Let me start by stating that I am a supporter of team approaches to medical care. Data from numerous observational trials has shown that patient outcomes are improved when a diverse group of healthcare providers work together to coordinate overall patient care. In my practice, we rely heavily on the excellent care provided by both Physician Assistants as well as Nurse Practitioners both in the hospital and in the clinics. These physician extenders are essential to coordinating admissions, evaluations testing and treatments.
Last week in the Wall Street Journal, columnist Laura Landro discusses the new push for team based care in today’s healthcare market. As Ms Landro states, there are numerous advantages to the team based approach. Patients benefit from the more intensive one on one time that they are afforded with nutritionists, pharmacists, nurses and other advanced practitioners. In previous decades, most of this work was solely the responsibility of the physician. However, increasing demands for documentation and electronic paperwork have begun to consume physician time. While the ACA promises to flood primary care offices with even more patients, physicians are scrambling to perform all of the duties that are currently required of them (with more government mandates on the horizon). Most of my colleagues prefer to focus on patient care (rather than administrative paperwork and government mandates) but are often frustrated by how little time they have to interact with their patients. Managing chronic disease is a process and requires numerous “touch points” with the patient in order to be successful. In reality, as a cardiologist, I am able to see most of my stable patients only once a quarter–unless they have an acute event or decompensation.
It is clear that patients now are living with more complex diseases and that we have far more advanced therapies to treat them with. Many of these therapies rely on strict patient compliance and on patients having a thorough understanding of their disease process and its management. For instance, a patient with Congestive Heart Failure (CHF) may need to be able to interpret daily weights and adjust diuretic dosing accordingly in order to prevent hospitalization from a more serious CHF exacerbation. Now, rather than see a physician for medication discussions every three months, a patient can make an appointment with a Pharmacist in our office and see them on a more frequent basis to discuss concerns over efficacy or side effects of their medical regimen. In our experience, this has improved patient compliance and improved metrics such as blood pressure control and time spent in the therapeutic range for chronic anticoagulation patients. Other primary care physicians report similar results when managing diabetes via frequent nurse educator or NP visits–patients seem to have more consistent control and better HbA1C results when they have more frequent touch points.
While a team approach is quite effective, each team must have a leader. The team leader must be experienced and well trained. While physician extenders do receive extensive training in a 2 to 4 year program, nothing replaces the years of experience that MDs obtain during residency. In order to maintain a high standard of patient care, these teams must still be led by physicians. With the cost cutting efforts and the changes that are occurring in healthcare due to the Affordable Healthcare Act, I am concerned that hospital administrators and government bureaucrats will ultimately attempt to replace physicians with other healthcare providers in the interest of curtailing costs. Physicians are trained in real life patient care scenarios over a period of years–many residencies last from three to ten years depending on specialty. The experiences of call nights and handling real time emergencies over a period of years (under the supervision of more experienced attending physicians) cannot be undervalued. My experiences during my 7 years of post-graduate training at both the University of Virginia and Duke University Medical Center certainly shaped my clinical judgement and certainly sharpened my diagnostic abilities–I call on these experiences even today when faced with complex cases. Efforts to replace physicians with other healthcare professionals with less intensive training may ultimately harm patient care.
Patient care comes first–I believe that a team based approach is essential to optimizing outcomes. We must all work together–Nurses, NPs, PAs, Pharmacists, Nutritionists, and MDs–in order to provide the best possible patient centered care. However, we must not attempt to replace physicians and the experience that they bring to the clinical arena in the interest of cost containment. While balancing cost and optimal care is a slippery slope, we must always focus on the patient–nothing can or should replace the Doctor-Patient relationship–we must all work together to preserve the core principles of our noble profession and put our patients first.