Physicians Must Become Team Players in Reinvention of Primary Care

May 04, 2010

May 4, 2010 — Discussions of the primary care crisis often focus on the number of physicians needed to deliver primary care — an extra 46,000 full-time equivalents by 2025, according to one frequently cited estimate. By extending insurance coverage to 32 million additional Americans through 2019, healthcare reform will only deepen that shortage.

The May issue of Health Affairs, however, looks beyond the numbers to explore something more qualitative — the role primary care physicians will play in the multidisciplinary teams staffing patient-centered medical homes, considered so critical for healthcare reform. In an issue devoted to the topic, titled "Reinventing Primary Care," various authors write that physicians must learn how to better manage — and collaborate with — other clinicians such as nurse practitioners, physician assistants, medical assistants, and even pharmacists, all of whom can help alleviate the primary care crisis.

Publication of the theme issue coincided with a briefing today at the National Press Club in Washington, DC, that featured Kathleen Sebelius, secretary of the US Department of Health and Human Services.

Physicians Must Learn to Practice Outside the "Frantic Bubble"

Healthcare reform legislation passed by Congress earlier this year devotes more money to experiments with medical homes, a model of care in which a physician-led team replaces "episodic care based on illnesses and patients complaints with coordinated care and a long-term healing relationship," in the words of the National Committee for Quality Assurance. Two articles in the May issue of Health Affairs, however, question how easily physicians will be able to step into the role of team player, much less team leader.

Benjamin Chesluk, PhD, clinical research associate at the American Board of Internal Medicine, and American Board of Internal Medicine Senior Vice President Eric Holmboe, MD, report on how internists in 3 different practices — a solo practice, an internal medicine group designated a medical home under National Committee for Quality Assurance guidelines, and a multispecialty group — worked in a "frantic bubble" of relative isolation. Their jam-packed schedules inhibited collaboration, as well as reflection. The authors observed no staff meetings in any of the practices.

In contrast, the physicians' employees worked together as teams, but only to support the physicians and keep them on schedule. In that sense, all 3 practices were physician-centered, as opposed to patient-centered, Dr. Chesluk and Dr. Holmboe write.

Richard Bohmer, MD, MPH, MBA, sees the same discouraging landscape. Existing primary care practices are not "well positioned" to become the medical homes of the future, he writes in an article titled "Managing the New Primary Care: The New Skills That Will Be Needed."

"The infrastructure required to support proactive care — for example, information systems or care coordination staff and tools, is still not widespread," he writes. "Nor are the activities and routines usually associated with coordinated care, such as team meetings, performance feedback, and automated reminders."

Not surprisingly, Dr. Bohmer recommends that primary care physicians acquire more management skills. Some needed skills, writes Dr. Bohmer, are people-oriented, such as assigning tasks, setting team goals, resolving conflicts, and assessing performance. Other skills are more technical, such as collecting and analyzing financial and clinical performance data, understanding the practice's revenue streams, or raising capital for a new computer system.

Medical schools and residency programs also need to beef up their educational offerings on management to produce a physician who can function outside the "frantic bubble," writes Dr. Bohmer. This training can continue after physicians begin practicing, with more advanced topics such as raising capital and marketing becoming relevant to physicians in senior administrative roles.

Core Teams and Daily Huddles

Two other Health Affairs articles illustrate what patient-centered teamwork looks like. Two physicians and 3 nurses at Medical Associates Clinic and Health Plans in Dubuque, Iowa, write about the successes achieved by "core teams." In a core team, a physician works with 1.5 to 2 full-time equivalent nurses to manage patients, with the nurses concentrating on preventive care and disease management and taking charge of lab, X-ray, and consultation reports.

This distribution of duties, write the authors, has "reduced stress and promoted collegiality" in the practice, designated a medical home. Sixty percent of internists there describe their overall satisfaction as excellent — more than double that for the specialty.

UNITE Health Center in New York City, which serves union members and their families, has created medical homes with the help of medical assistants who are trained to teach patients how to manage their chronic diseases. Physicians hold daily huddles with these "health coaches" to coordinate patient-care plans. UNITE Chief Executive Officer and Medical Director Karen Nelson, MD, and other administrators report in Health Affairs that, thanks in part to these health coaches, the percentage of diabetic patients with their blood glucose, blood pressure, and cholesterol levels under control rose from 13% to 39% between 2005 and 2009.

Nurse Practitioners, Pharmacists Seek Expanded Roles

The era of team care promises to stretch physicians accustomed to professional autonomy. For example, the authors of an article titled "Why Pharmacists Belong in the Medical Home" argue that pharmacists could "perform medication-related care coordination and quality improvement functions that physicians lack time to accomplish."

Pharmacists, the authors state, can recommend medication plans that avoid subtherapeutic or excessive doses, help patients develop methods to stick to their medication regimens, and encourage the use of cost-effective generics.

Another challenge involves nurse practitioners. They are traditionally viewed as clinicians who, like physician assistants, fall under physician oversight, but 2 articles in Health Affairs argue that nurse practitioners are qualified in their own right to head medical homes.

An article titled "The Role of Nurse Practitioners in Reinventing Primary Care" cites a number of studies showing that within the scope of their license, nurse practitioners provide patient care equal to what a physician renders, but at a lower cost. Yet some states have passed laws that prevent nurse practitioners from delivering the services "permitted by their licenses and educational preparation."

Nurse practitioners and physicians alike publicly affirm the notion of teamwork, but the 2 professions have different views of what that means, according to an article titled "Unleashing Nurse Practitioners' Potential to Deliver Primary Care and Lead Teams." One problem, write the authors, stems from state and federal regulations requiring that nurse practitioners collaborate with physicians. "Unfortunately, the term 'collaboration' has been interpreted to mean 'supervision,' " the authors write.

True collaboration between the professions hinges on achieving respect, trust, and power-sharing, but "tradition, professional socialization, and hierarchical relationships" have stood in the way, the authors lament. One solution is interdisciplinary education that will bring together future physicians and nurse practitioners so that team-building gets off to a head start. Such training is one more example of the qualitative changes that the authors in the special issue of Health Affairs say must occur among primary care physicians looking at the year 2025.

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