Despite the current outcry over Healthcare.gov, Obamacare will soon bring 30 million Americans healthcare coverage. But if the website to signup may have lacked adequate planning, is our infrastructure for primary care ready? With some estimating a current shortage of 20,000 doctors, legions of new patients will add stress to an already crippled system. As a junior medical resident managing my own panel of outpatients at our local VA hospital, I’m discovering the surprising solution to this impending crisis. Many patients who come to the doctor’s office, don’t need to see a doctor at all. In fact, they could actually benefit by seeing other healthcare professionals instead. Lauded for years by leaders in primary care, this approach to outpatient medicine may not only soon become a necessity, but it may deliver superior care.
In medical school, seeing my 54 year-old patient again and again, gradually bringing down his blood pressure at each visit, and slowly developing a mutual trust to convince him to quit smoking, drew me to outpatient medicine. In my eyes, what I was doing was essential in preventing my patient from having a heart attack in 10 years. The Affordable Care Act is counting on the same thing — expansion of healthcare access and preventative medicine as the key to reducing healthcare costs and improving the health of all Americans. But the major glitch — the lack of primary care doctors — could actually be the solution. Research shows that non-physician healthcare workers may deliver preventative medicine more effectively.
A series of patients I saw my first day of residency forced me learn this early. First was a grimacing 65-year-old Vietnam Veteran with chronic knee pain, asking what he could do to stop taking ibuprofen for his knee. Next was an 80-year-old lady with heart disease, who was taking seven daily medications prescribed by her private cardiologist. Tearful, she described paying upwards of 300 dollars a month for her pills, and wondered which ones could be switched to generics. My next two patients were newly diagnosed diabetics, determined to not take medications, they both were interested in whether dieting alone could keep their diabetes at bay. Scrambling to print out how-to’s on chronic knee pain exercises, calling local pharmacies to figure out pharmacy insurance benefits, and finding brochures on diabetic diets, meant I was running 40 minutes late and completely behind in charting. I wondered if my patients knew that a physical therapist, pharmacist, and dietician would likely better serve their needs.
My clinic is at one of five national Centers of Excellence in Primary Care Education, an outpatient training program that emphasizes a patient centered medical home model (PCMH) of healthcare delivery. Though awkwardly named, the PCMH is a home only in the figurative sense. Patients are meant to feel at home among a team of doctors, nurse practitioners, and physician assistants, along with psychologists, physical therapists, and pharmacists.
Now in my second year of residency, I’ve witnessed time and again how this coordinated, multi-faceted approach delivers better care. The other day, a 22-year-old Afghanistan combat veteran nervously walked into my exam room. Fresh from the mountains of Afghanistan, he fidgeted while describing the shock of transitioning to civilian life. He described nightmares of roadside bombs, and admitted to feeling numb with his family and friends. Unable to interrupt his torrent of thoughts, our thirty-minute appointment was up before I could ask him about his back pain. Before I had to move to the next patient, I brought in our team psychologist and encouraged my patient to meet with her the next day to start working on his PTSD. Despite having told me he doesn’t drink or do drugs, he admitted to her that he was abusing cocaine as means of coping with incessant nightmares of combat. Encouraged by our team psychologist to enter a VA program for substance abuse rehabilitation, my patient is now drug free and going to college.
If it weren’t for my clinic’s team approach to care delivery, I may not have uncovered this crucial part of my patient’s health. Studies have shown that the PCMH model of outpatient medicine relieves stress for both providers and patients, and improves health outcomes. For those interested in the bottom line, it has been shown to deliver this care at lower costs. Simply put, the PCMH may be the key to saving primary care. For the millions of Americans that will soon get healthcare coverage, it could be about survival itself.
Yogesh Khanal is an internal medicine resident.