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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