Declaration Of Interdependence: Why Primary Care Must Be Team-based

Clinical innovation and team-based care could dramatically change the answer to the most common patient question: When do I need to come back to see you? We not only need means of reimbursement for these models; we need to train the next generation of health care professionals to practice in these models. The Primary Care Project is a campaign to promote just that type of training. Read Dr. Earnest's story, then take the pledge.

By Mark Earnest, M.D., Ph.D.

“When do I need to come back and see you?”  Jane asks.

Her simple question is probably the most common question a doctor has to answer.  It comes up in literally every patient encounter. She asked it as we finished discussing the possible side effect of the new medication she will start to control her blood pressure. Like most doctors, I devoted little thought to her query and answered according to my habit and training, but her question deserves a lot more thought. How doctors like me answer this question may be the key to improving access to care and solving the looming doctor shortage.

Soon, millions of Americans who haven’t had it before will have insurance.  Most of them will need a medical home. I’d like to be part of the access solution for the newly insured, but my practice is closed to new patients, and I already struggle to see my current patients in a timely way. Surveys indicate that my practice is typical. It’s hard to find a primary care provider taking new patients and I’m not the first to worry where all these new patients are going to go.

Having prescribed a drug for Jane, I am responsible for ensuring that her blood pressure comes down to an appropriate level and that she has no side effects or complications from the medication. My usual practice is to have her come back and see me in a few weeks. In that visit, I will check her blood pressure, draw some blood, and discuss how she is feeling. It will take 20 minutes of my day. In a typical month, I might have dozens of encounters like this that are routine and straightforward. In truth, Jane could get these needs met without seeing me, and if my practice could provide her, and the patients like her, an alternative to a doctor’s visit for this sort of routine follow-up, I would have several hours a month free to see new patients whose needs are more complicated.

The alternatives to seeing me are numerous. In my practice, we have a pharmacist and a team of talented nurses who are all highly capable of meeting the needs I would address with Jane. I have partners who facilitate group visits where Jane might join 15 or 20 others with a similar condition to monitor their progress, learn about their shared challenges and share solutions. We have an electronic medical record that would allow all of them to easily keep me in the loop on her progress and address any complications that arise that might require my attention. If we had resources and were really creative, Jane might not have to come to our office at all; she could have her blood pressure checked at home with an ambulatory monitor that would provide us with her readings, and she could communicate by phone or email with my practice about the results and how she is feeling. She could get her blood drawn at any number of places.

While payment is the barrier that gets the most attention (my practice only gets paid when Jane physically sees a provider), skills and habits are equally daunting obstacles. I was trained to do all of this myself. I was not trained to share these responsibilities with nurses and pharmacists, nor was I trained in how to create, contribute to, and maintain systems of care for my patients. It was all on me, and in truth, most of us doctors have liked it that way. But we have to change these habits and most of us know it.

At the University of Colorado Anschutz Medical Campus, we are working to change these outdated paradigms. The campus has created an interprofessional education program that brings all the health professions students together to learn core skills in teamwork and communication as well as to develop a strong sense of their respective roles and their mutual interdependence. These students will be the vanguard of a health professions workforce that can harness the broad expertise and talents of their respective professions and organize themselves into effective, efficient models of care that old school docs like me can’t even imagine. If we are successful, we’ll be able to provide a lot more high quality care without minting a million new doctors and without breaking the nation’s pocketbook.

When Jane asks one of these graduates when she needs to come back and see them, she will probably get a very different answer.

Dr. Mark Earnest is a professor of medicine and the director of Interprofessional Education at the University of Colorado Anschutz Medical Campus. He is Vice President of the board for the Colorado Coalition for the Medically Underserved. This post originally appeared on CCMU’s blog.

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Posted by Sonya Collins on Dec 3, 2013 11:49 AM US/Eastern
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