treating the economy

I blog about patients, physicians and hospital systems. We converse about children, my foibles and occasionally my love of wild birds. Recently we have chatted a bit about Twitter. But the economy??

This morning I was listening to an interview on NPR with the Washington Chief of The Economist (a London publication), who was talking about how the dollar is used as the international currency, and how that benefits the USA, and what might happen if THAT competitive advantage should go away, as part of our current economic stress.

The political battle that has been waging about how to handle our current economic situation has not necessarily addressed that issue. I started to think about the enormous number of concerns that EACH have to be addressed and considered simultaneously in order for any "fix" to have its desired effect on the overall economic outcome.

I experienced one of those "AHA" moments in my car as I drove to work.

"That's just like trying to treat a PATIENT with a complex condition affecting many organs, " I said out loud to myself (no one answered). "That's why we need primary care physicians in the outpatient areas and hospitalists or intensivists in the inpatient arena."

Do you get it?

Lately everyone  (well, every every politician and media pundit) has been prescribing a cure for the economy. Typically, they are looking at the disease as well as the proposed treatment from only one point of view, or from their perspective of specialty knowledge. While they may be technically correct, when they recommend an action in order to obtain a specific result, they often fail to recognize other, potentially predictable, but for them unintended or unseen consequences in another sector of the economy.

I see the same phenomenon in what has become our very super sub-specialized approach to patient care, if it happens without robust coordination, collaboration and communication among all the specialists, and between the specialists, generalists and the patient. This is one of the reasons that the  Institute of Medicine and many other agencies such as the National Committee for Quality Assurance (NCQA) have been supporting the concept of the "patient-centered medical home" as the site of coordination of health care.

The age of super-specialization has its benefits; we have doctors who are international experts on specific diseases, some exceedingly rare problems and can offer therapeutic options never available before. However, the downside of that superspecialized knowledge is often blinders on the physicians to the other physiological, psychological and social needs of the patient and his or her family.

In my own practice, initially as a pediatric intensivist, and more recently as a pediatric hospitalist, I care for many children who have complex problems. Sometimes they require hospital admission to treat a relatively simple, self-limited problem. More commonly they are suffering from problems that affect multiple organ systems, and might require advanced techniques of life support to foster recovery.

I have frequently found myself at the center of  "dueling subspecialists."

  • The neurologist who requires a 2-hour MRI on a patient with an unstable respiratory system or cardiac system, in whom the very act of transporting the child to the radiology suite would be deleterious.
  • The cardiologist who recommends a drug that might adversely affect the blood flow to the brain of a child with an acute head injury.

I could go on but you get my point (and I am not intending to demean any particular subspecialty group). If I or one of my colleagues hadn't been there, moderating and coordinating the care, many of our patients would have been treated in pieces (like the blind men examining different parts of an elephant) without a clear overall goal, and sometimes with less than optimal outcomes. The physician specialists mean only to offer positive suggestions, and they all want to help the patient, but their particular frame of reference and highly specialized knowledge base may prevent that from happening. On the inpatient floor, where patients tend to be less acutely ill, but often no less complicated, we see the same phenomenon.

More and more children with complex and congenital diseases are now treated in the home.

Our goal is to keep them OUT of the hospital. They see multiple subspecialists, often traveling to different medical centers in multiple cities. Without a coordinated plan, and collaborative care, the home care can become a disaster as patients and their families become confused and get pushed in multiple directions  which are often contradictory rather than complementary.

So, the importance of the primary care physician remains strong, and I believe, even more critical in these days of super sub-specialization. Our generalists have to be well-educated in all aspects of their field of medicine (such as pediatrics) , and must be excellent at communication, advocacy, negotiation, and education in order to obtain the best health outcomes for their patients. They cannot sit back and just send a patient from one sub-specialist to another, but have to lead that team of physicians much as a conductor leads an orchestra, so that they play a harmonious tune at the correct tempo and each instrument enters and exits at the right time.

Just as  our doctors and mid-level practitioners must take a coordinated approach to our complex patients, our politicians and economists must learn to  take a coordinated and cooperative approach to our complex, ailing economy.

Please leave me your thoughts, suggestions, etc. Do you agree with my analogy or do you think I am way off? Either way I look forward to your comments. As electronic health records become more prevalent, do you think these issues will improve for patients? Do you have any experiences, positive or negative that you would like to share?


I think the analogy is close. With complex multisubspeciality patients in the end the final decision rests with the attending of record so even if subspecialists disagree a final decision will be made by the hospitalist or intensivist. Essentially inpatient medicine is like a dictator with advisors.

These debt talks and the economy are analogous to if you had 4 intensivists managing the same patient and they all had to agree if an order is placed. Confounding this is that one of the intensivists is willing to let the patient die to prove his/her point.

That's the problem with our current hyperpartisan climate in DC. (Not that I'm advocating a dictatorship...)

I think you are correct, but it might be that in the case of our current economy, more than one of the intensivists is willing to allow the patient to die. What a mess. Thanks for the comment and adding your insights.

"As electronic health records become more prevalent, do you think these issues will improve for patients?"

Yes. As long as the health records make it to each doctor and each doctor is in the loop. If the records aren't being read by everyone, then there is no point. We have doctors who don't scan their records into the system and no one ever gets the information they need. And what about when you see doctors from multiple health systems?

L has been on the negative end of specialists who take her apart piece by piece and only look at their own part. We spent two years seeing countless doctors who looked at pieces and told us she was fine. We finally found someone (a specialist!) who looked at the whole picture and was able to put everything together. But what if all the doctors had communicated with each other? Perhaps more help and less "blowing off" and not wasting valuable time where we could have been helping her.

Having a PCP (or a doctor in charge while inpatient) is like having a team manager. The PCP keeps track of all the specialists and their "pieces" and how they all work together. The PCP may not understand everything because of their more general training, but they can be the communicator to make sure that everyone knows what is going on. The patient (or parent) should not have to have the stress of being in charge of all the communication and management. But the PCP also has to establish trust so that it is known that he or she is making the best decisions in the interest of the patient.

We are lucky because our PCP does not just send us off to different specialists, she does as much as she can to help us stay home and on a "normal" routine because she makes it her job to keep up to date with everything going on with L and to do as much research as she can, and to know what the specialists' goals are, so that she can help us accomplish them in the easiest way possible.

The thing is, when you have a ton of doctors all doing different things for the same person, they HAVE to be in communication with each other. I wish it was easier!

As for the analogy, it was good. :)

Thanks for adding the perspective that the sub-specialist can also sometimes be the one who does see the whole patient.
While we certainly HOPE the EHR will help in the long run, it never will accomplish much unless it is coordinated, and UNLESS REAL PEOPLE ACTUALLY READ IT. Tons of information are available but must be utilized by the provider.

I understand your desire to not have the burden of coordination in the lap of the parent or the patient, but sometimes the parent is the only one with all of the info, and certainly is the person with the most invested in the outcome.

As with most things, it is all, in the end, related to communication. If we could ensure that doctors had excellent communication skills, came into medicine with traits of compassion and empathy, behaved ethically at all times, and were ultimately associated with the outcomes their patients experienced, the world would be a better place. Unfortunately, compassion and empathy are impossible to measure, and so those docs who do it best may not be the fastest, or the cheapest, and their outcomes in measurable quantities may not look as good. They depend upon word of mouth for patients to find them. Then, if they have too many patients who require a high level of emotional investment, they may burn out.

Not sure I have the answer, but every time we add to this discussion it helps.

I do agree that the parent/patient has all the info and is most invested and don't think the PCP should do everything, but rather work with the parent to ensure the best results and communication. Unfortunately it is not a perfect world or system. We just happen to have a

PCP who works with us as part of our team. I know everyone is not so lucky in that regard. I don't think the emotional investment has to be high. We can't be needy, but trust and good communication would eliminate some of the extra feelings of needing more from the PCP. Does that make sense? If a patient trusts their team members they can be more relaxed hopefully and not put so much of a burden on them.

I'm a lot late coming to this conversation and I agree with the comments. My question is what do you do if when you need a PCP to take the lead, he/she doesn't after years of seeing this patient? All that time invested in the "relationship" is pretty much gone if you move to another physician. I've seen it a number of times where the physician begins a relationship with the patient, listening, making recommendations, only to suddenly seem disinterested or not check records or make recommendations as the patient continues with years of followup. Especially when dealing with older patients . . . "whatever you say doc" when there might be something going on.

Rhoda, Thanks for your comment and question. The issue you raise is a difficult one to address, since physicians age along with their patients, we must always be careful to evaluate the doc's advice. This gets much harder as one ages. Possibly bringing a trusted family member along on a visit would be a good thing to do, so that the patient's desires for guidance, information, and understanding can be emphasized by the friend or relative. Of course, issues of privacy can make that tricky.

Wish I had a simple answer for you, but as you can see, the problem is multifactorial and complex. Another option would be to request a consult with a specialist such as a geriatrician (for those folks in their mid-60's or over), who can make recommendations back to the primary care provider. Sometimes new eyes on a problem can really help the primary doc to recognize things have changed.

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