A Senior Primary Care Physician Trying to Take Good Care of His Patients

    Eileen Reynolds, MD

ABSTRACT

The physician described and interviewed below faces a crossroads in his clinical practice. Consider his history and perspective, expressed in his own words, and review the questions posed. How would you approach this crossroads? Using evidence from the literature as well as your own experience, respond by selecting Submit a Response. Responses will be selected for posting online based on their timeliness and quality, including use of the available evidence, weighing the issues, and addressing the physician's concerns. The discussion of this Clinical Crossroads case, authored by Bruce Landon, MD, MBA, MSc, will be published in the March 7, 2012, issue of JAMA; responses must be received by March 4, 2012, to be considered for online posting.

CASE PRESENTATION

Dr A is a senior primary care internist who recently moved from a small private practice to a larger group-model practice. He is adjusting to his new practice structure and feels he is struggling to take high-quality care of his patients.

Dr A began practicing primary care more than 30 years ago. In his small private practice, shared with 1 to 4 other physicians during the past decades, Dr A worked with a single nurse and a small office staff. He used an electronic prescription program, had paper records, and did not have any income dependent on “pay for performance.” As his practice coverage pool shrank, he took more and more calls for his patients and his income dropped; life in a small practice became untenable.

Two years ago, Dr A moved to a large group practice affiliated with a very large hospital network. In his new site, there are numerous primary care physicians, a staff that includes off-site managers and mid-level staff, and an electronic medical record. He gets summary reports of some quality indicators at intervals.

DR A: HIS VIEW

I think that the quality of care that the small practice, my old practice, provided was better than what we do now. That is my opinion; I am not sure I’ve got any data for that. We took care of all of our patients in the hospital, and I think the most important element of providing quality care was my nurse, as she was central to everything.

In my current practice, there are no nurses. There are nurse practitioners who are seeing patients, of their own and of ours, who tend to be more isolated to 1- or 2-problem visits. I have a medical assistant, who is very smart and very good on the computer, but still without that nursing piece that distributes where all of these pieces fit together in the patient's life. I think it is a big downgrade of the kind of services that we provide.

I think the potential is there to provide better care. I really think the electronic record and electronic counting of things will be helpful, but I think we're at an embryonic stage where it isn't good yet. I think these pay-for-performance things, if we somehow got immediate data on where the computer is saying there is a shortfall—if we had immediate patient data, had an hour set aside with our medical assistants—we might be able to take action on these people that we are somewhat neglecting. Unfortunately, it doesn't happen that way. What we get are indicators that we're having less pay or more pay, green light, red light, as to how you’ve hit those targets over the course of the year, but it doesn't come back to meaningful patient care as it should. I wasn't provided with a sheet of paper saying fix this for these patients, and that's what I need.

I’m not hitting cardiovascular targets on people who have had MIs or peripheral vascular events up to state average, yet I’m doing better with diabetes than I would have predicted and wanted to. It comes to another question about who is making these targets. Two years ago, different insurance companies had different targets. Why should they know what's the right way to manage or the best evidence to manage patients? One of the targets is having a hemoglobin A1c under 7; the nadir of the death rate for people on insulin taking care of patients in the ACCORD study is 7.5. So on the one hand, you can say, well, you’ll have less retinopathy or maybe less microvascular disease and kidney failure if we keep you down at 6.5, but more of you will be dead. I think the patient should have a vote in those sorts of things and I’m not sure that the insurance companies should be setting the targets, and the targets are different at different age groups, so all of those targets bother me.

Many people complain that they are only hitting 70% or 80% of their electronic prescribing. I apparently hit 93% but there's no way it can't be 100% because I haven't written a prescription or called in a pharmaceutical in 8 or 10 years, so I think all of us look at this data and kind of wonder, is it accurate or not?

I think patient satisfaction is a huge measure. I don't like to take my car to somebody that I don't like to deal with or who doesn't give me the right answers. I think patients have to feel their doctors are doing the most they can for them. I think patients have to have a sense that they are getting the best effort they can; I think it's a huge measure.

I think for years we’ve tried to do the best we could for individual patients. Now we’ve got more yardsticks to measure but we don't really know where the yardsticks should be.

AT THE CROSSROADS: QUESTIONS FOR READERS

Why should physicians care about quality measurement? How frequently are physicians, practices, and plans engaged in active performance measurement and improvement? What barriers exist that prevent physicians from adopting quality improvement measures? What important dimensions of quality are not yet measurable? What is the path forward? How can organizations or physicians create practice environments that support delivering high-quality care? How can payment systems support improvement in quality of care? What do you recommend?