In 1948, Life magazine published a now iconic photoessay by Eugene Smith titled “Country Doctor” about the life and practice of a solo general practitioner in rural Colorado. That physician was solely responsible for his patients' care and clinical outcomes. He did home visits, delivered babies, developed and read his own X-rays, attended injured workers at a mine, visited the elderly in their homes, and performed surgery. He carried a large doctor's bag with essentially the whole armamentarium of available treatments.
The story of his commitment to his patients and community inspired a generation to pursue careers in medicine. (The essay can be seen here. )
The physician did not need to report his outcomes to anyone. He was the defining voice of medical quality at the hospital, did not get calls for preauthorization, never saw a patient's rating of his care, was never challenged on his medical decisions, and had no requirements for continuing medical education or maintenance of certification. He was a physician of that particular time.
Sixty-four years later, medical knowledge has exploded. One physician is no longer able to have the comprehensive base of knowledge and skills to handle all of our patients' problems. We now have many highly effective yet complex treatments and diagnostic tools that demand both focused expertise and multidisciplinary approaches to achieve successful outcomes.
We have evolved from the days of a single physician providing essentially all the care to an environment where the efforts of a whole team are needed to care for our patients. Internal medicine specialists, subspecialists, and other specialty physicians are important partners in providing excellent care. The best clinical outcomes also depend on the best efforts of a team of associated professionals and support staff, including psychologists, social workers, physician assistants, nurse practitioners, nurses, physical therapists, occupational therapists, and others. Of all the medical specialties, internal medicine is arguably the field where this team effort is most important.
Despite the importance of the team in providing care, we still act like the outcomes of care are the product of that solo physician. When outcomes measures are reported, they are often focused on the individual physician, and not the care team or practice. You can put an excellent physician in a lousy practice setting where information is lost, calls go unanswered, and office support is lacking, and that physician's “quality scores” will suffer. It takes a highly functioning team and practice to provide great care.
I am a member of Better Health Greater Cleveland, an initiative funded by the Robert Wood Johnson Foundation to improve chronic disease outcomes in primary care settings. We began in 2007 with efforts to improve diabetes outcomes through a combination of collaborative-based learning and public reporting. We have since expanded to include hypertension and heart failure. The collaborative now includes more than 550 primary care physicians from 55 practices, and we have seen steady improvements in glycemic control, blood pressure control, and other measures for more than 100,000 patients.
We made the decision at the beginning not to report the results for individual physicians, but to report on the practices. We believed that the whole team is responsible for the results of care, and that the practice team is the appropriate entity for public reporting. As external agencies and insurers increasingly seek to report the performance of individual physicians, shouldn't we begin exploring and reporting the performance of care teams?
The patient-centered medical home is designed to deliver that team-based care. Care outcomes also depend on the effectiveness of subspecialty support as provided through the medical neighborhood. By shifting our public reporting emphasis from individual physicians to teams, we will drive the work necessary to build effective teams and improve care coordination. We will also develop more effective measures of team success.
The evolution to team-based care also has implications for the College. Our membership until recently has been limited to individual physicians, with an affiliate category available for licensed non-physician health care professionals who work in our practices. Other organizations have been more progressive in including the whole team in their membership.
One example is the American College of Rheumatology (ACR), which recognized the vital role of the team and established the Association of Rheumatology Health Professionals (ARHP). This division of the ACR includes the affiliated professionals who collaborate in the care of patients with rheumatologic problems, including nurses, physician assistants, nurse practitioners, occupational and physical therapists, psychologists, and others.
In addition to membership, the ACR and ARHP have developed courses and programs for ARHP members to enhance the effectiveness of the care team. ARHP members actively participate in the ACR/ARHP annual meeting, governance, and committees. This is a great model to consider for ACP. Is it time to develop a division of ACP, the Association of Internal Medicine Health Professionals? I look forward to hearing your thoughts.