Why team based primary care won’t help evidence based medicine soon

Despite the advances in evidence-based medicine, not every patient benefits.

In a recent column from the New York Times, Pauline Chen looks at a study showing exploring the issue:

For many patients, evidence-based medicine isn’t working. Two-thirds of patients with diabetes, a disease with some of the strongest evidence-based guidelines available, continue to have trouble controlling their blood sugar levels; and only half of all patients with hypertension, another well studied disease, ever get their blood pressures under control.

The reason? It’s suggested that the models used to treat patients, namely, a clinic-based construct, don’t account for how patients actually live their lives.

According to the authors of the study from the Journal of General Internal Medicine,

evidence-based medicine ignores the impact of the patient’s life at home and results in fractured and desultory care. To remedy the current system, they call for a fundamental shift in the way that primary care is practiced. They advocate an approach that blurs the traditional division between doctors’ offices and communities, a new paradigm they call “evidence-based health.”

I’d also like to add that how patients are selected and treated in studies don’t often reflect the realities of a non-academic primary care practice.

So, what’s the answer? A team-based approach, which is certainly becoming popular as terms like Accountable Care Organizations and Medical Homes are bandied about:

But an evidence-based health model would change all of that. Primary care providers and community and public health workers would no longer have to work alone but together in coordinated efforts that would extend from the exam room to the home.

The problem is re-organizing primary care into teams is easier said than done. Another piece from the Times looked at a Health Affairs study illustrating such difficulties:

The transition to a new model can take years and requires outside assistance from management and health care consultants … Part of the problem was that the practices tried to make the conversion in incremental steps, checking things off a list as they went along. But each new change had the potential to create other problems downstream, Dr. Nutting said, especially when it came to technological upgrades …

… But that was only the beginning of the issues Dr. Nutting and his colleagues uncovered. Many of the practices started out well as they moved toward becoming medical homes, but eventually encountered what the report called change fatigue, defined as that “which was manifested as faltering progress, unresolved tension and conflict, burnout and turnover, and both passive and active resistance to further change.”

Dr. Chen’s assertion that doctors simply re-invent themselves as team-based providers won’t happen soon. Changing the way doctors are paid, as she cites as what’s happening in Vermont, is a start. But it’s a slow, expensive process. Purchasing the requisite electronic record system, and fundamentally transforming the way primary care doctors practice is near-impossible to do in our fragmented heath system.

The changes need to come from the top-down. You can see this is already happening, with practices merging, and being bought by hospitals and large integrated health systems.

There are incremental baby steps. I’d estimate we’re at least 10 to 20 years away from the team-based models primary care visionaries are imagining.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Dr. Kene Mezue

    What if patients are not getting the benefits of evidence-based medicine because physicians are not using the evidence (especially due to inducements from the pharmaceutical industry)? Taking Hypertension for example, how many physicians are using diuretics as a first line drug for their patients? These are the REAL ISSUES…

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Physicians need to begin team training as medical students if the system is going to change dramatically. Medical schools recruit individuals. Internships and residency programs may divide physicians into ” teams” for purposes of dividing the workload and organizing call coverage but unlike the corporate world, there are no benefits or rewards for being the best team.
    In my generation of physician, doctors chose private practice to be individuals and not have to answer to an employer.
    If the training begins in medical school , and the only system a student knows is an integrated team approach then eventually the concept will work. Whether it will be able to overcome the socioeconomic problems which influence care and outcomes and compliance and produce better results remains to be seen.

  • Alexis Meyers

    and what if patients aren’t getting the benefit of EBM due to compliance? Taking diuretics and peeing every 20 min must seem really annoying until their first admission for a CHF exacerbation.

    Explaining to patients that they should take a medicine which makes them miserable to treat a condition which doesn’t make them feel bad is really difficult. Delayed gratification and consideration of future consequences are not a strong points in our society.

  • DRJEBJ

    Alexis has hit on a very important consideration that is often overlooked; what is the patient’s reaction to the evidence based recommendations. Too often we as physicians minimize factors that are important to the patient in favor of pursuing the evidence based outcome. How often do we truly sit and listen to the patients’ experiences of the intervention and make modifications based upon a true collaborative interaction with the patient? Do we offer treatment or force it upon the patient. Does the patient truly value the outcome we are seeking? Are we really listening?

  • jsmithfan

    Ahh yes. Team based medicine and the almighty EBM. Just another step further towards the complete destruction of the patient-doctor relationship and closer to absolute formulaic mediocrity. A vocal minority of the public and vast majority of the government continue to believe that it’s the dumb PCPs that don’t know how to control blood pressure, diabetes, or anything else that has generally accepted GUIDElines.
    I’m going to let you in on a little secret. Humans are complex beings. A good PCP knows their patients’ psychosocial situation, their philsophy on life, their responses to prior treatments, AND all the EBM guidelines you can conjure up. The GREAT PCP knows how to synthesize all of that info into an individualized/realistic treatment plan for the patient to implement in their particular life circumstances. If anyone truly thinks that primary care doctors want to be glorified panel managers of thousands upon thousands of patients that they never get to know, following cookie cutter one-size-fits-all guidelines while further fragmenting the care of their patients, our healthcare system will implode even faster than I would’ve thought 5 years ago. (Maybe that’s a good thing) Furthermore, the notion that anyone thinks that aforementioned construct will attract a new generation of PCPs to save the system is downright laughable. Everyone out there continues to just reshuffle the deck chairs on the titanic when all it would take to save primary care (and a boatload of downstream expenditures) is doubling the reimbursement of PCPs so that they actually have TIME to spend with their patients. More trainees will choose primary care careers, more patients will have great primary care doctors, AND the system will save boatloads of money by not relying on high-priced specialty/procedural care. Promblem solved.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Amen.

      This new type of PCP training will attract people though. Different type of people. It will probably attract folks that are now looking at MBAs and business management careers, because that’s exactly the premise behind the PCP floating manager. Maybe a medical degree won’t even be needed. Maybe a graduate degree in population health management will emerge…..

      • jsmith

        Don’t hold your breath. MBAs aren’t that stupid. They know or would soon learn that massive responsibility with zero control is a game for fools.
        A medical degree is already not needed. An NP degree will suffice. Just don’t be unfortunate enough to get a rare or serious disease.

      • pcp

        “It will probably attract folks that are now looking at MBAs and business management careers, because that’s exactly the premise behind the PCP floating manager”

        Not at the salaries that PCPs now get!

        Who in their right mind would go through the rigors of pre-med, med school, internship and residency to become the glorified case manager/social worker/ data entry clerk that the AAFP envisions as the future of primary care?

        And what will patients think when they find that their “care team” includes every one but an MD?

        • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

          There are plenty weekend and distance education MBA students that will never make what a PCP is making today, and if all you need is someone to make sure the production lines are constantly moving, and the rolled-up reporting to “management” is done on time, you really don’t need medical education. Since bureaucracy is very good at sustaining itself, I bet they will get paid rather well.

          The patients? Nobody’s asking the patients. They will be “assigned” to these production systems automatically, remember?

    • jsmith

      “If anyone truly thinks that primary care doctors want to be glorified panel managers of thousands upon thousands of patients that they never get to know, following cookie cutter one-size-fits-all guidelines while further fragmenting the care of their patients, our healthcare system will implode even faster than I would’ve thought 5 years ago.”
      Perfectly said, jsmithfan. I shake my head. These bozos so fall in love with their theories that reality impinges not in the least. Just call me jsmthfanfan.

    • Leo Holm MD

      Much of evidence based medicine is hardly evidence based as it is. On top of that, it is cohort driven and not based on the individual sitting in front of you. Patients are no more likely to want to have their lives run by team of people than they are by a solitary physician. If someone wants me to “control” diabetes and high blood pressure, simply put me in charge of the food supply and peoples lifestyles and I will have it corrected for you right away.

  • Doc99

    You can lead a patient to the Mediterranean Diet, but you can’t make him eat it.

    • jsmithfan

      Same applies for insulin, a 4th or 5th antihypertensive agent, physical therapy participation, mental health counseling participation, or really anything that takes time and or has any possible side effect.

      Here’s an idea. Let’s make a large portion of board certification/maintenance of certification exams focus on EBM principles. Those that pass are paid higher E&M fees and immune to the bogus P4P principles. Those that don’t pass are paid less and subjected to the sticks and carrots of P4P B.S. Needless to say, those that are grandfthered into lifelong board certification will be subjected to the lower E&M fees and P4P initiatives unless they actually choose to retest and recertify.

  • Leo Holm MD

    “So, what’s the answer? A team-based approach, which is certainly becoming popular as terms like Accountable Care Organizations and Medical Homes are bandied about:”

    How much more team would we need? Physicians, drug companies, insurance companies, home health agencies, insurance companies, social workers, nurses, politicians, 15% of gross domestic product? Seems like we have plenty of teams. I guess one more would not hurt. However, it does not seem to be working. Separation of power does serve the patient. Its only when things like evidence, profitability, politics and collusion of interest come together that patients suffer. Monopoly style organizations like ACOs will send the problems we are having now into total orbit.