing mysterious about what we're seeing. As is so often true, the enemy is ourselves. We structure medical education so that it creates huge debt for many students. We pay primary care physicians poorly, so indebted students don't go into it. And between the relatively low income, which can only be offset by higher volume, and reduced numbers, which pressures primary care physicians to take on new patients, we run them ragged. It's no surprise that patients feel rushed as well.

Baron's article documents the magnitude of uncompensated activity that goes into primary care. As a clinician and as a patient, I've experienced how important these non face-to-face activities can be for the ethical quality of health care. I practiced primarily in a capitated system and was paid by salary (a system I favor), so I wasn't financially penalized for providing indirect services. In the patient satisfaction surveys we regularly did I got feedback on just how much my patients valued my relative promptness and reliability in returning phone calls. And, patients who liked to use email were very grateful for my readiness to incorporate it into their care. And as a patient I've similarly appreciated being able to exchange email with my primary care physician.

I have the privilege of co-facilitating a longitudinal seminar for some of the best primary care residents in the U.S. I've learned a lot from them about the clinical and human richness primary care can offer. Baron's practice has set itself the task of engineering its logistics to allow caring physicians to live the same values:
The core of primary care remains the longitudinal, trusted relationship with the patient, in which diagnostic skill, therapeutic understanding, and compassion come together for the benefit of the patient who seeks our help. Achieving that mission for patients with varying communication and computer skills is a daily challenge, even as our office faces a fragmented payment system and rapidly evolving technology. The work we describe arises from the needs of patients in a society that assigns many roles to physicians — from making diagnoses and providing treatment to ordering tests and filling out forms — and the practice must be organized to respond reliably. How and by whom the work is done is a continuing project of primary care redesign, dependent on both the skills of available nonphysician staff and the extent of information-technology support.
Greenhouse Internists are doing their part to live the ethical vision of primary care in their daily work, and Baron's article helps the rest of us understand more about the impediments our health "system" forces them to deal with. For health care reform to work, we'll have to make life easier for all the Greenhouse-like practices that want to walk the talk of primary care ethics.

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