Urgent care centers, emergency departments, and clinics are over-prescribing antibiotics. Can they reform without alienating their “customers”: patients?
There’s a lot of commentary on the current state of healthcare in this Wired article, stated and unstated. I don’t blame only urgent cares for antibiotic overuse – there’s data to suggest it’s a systemic problem, but this article does illuminate the road we’re on as a health system a little more, and caused me to think about some dangerous curves we are approaching. Antibiotic overuse may just be signaling a deeper problem in how healthcare is evolving in the US.
Reflections I had on reading this article:
- The idea of the triple aim as an overall health care goal only works if the three aims are appropriately balanced – if one dominates or is poorly measured (like patient satisfaction in this article), we increase the risk of unintended consequences. My hope is that we learned that in the 80s and 90s, the first time we seriously experimented with managed care.
- One concerning direction to achieve “efficiency” in the patient centered medical home (PCMH) involves using expert primary care resources (family physicians) for the sickest patients, and relegating the relatively healthy to urgent cares and telemedicine visits. Tell me that’s not a set up for an epidemic of these kinds of problems. The situation is made worse because 1) the monitoring resources for quality are tied up examining the sickest patients, and 2) we are generally terrible at watching for long-term outcomes and adverse effects.
- I worry that the economic drivers for greater efficiency in primary care will cause devastating unintended consequences. Quality improvement work, emphasized by the PCMH, is all about constraining unnecessary variation. But I believe that there is some necessary variation in primary care, especially in family medicine – the type that has the physician performing well child checks and adult preventive visits, treating sprained ankles, removing sutures, scheduling an appointment on the day after a patient’s smoking cessation date. The goals for these visits are less concrete in our triple-aim-focused world: relationship-building, cognitive variety, quality shared decision-making, respite. But if we broaden our goal to the quadruple aim (and we should – goose and the golden egg and all), we should value these goals equally to the triple aim measures. The best primary care physicians are specialists in generalism (a superficially paradoxical phrase whose deeper truth I’ll defend until I die). While it is important to practice with efficiency and to constrain unnecessary variation to deliver better health care, we must equally recognize and support ways of practice that sustain generalists. And I believe those are: smaller panel sizes (with the necessary increase in the number of primary care physicians) and relationship-centered care to include the widest variety of ages, conditions and needs.
As I write this post, I am struck by how much we know about optimizing specialized processes (through rigorous, near-industrialization of those processes), but how little we know (despite my beliefs!) about optimizing generalist practice. A topic for another post…