Dr Simmons’s post is the first in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature. The question for Dr Simmons’s debate with Dr Susan McDaniel will be “Does the PCMH require that a physician be the team leader?”
The patient-centered medical home (PCMH) is all the rage nowadays, despite recent evidence that the “team-based” model of primary care delivery does not lower service use or total costs, nor does it improve care quality significantly1. Although populated by highly-educated graduate degree holders who should probably know better, PCMH and collaborative care advocacy is often an exercise in cart-before-horse confirmation bias. Advocates want collaborative care teams to work, so they design, execute and publish studies that make them look like they work. Where is the null hypothesis? Where is the study that seeks to show that team-based collaborative care does not work and, much to the researchers’ collective surprise, it actually does? I fear that we’d still be bleeding people if real medical research were done this way. One marvels that a negative study like the one above was published!
Now, some PCMH true believers are advocating that someone, anyone, other than physicians should lead the teams on which the collaborative care approach is based. Nurse practitioners, physician assistants, behavioral health practitioners...one assumes physical therapists, chiropractors and homeopaths are not far behind to accede to the throne. This democratic, egalitarian idea is bad for primary care medicine and for patients. Below, I will explain why.
|This democratic, egalitarian idea is bad for primary care medicine and for patients |
But first, an analogy: I boarded a flight the other day (of course airline analogies are required - all the quality improvement types are in love with medicine-as-airline-industry metaphors) on my way to yet another PCMH conference. As I crossed the threshold, I was greeted by a chipper flight attendant. Looking to my left through the cockpit door, I saw the pilot and co-pilot going through their preflight checklist. About a half hour into the flight, a plume of black smoke emerged from the right side turbine. I looked worriedly from my window up toward the cockpit, where the pilot, co-pilot and two flight attendants were having a team meeting. I could overhear bits of their discussion. To my shock, the pilot and co-pilot were asking one of the flight attendants what they should do! Not usually one to speak up, I raised my trembling hand and politely interrupted, “Er, Captain - shouldn’t you be flying the plane? I mean, you’ve got years of experience, hundreds of hours in simulators dealing with problems like this, and the flight attendant...well, doesn’t (all due respect to him).” The pilot held his hand up to stop me. “Sir, he said, “this is our new passenger-centered, team-based model of flight, and the flight attendant is the team leader today.”
Obviously, this is a ridiculous scenario. Pilots on airliners are in charge because they have the experience, training and expertise - they know the most about the plane, how it works, and how problems should be managed. To switch analogies, the military has not historically advocated team-based operations led by junior enlisted men, and there are very good reasons for this. When lives are on the line and important decisions need to be made, the person with the most experience, training and expertise should make those decisions. Perhaps collaborative care advocates have forgotten that patients’ lives and health are in our hands - perhaps medical care in modern America doesn’t feel like a life-and-death, serious responsibility - but it is. It should be approached with the moral weight it deserves, not as an opportunity for committee-based social experimentation meant, one might suppose, to inflate the perceived importance of certain professional groups.
The possession of a medical doctorate, in the United States, certifies that its holder had completed a certain depth and breadth of training, regardless of what state or graduate school awarded the doctorate. Family physicians (to focus on one specialty) complete 11 years and 21,000 hours of standardized training regulated by one licensing body, the American Board of Family Medicine. Furthermore, though it may seem anachronistic and quaint to cynics, physicians take an oath that has historically defined our profession: to put patient interests always above our own. This oath gives physicians a moral burden of responsibility not shared by others. The ultimate responsibility for our patients’ well-being, like the well-being of troops under a general’s command, falls to us and cannot be transferred to other “team members” when convenient.
However, if advocates of team-based, collaborative models want to stand on a democratic approach, then they should listen to what patients want: “72 percent of American adults prefer physicians to non-physicians when it comes to health care, 90 percent of adults would choose a physician to lead their ‘ideal medical team’ when given the choice, and by a greater than two-to-one margin, adults see physicians and family physicians as more knowledgeable, experienced, trusted and up-to-date on medical advances than non-physicians.”2
|We should listen to what patients want |
So other clinicians want to lead the collaborative care team? This perspective suggests not only a low opinion of physicians, our professionalism and our training, but a low opinion of what it means to work in a team. Is there not nobility and usefulness in performing one’s vital, though limited, role as part of the patient’s care team? Is being designated the “leader” the only viable way to make oneself indispensable and, when it comes down to it, to get paid?
If so, then I have little confidence, as American health care flies toward the mountainside with engines failing, that those who are least qualified to fly the plane will get us safely back home. All parts of the crew are valuable, whether we’re talking air travel or medical care, but not everyone is equally qualified to lead.
1. Friedberg, Mark W., et al. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA 311.8 (2014): 815-825. doi:10.1001/jama.2014.353
2. AAFP 2013 Dec 18, “Americans Want Physicians Handling Their Health Care”. Retrieved from http://www.aafp.org/news/practice-professional-issues/20131218ipsossurvey.html
Dr. Simmons is a faculty physician at St. Mary's Family Medicine Residency. He received his medical doctorate from the University of Colorado, and completed his residency in family medicine in 2002. He practiced full-spectrum family medicine in rural communities in Wisconsin and Colorado before joining the St. Mary's faculty in 2010. He is an advocate of evidence-based medical practice, a merciless critic of wishful thinking, an armchair philosopher, and an avid spoiler of domesticated animals.