Sunday, September 30, 2012

Family Medicine Paradox: Wholeness Interferes with Quality

"The Paradox of Primary Care" by Kurt Stange, MD PhD and Robert L. Ferrer, MD, MPH is a perplexing but telling article in a monograph from the Annals of Family Medicine in 2010.

"Quality of health care most commonly is measured by the application of disease-specific, evidence-based process-of-care guidelines.  This evidence fairly consistently shows that primary care clinicians deliver poorer quality care than specialists.

Evidence from the Medical Outcomes Study assesses care of patients with several chronic diseases.  The study finds that patients functional health status outcomes are similar for care rendered by specialists and generalists but that generalists use fewer resources.  Similar outcome at lower cost represents higher value.

A growing number of studies show that for patients with chronic somatic and/or mental illness, shared care between specialists and  generalists is optimal.

In further contrast, ecological studies comparing states in the United States find that a greater supply of generalists and a lower supply of specialists is associated with greater quality of care on multiple disease specific quality measures....more primary care is associated with better population health and lower cost and greater equity.

Thus, the paradox is that compared with specialty care or with systems dominated by specialty care, primary care is associated with the following:  (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations."
 ...Stange and Ferrer

I see a couple key words to ponder:  diseases and whole people.  We (I am a Family Physician) do better taking care of whole people than specific diseases (although we do that pretty well, too).  We understand patient personal values and integrate them into clinical decisions.  We value their wholeness, which we consider one of the outcome goals of a disease process.  We want our patient to be whole and able to live the life they've intended.  The disease is not the major focus of their life and is considered in the context of the patient's goals and dreams. 

If we measured quality that means wholeness instead of measuring a narrower disease focus that is less likely to align with wholeness, we might be viewed as having high quality across the board. Maybe the paradox disappears when we use patient driven quality indicators of wholeness.  What do you think?

1 comment:

  1. It seems to me that society is off on the wrong track in wellness. I think if one concentrates on their goals in life, they tend to dwell less on minor causes of physician's visits. Frequently we get so bogged down with our aches and pains that we allow them to take over our lives; therefore, we miss the "wholeness/wellness" life has to offer. In other words... is wellness the accumulative effect of our physical, mental, emotional and spiritual make up... or is it strictly science centered? I have found that when I have goals and God in my life, I have less time to make a bigger issue of what is or isn't wrong with me. mas