“Therefore, instead of handing off prevention, I propose that it’s time to let go of stable chronic disease management. It’s not that it’s unimportant, but it is mostly predictable and amenable to management by protocol. Much of this work does not require a physician’s judgment at every step and can be delegated to a team that includes pharmacists, nurses, and advanced practice providers operating within physician-defined protocols.”
This physician has useful information about OMT protocols and their execution:
I am so delighted you wrote this. I couldn’t figure out why I so profoundly disagreed with Kuma Folmsbee’s solution of abandoning preventative care in favor for sick visits. The examples I thought of for the necessity of seeing the doctor during well visits— the vague abdominal discomfort hiding uterine or pancreatic CA, the happy but pale child with undiagnosed leukemia — require the intellect of the physician to discern the uncommon from the ordinary. It is our intellect and, with practice , our experience, that makes our time so poorly spent on guideline-driven prevention. I disagree that routine colonoscopy and vaccines are a waste of resources. They are just a waste of OUR precious resource (our brains), especially when they can be done expertly and unhurriedly by a qualified team of allied health professionals.
"A frequently-cited study estimates that it takes 27 hours per day to deliver guideline-recommended primary care for a typical panel of patients"
It's a serious problem if you (or anyone) believes that when a patient comes to see you, your job is to deliver recommended guidelines. That can be done by a high-school graduate with a clipboard.
If someone, or a system, taught you that that was your job, they should be ashamed of themselves.
We're all effed. I come from a different age when the physician's job was to figure out the patient's problem expeditiously and begin treatment or referral. But thats when doctors were in charge. Doctors being nice people thought our leaders would continue to support us. Just the opposite. They abandoned us to documenting and complying and typing and dictating. Does a cold require 7 pages in Epic? Has cut and paste ever helped a patient?
Primary care is dead. It's all about the EMR, only about the patient by mistake. Anyone going into it is on a fool's errand and will burn out and get out. I have split teaching and patient care, with some adm work my whole career. I love medicine and still practice at age 79. I recently made a diagnosis of Shy-Drager which the neurologist missed because he was focussed on the EMR instead of the patient.
I was always a concierge physician, only didn't charge for it. When my hospital wouldn't give me a raise after 5 years I became thefrugalconcierge.com and doubled my income and cut my hours by 80%! My self satisfaction went up 1,000%. I'm saved and trying to save some colleagues but for the rest-lasciate ogni speranza Voi che entrate.
I like the idea, generally, of offloading low value, routine care (like immunizations and other checkbox activities). Being the beginning of a new year, the largest asset in Jan would’ve been a team of med access counselors to triage preferred med options as patients were left without a cost effective inhaler, GLP1, or other med last month. 80% of my chronic disease visits are spent finding out what patients are actually taking because it’s so rare for patients to be honest in the med rec. This challenge of relationship based, chronic disease management is where I get hung up. Some of my most challenging decisions are in chronic disease management. How can we preserve complex, multi-morbid care and leave room for undifferentiated problems in the PCP schedule? The last time I opened up acute slots more liberally, they quickly get filled with a CC of STI exposure or nosebleeds or shin splints in a young person. Effective triage has to be part of this solution and I’ve not yet seen it done well.
I was thinking about this when I had Dr. Colleen Smith on my podcast to discuss her idea about increasing the number of primary care physicians. Another thing that should be left to the physician is Palliatjve Care. It’s desperately needed.
I'll have to listen to this to hear her ideas! From a free-market economist point of view, it sounds like there is a supply-demand problem induced by regulation. Medical schools have limits on the number or students they can graduate, I believe. Is it quality control, or to increase salaries? (I know PCP's are not the highest paid doctors, so I hope no one will get angry at me for asking that.) Adam has written a few times about the high caliber of med students nowadays, so I'm betting we could accept and graduate more of them, with minimal decrease in quality. More programs might mean lower tuitions, too. In every other industry we have "good/better/best" to choose from, at corresponding prices--why can we not accept this in healthcare? Perhaps because we're not paying cash, where the "good" doctors and clinics would get paid less than the "best." Deregulated, free-market healthcare always seems to me to be a solution to scarcity that no one is considering.
As I continue to wrestle with these ideas, I continue to come back to the core goal of using our core asset, our mind as you eloquently stated above and prioritizing it for higher value interventions. It is why I chose well visits as because of their low value. While they are preference sensitive, the absolute benefit of colon cancer screening or immunizations is even lower than management of someone with stable HTN.
But its one thing for us to talk about broad concepts, and another to actually propose policies to improve the system. This is where I have stalled. How can we alter policy which incentivizes higher value care, but also build/preserve continuity of care. To start, in my opinion, that means trimming off low value (vaccines, cancer screening) care to theoretically free up time for higher value interventions.
And in my opinion, highest value is acute care of chronically ill patients. But how do we maintain continuity without well visits or chronic management. It feels like a unsurmountable problem, but as the primary care situation becomes even more dire, I think we need bold policy solutions.
I believe the obvious (and tired and likely inevitable) answer is that AI (or interacting with an LLM) will take over both low value screening and uncomplicated chronic care, with us docs focusing on acute care of medically complex patients or complications from medical care.
I think we do too! In fact, I think we agree on a lot.
What I appreciated the most about your proposal was a willingness to think outside the box and make a bold suggestion to address an obvious problem. I spent so much time thinking about what you wrote, and it led me down this path.
You're right though, it's one thing to talk, it's another to actually influence change. I'm sure there are many potential barriers to this model that I don't foresee, but I am hopeful that this can at least provide a framework.
At least in my hospital system, the emphasis is on population management, and many of the value-based care proposals align with that. I suspect there are ways to make this a win-win(-win?) for physicians, administrators, and patients. If forward-thinking systems/practices are willing to pilot it, the kinks could be worked out.
I volunteer at a free clinic where our main practitioner is a nurse practitioner. We have a few volunteer physicians, and a volunteer medical director that oversees the NP. This work well. The NP can handle most cases, leaving the more complicated cases for the physicians. If she has questions, she can speak with the medical director.
I have seen a lot of physicians question the abilities of NP's instead of embracing a team approach where NPs could see the basic patients and physicians could focus on complex cases.
In a team approach patients should be able to meet with the team, at least once, so they know who the physician and NP are, as well as any other ancillary staff. It would allow for the structure of care to be explained to the patient. In this way, a patient becomes a member of the team and doesn't feel like they are being pushed aside by the physician.
Dr. Scott's suggestion is the sort of "eureka" idea that deserves close examination. The devil is always in the details. Would the MD who supervised the ACP's taking care of patient needs arising between the less frequent routine preventative visits be unburdened? Or would this be a "hands off" but "head in the game" role leading to more mental stress and risk for the MD leading the team?
That's a great point - I think that's why it must be founded on the premise that a physician's cognition is valuable and should be protected. This level of buy-in is crucial. If you were to implement this model without that starting point, it could easily turn out to be as demanding as our current system, or maybe even worse. If we just add it on top of our current model (complex patients every 15 minutes every day plus supervision of this expanded team role), it's not really accomplishing anything.
I envision seeing less patients per day in expanded time slots, much like a DPC physician's experience. That would leave room to see patients with acute needs or address clinical questions from the team.
Sage presentation; “patients can schedule appointments that align with their agenda, not ours” struck me. As a teacher of FL residents I frequently remind them that patients often have an agenda for their visits and addressing this up front avoids getting behind with the ever present “ doc I have this problem “ as they approach the exit door.
Love the idea. Sounds sensible, even reasonable. But the idea flies in the face of Washington DC's consultants hired to increase throughput and increase revenues. Think of all the staff needed for such a venture that need to be hired, scheduled and vetted. (God I sound so, well, corporate!)
And therein lies the problem. Corporations are running medicine, not doctors. 28-year old MBAs who have never sat before a patient know what needs to be done, not you.
I have no doubt we'll never get back to yesteryear in medicine, but our current construct is not tenable. The populist movement in medicine is growing. We hear from our patients who can't find a doctors as the quiet quitting movement grows or their primary care ad specialty docs move to direct pay models, Medicare Part B mushrooms 10% in a single year, and even the murder of an insurance executive is strangely celebrated, Change is coming because it has to. The current system feeds elites and ignores the populace. God help us if "single payer" is the answer since things will only get worse. But then again, that might have been the plan all along.
“Therefore, instead of handing off prevention, I propose that it’s time to let go of stable chronic disease management. It’s not that it’s unimportant, but it is mostly predictable and amenable to management by protocol. Much of this work does not require a physician’s judgment at every step and can be delegated to a team that includes pharmacists, nurses, and advanced practice providers operating within physician-defined protocols.”
This physician has useful information about OMT protocols and their execution:
Slow Aging and Delay Chronic Disease Development
https://substack.com/redirect/db321608-9ff6-4874-9cd9-0ffb7dc86290?j=eyJ1IjoiMWtoaGpjIn0._7Vl7rK6XP_kdo1QRTKYkjb-eLe6bdxrtc0XmLbJqjc
I am so delighted you wrote this. I couldn’t figure out why I so profoundly disagreed with Kuma Folmsbee’s solution of abandoning preventative care in favor for sick visits. The examples I thought of for the necessity of seeing the doctor during well visits— the vague abdominal discomfort hiding uterine or pancreatic CA, the happy but pale child with undiagnosed leukemia — require the intellect of the physician to discern the uncommon from the ordinary. It is our intellect and, with practice , our experience, that makes our time so poorly spent on guideline-driven prevention. I disagree that routine colonoscopy and vaccines are a waste of resources. They are just a waste of OUR precious resource (our brains), especially when they can be done expertly and unhurriedly by a qualified team of allied health professionals.
"A frequently-cited study estimates that it takes 27 hours per day to deliver guideline-recommended primary care for a typical panel of patients"
It's a serious problem if you (or anyone) believes that when a patient comes to see you, your job is to deliver recommended guidelines. That can be done by a high-school graduate with a clipboard.
If someone, or a system, taught you that that was your job, they should be ashamed of themselves.
We're all effed. I come from a different age when the physician's job was to figure out the patient's problem expeditiously and begin treatment or referral. But thats when doctors were in charge. Doctors being nice people thought our leaders would continue to support us. Just the opposite. They abandoned us to documenting and complying and typing and dictating. Does a cold require 7 pages in Epic? Has cut and paste ever helped a patient?
Primary care is dead. It's all about the EMR, only about the patient by mistake. Anyone going into it is on a fool's errand and will burn out and get out. I have split teaching and patient care, with some adm work my whole career. I love medicine and still practice at age 79. I recently made a diagnosis of Shy-Drager which the neurologist missed because he was focussed on the EMR instead of the patient.
I was always a concierge physician, only didn't charge for it. When my hospital wouldn't give me a raise after 5 years I became thefrugalconcierge.com and doubled my income and cut my hours by 80%! My self satisfaction went up 1,000%. I'm saved and trying to save some colleagues but for the rest-lasciate ogni speranza Voi che entrate.
I like the idea, generally, of offloading low value, routine care (like immunizations and other checkbox activities). Being the beginning of a new year, the largest asset in Jan would’ve been a team of med access counselors to triage preferred med options as patients were left without a cost effective inhaler, GLP1, or other med last month. 80% of my chronic disease visits are spent finding out what patients are actually taking because it’s so rare for patients to be honest in the med rec. This challenge of relationship based, chronic disease management is where I get hung up. Some of my most challenging decisions are in chronic disease management. How can we preserve complex, multi-morbid care and leave room for undifferentiated problems in the PCP schedule? The last time I opened up acute slots more liberally, they quickly get filled with a CC of STI exposure or nosebleeds or shin splints in a young person. Effective triage has to be part of this solution and I’ve not yet seen it done well.
I was thinking about this when I had Dr. Colleen Smith on my podcast to discuss her idea about increasing the number of primary care physicians. Another thing that should be left to the physician is Palliatjve Care. It’s desperately needed.
I'll have to listen to this to hear her ideas! From a free-market economist point of view, it sounds like there is a supply-demand problem induced by regulation. Medical schools have limits on the number or students they can graduate, I believe. Is it quality control, or to increase salaries? (I know PCP's are not the highest paid doctors, so I hope no one will get angry at me for asking that.) Adam has written a few times about the high caliber of med students nowadays, so I'm betting we could accept and graduate more of them, with minimal decrease in quality. More programs might mean lower tuitions, too. In every other industry we have "good/better/best" to choose from, at corresponding prices--why can we not accept this in healthcare? Perhaps because we're not paying cash, where the "good" doctors and clinics would get paid less than the "best." Deregulated, free-market healthcare always seems to me to be a solution to scarcity that no one is considering.
I believe we agree more than we disagree.
As I continue to wrestle with these ideas, I continue to come back to the core goal of using our core asset, our mind as you eloquently stated above and prioritizing it for higher value interventions. It is why I chose well visits as because of their low value. While they are preference sensitive, the absolute benefit of colon cancer screening or immunizations is even lower than management of someone with stable HTN.
But its one thing for us to talk about broad concepts, and another to actually propose policies to improve the system. This is where I have stalled. How can we alter policy which incentivizes higher value care, but also build/preserve continuity of care. To start, in my opinion, that means trimming off low value (vaccines, cancer screening) care to theoretically free up time for higher value interventions.
And in my opinion, highest value is acute care of chronically ill patients. But how do we maintain continuity without well visits or chronic management. It feels like a unsurmountable problem, but as the primary care situation becomes even more dire, I think we need bold policy solutions.
I believe the obvious (and tired and likely inevitable) answer is that AI (or interacting with an LLM) will take over both low value screening and uncomplicated chronic care, with us docs focusing on acute care of medically complex patients or complications from medical care.
I think we do too! In fact, I think we agree on a lot.
What I appreciated the most about your proposal was a willingness to think outside the box and make a bold suggestion to address an obvious problem. I spent so much time thinking about what you wrote, and it led me down this path.
You're right though, it's one thing to talk, it's another to actually influence change. I'm sure there are many potential barriers to this model that I don't foresee, but I am hopeful that this can at least provide a framework.
At least in my hospital system, the emphasis is on population management, and many of the value-based care proposals align with that. I suspect there are ways to make this a win-win(-win?) for physicians, administrators, and patients. If forward-thinking systems/practices are willing to pilot it, the kinks could be worked out.
I volunteer at a free clinic where our main practitioner is a nurse practitioner. We have a few volunteer physicians, and a volunteer medical director that oversees the NP. This work well. The NP can handle most cases, leaving the more complicated cases for the physicians. If she has questions, she can speak with the medical director.
I have seen a lot of physicians question the abilities of NP's instead of embracing a team approach where NPs could see the basic patients and physicians could focus on complex cases.
In a team approach patients should be able to meet with the team, at least once, so they know who the physician and NP are, as well as any other ancillary staff. It would allow for the structure of care to be explained to the patient. In this way, a patient becomes a member of the team and doesn't feel like they are being pushed aside by the physician.
Experienced nurse practitioners are a god send to many medical practices
Dr. Scott's suggestion is the sort of "eureka" idea that deserves close examination. The devil is always in the details. Would the MD who supervised the ACP's taking care of patient needs arising between the less frequent routine preventative visits be unburdened? Or would this be a "hands off" but "head in the game" role leading to more mental stress and risk for the MD leading the team?
That's a great point - I think that's why it must be founded on the premise that a physician's cognition is valuable and should be protected. This level of buy-in is crucial. If you were to implement this model without that starting point, it could easily turn out to be as demanding as our current system, or maybe even worse. If we just add it on top of our current model (complex patients every 15 minutes every day plus supervision of this expanded team role), it's not really accomplishing anything.
I envision seeing less patients per day in expanded time slots, much like a DPC physician's experience. That would leave room to see patients with acute needs or address clinical questions from the team.
Sage presentation; “patients can schedule appointments that align with their agenda, not ours” struck me. As a teacher of FL residents I frequently remind them that patients often have an agenda for their visits and addressing this up front avoids getting behind with the ever present “ doc I have this problem “ as they approach the exit door.
Love the idea. Sounds sensible, even reasonable. But the idea flies in the face of Washington DC's consultants hired to increase throughput and increase revenues. Think of all the staff needed for such a venture that need to be hired, scheduled and vetted. (God I sound so, well, corporate!)
And therein lies the problem. Corporations are running medicine, not doctors. 28-year old MBAs who have never sat before a patient know what needs to be done, not you.
I have no doubt we'll never get back to yesteryear in medicine, but our current construct is not tenable. The populist movement in medicine is growing. We hear from our patients who can't find a doctors as the quiet quitting movement grows or their primary care ad specialty docs move to direct pay models, Medicare Part B mushrooms 10% in a single year, and even the murder of an insurance executive is strangely celebrated, Change is coming because it has to. The current system feeds elites and ignores the populace. God help us if "single payer" is the answer since things will only get worse. But then again, that might have been the plan all along.