Fitzhugh Mullan, M'D

1

Big Doctoring in America  Primary Care
Essential and At Risk

• Fitzhugh Mullan, M.D
• Case Western Reserve University
• Cleveland, Ohio
• December 6, 2002

2
(No Transcript)
3
Primary Care Defined

• Primary care is the provision of integrated,
  accessible health care services by clinicians who
  are accountable for addressing a large majority
  of personal health care needs, developing a
  sustained partnership with patients and
  practicing in the context of family and
  community.
• Institute of Medicine

4
Value of Primary Care

• Comprehensiveness of Care
• Coordination of Care
• Continuity of Relationship
• Disease Prevention and Health Promotion
• Bridging Individual, Family, and Community Care
• Big Doctoring

5
U.S. Health Outcomes

• Multiple Studies Have Shown That Primary Care Is
  Associated With
• Lower Costs
• Better Access
• Fewer Ambulatory Care Sensitive
  Hospitalizations
• Better Outcomes for Primary Care Sensitive
  Conditions

6
International Comparisons of Primary Care Systems

• The stronger the primary care, the better the
  infant and child outcomes.
• The stronger the primary care, the better the
  outcome for conditions primarily in the province
  of primary care (e.g., postneonatal mortality,
  stroke, suicide).
• Weak primary care systems do poorly on general
  health outcomes, e.g., overall mortality,
  especially at young ages.

Starfield 11/01
7
Primary Care Score vs. Health Care Expenditures,
1997
8
The History of Primary Care

• 1900-1950 -- Generalism by Instinct and
  Default, The GP
• 1940 - The Present -- The Rise of Specialism

9
White et al, 1961
10
The History of Primary Care

• 1970 - 1990 -- The New Constructprimary Care
• 1990 - 2001 -- The Best of Times, The Worst of
  Times

11
Primary Care Troubles

• Managed Care Backlash
• Genome Fever
• Hamster Health Care

12
(No Transcript)
13
Median Starting Income of New Primary Care and
Non-Primary Care Physicians (in 1,000s)(of
Physicians with Confirmed Practice Plans)
Source Resident Exit Surveys, CHWS
14
Physician PayMedian -- 1999

• Family Practitioners 128,000
• Internists 127,000
• Pediatricians 134,000
• Invasive Cardiologists 274,000
• Gastroenterologists 235,000
• Orthopedists 270,000
• Ob/Gyns 191,000
• Source Medical Economics

15
Future Patient Needs

• Care
• Interpretation
• Selection
• Coordination
• Navigation
• Care

16
Primary Care Policy Strategies

• Systems Reform Putting Primary Care at the
  Center
• 2) Primary Care Re-engineering
• 3) Compensation Pay Parity for Primary Care

17
Primary Care Policy Strategies

• 4) Research Building Generalist Knowledge
• 5) Education A Core Curriculum for Primary Care

18
Primary Care Policy Strategies

• 6) Leadership Coalition Building
• 7) Communication A Better Message

19
The Mandate to Re-engineer

• The Tyranny of the Urgent
• The Boundaries of the Brain
• The Frailty of the Hand
• The Chaos of the System
• The Potential to Help

20
Re-engineering Strategies

• Primary Care Teams
• EMR
• Clinical Information Systems
• Patient Self Management Support
• Open Appointments
• Group Visits
• Hospitalists

21
Evolving Culture of Medicine

• Resident Work Hour Limits
• Feminization
• Decline of the Single Combat Warrior
  Physician
• Changing Boundaries of Medical Practice
• Flexner (and Then Some) by the Back Door

22
The Primary Care Challenge

• Big Doctoring
• vs.
• Heroic Doctoring

23
(No Transcript)