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Rebuilding the Social Contract, Part 2
In this report I will continue to consider what the “Five A’s” of small medicine can teach us about how to rebuild the social contract. Last time we looked at why availability is lacking in primary care; this time I want to look at the issue from a specialty perspective. As I see it, there is a mismatch between what physicians are rewarded for doing as opposed to what patients want. I am going to use cardiology as an example, not because the issues are unique to that specialty, but because it is the most numerous medical subspecialty and a common issue for patients. I had a conversation with a man I know casually, who told me he had been referred to a cardiologist for symptoms, which he shared with me. I told him I thought the consult was needed, as it sounded like he was developing congestive heart failure. Recently, I heard that he had undergone coronary artery bypass grafting, and was recovering. The surgeon will “sign off” his case, likely in the next 90 days if all goes well, but the patient is going to expect to see “his cardiologist” for the rest of his life. The cardiologist, though, is going to need to see patients in the emergency room with acute coronary syndromes, and is going to need to see new patients in the office with problems like those my acquaintance had. Where is the doctor supposed to find the time to see the constantly expanding horde of previously treated patients? In an ideal world, the family doctor would be able to see to him unless/until he developed new problems, but we have already discussed the pressures the “PCP” is under. But so is the patient, so he may “demand” specialty follow-up. In my area, many specialists are using mid-level practitioners to fill some of the gap, but in many cases, they may not be being used effectively. While these practitioners are often used for things like pre-endoscopy evaluations, a patient referred to a specialist by another physician for a specialist evaluation, is unlikely to be satisfied with a consult rendered by the mid-level provider. On the other hand, follow up of stable patients might be acceptable if the specialist maintained at least casual contact during the visit. But that creates billing problems, and generally would not be compensated. The lack of availability for physicians of any sort means we must train physicians, beginning in residency, on how to supervise a team of lower-level providers without the need to take over, except in emergencies or for patients with complex problems. My experience leads me to the view that most practicing physicians are quite good at n=1 problems, one doctor, one patient, but only a few ever get to n=x problems, one doctor, multiple patients. You might expect nephrologists, who see groups of patients on dialysis would learn to do this, but I find it is an 80%/20% issue; 80% look only at the individual, and 20% look at both the individual and the group. Finding ways to promote this kind of thinking in the hospital and the office, I suspect, will require re-framing medical education in ways that have yet to become “standard.” Another issue affecting availability is the problem the business world calls “reskilling.” All cardiologists are trained in general internal medicine before focusing on cardiology, but the tools available to the cardiologist have become so numerous that most end up focusing on a particular set of tools, such as interventional cardiology or electrophysiology. It is not that the doctor can provide care in only one area, rather it is they become invested in those techniques for which they trained, and acquiring skill and expertise in new techniques is difficult, if not practically impossible. Consider a 50-year-old cardiologist. He or she was likely about 30 years old when they started subspecialty training, so they were picking an area to master based on what was available twenty years ago. In my part of the country, the major emphasis was on interventional approaches to coronary artery disease. Electrophysiology, on the other hand, involved intractable problems with few good approaches, and only a few cardiologists chose that area. Today, though, treatment of atrial fibrillation, the most common rhythm problem, often involves newer interventions that require considerable training and expertise to get the desired result. But our 50ish cardiologist is going to find it difficult to take a year or two off to go acquire skills in the new techniques. So, we have an availability problem—changing medical options cannot be dealt with by re-deployment of existing workers at the most skilled level. One challenge the profession has not really addressed is how to spread expertise among existing specialist physicians. What tends to happen is the physician gradually transitions his/her practice from to one focused on more general specialty care, or, alternatively, closes the practice to any patient who does not need the particular techniques the physician has been trained to do. The first option may help some with the availability issue, but the second rarely does. With the long pipeline of training, we are likely always going to be behind, since re-skilling is so difficult. To summarize—the first “A” of small medicine is availability, and we have problems in both primary and specialty care. We also have availability problems related to geographic concentration and its counterpart—care deserts such as inner city and rural areas, which I have not explored. I suggest we need to focus on “getting the tempo right” by allowing variation in visit times rather than corporate quotas, particularly in primary care, but also in specialty care. We need to focus on moving non-clinical functions away from physicians as much as possible. The gate-keeper concept needs to go away. And lastly, we need to start having conversations with patients about what to expect from specialists after the acute issue has resolved. This, of course, is dependent on the patient’s problem set, but many stable patients would do well with minimal to widely spaced interval contact with the specialist. Lastly, we need to start training physicians on how to effectively supervise a team of other providers to care effectively for patients they may rarely, or never, see. None of these steps is a panacea, but every step taken to improve availability will help rebuild the social contract with our people. 8 March 2026 |
Further Reading
Adding Versus Subtracting A recent study suggests people favor additive rather than subtractive solutions to problems. Advisory Report on Burnout, part 1 Health care worker burnout has become so prevalent, the US Surgeon General has issued an Advisory Report on immediate steps needed. Asking the Right Questions Solutions for problems in health care abound, but are we asking the right questions? Getting the Tempo Right Effective doctor and patient communication requires getting the tempo of the conversation, not speed, but the current production system makes this a rare event. Population Health Population health is a phrase that disguises some hard realities as illustrated by two recent reports. Primary Care Like Mom and apple pie, primary care medicine is more honored in principle than in practice. Simple Ideas Making simple ideas work turns out to be complicated and hard. The Primary Care Dilemma When people are well they want convenient care, but when they are sick they want "the best." Is that possible? What Matters What really matters to practicing physicians? |