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.