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PerspectivesA Health Care Utopia ?! Making the Case for Creating a New Kind of Training for a New Breed of PhysiciansNosshey F. Hanna, M.D. |
| I spent seven years in the United Kingdom training and practicing medicine. Moving the in the mid-eighties from this national health care system to the almost totally private system in the U.S. was stimulant for thought. The thought was not to find the better system, (because both have serious shortcomings), but rather to think of the best, cost-efficient, and high quality health care system. This system is still a dream for patients, politicians and health care economists alike. My first observation in the U.S. system was that of gross inequity, from the case of a patient who paid thousands of dollars for an organ transplant, to the case of a child who dies from pneumonia because his uninsured young mother did not have the means to acquire timely treatment for her child. Having the advantage of observing both systems first hand has given me the unique perspective to think of solutions through the eyes of a Primary Care Physician. I am not detailing the possible causes of inefficiency, but rather analyzing a very important segment of that cost, which is related to unnecessary referrals to specialists. Although I have several suggestions to attempt to reach that elusive goal of a quality and cost-efficient system, the first in my list, by far, is to have more ambulatory general physicians and educate them to know and do more. This new physician will be the Ambulatory Generalist Physician (AGP) and would assume the function of the current Primary Care Physician (PCP), whether a Family Practitioner, Internist or General Practitioner. The AGP would be a "hybrid" of an Internist, Family Practitioner, ER Physician, and a Surgeon. If teaching hospitals embrace the idea, a new Residency Program for the AGP would need to be created, as this physician would require analytical tools of a diagnostician, skills of an internist, and the ability to control minor emergencies independently (similar to that of an ER physician). In addition, the AGP would be able to perform more surgical and procedural medicine than the current Family Practitioner and Internist. If we have physicians with this knowledge and training, funds from the unnecessary use of specialists could be spent on the uninsured. The training of current PCP's does not prepare them to function in an office setting. This particular function is becoming increasingly separate from the functions of providing care for hospital inpatients by the new class of Hospitalist Physicians. Internists, although reasonably equipped to be a diagnostician, are unequipped to handle a good deal of the true functions of an AGP (e.g. treating children and adolescent patients, psychosocial issues, women's health care issues, traumas, minor surgeries, and preventive medicine). While the scope of their practice is wider than Internists, Family Practitioners are trained in a hospital setting, which is different from the office setting. This training results in a decreased ability in formulating a sound-differential diagnosis and the inability to perform some medical procedures and minor surgeries in the office, which will eliminate the unnecessary need for referrals. General Practitioners (as they are currently trained) are often lacking the "hands-on training" needed to supplement core knowledge. The office setting of PCP practice bears little resemblance to the training Internists and FP's currently receive. Inpatient training is suitable for an Internist who will probably become a Hospitalist and largely irrelevant to the office based Internist and Family Practitioner. Outpatient training is largely irrelevant to both Internists and Family Practitioners. The outpatient settings where these physicians are usually trained are either a Primary Care Clinic in the inner city (Epidemiologists will agree that this does not represent a true private practice setting) or Specialist Outpatient Clinics (e.g. diabetes, gastroenterology, renal, etc.) where the patient is already diagnosed (except for complications of these diseases). This is a sharp contrast to the proposed training of the AGP in actual community Generalists' offices as described below. The proposed AAGP residency training involves the Resident spending the overwhelming duration in community Generalists' offices under the supervision of a Medical School Faculty. These centers will train the physicians in the sound differential diagnostic process when confronted with a diagnostic problem whether it is a symptom (e.g. abdominal or shoulder pain), an abnormal physical sign (e.g. lymphadenopathy or hepatomegaly) or abnormal laboratory results (e.g. leukopenia or elevated liver enzymes). The training should be problem oriented rather than disease or system oriented. The line between medical and surgical specialties will be blurred. For example, in the case of a patient who presents to the AGP with acute knee pain, the diagnostic process could encompass the scope of Orthopedic Surgery (e.g. cruciate ligaments or meniscus tear, etc.), Rheumatology, (e.g. gout, bursitis, etc.) or Sports Medicine (e.g. sprain of collateral ligaments, iliotibial band syndrome, etc.). The certifying Examination of these physicians should be directed towards the same approach. The idea of an AGP who knows and does more is not only cost-efficient but also a sound means of delivering quality care. If the AGP is provided with knowledge to exercise sound differential diagnosis for multiple etiology problems, whether a symptom, physical sign, or abnormal laboratory results, this will save 1) the cost of unnecessary referral, and 2) avoid unnecessary testing ordered by the PCP. Testing will be targeted according to a sound-differential diagnosis. If more surgical training is provided for the proposed AGP's, they can perform minor surgeries normally sent to a surgeon. If they are trained to do more office procedures that are normally referred to medical subspecialists, they can know more about diagnostic procedures like reading X-rays and simple ultrasound. With health insurance giants like United Health Care and Humana embracing the concept of and contracting with Hospitalists, this action is, in effect, an admission that there is no need for the same PCP to provide for inpatient and outpatient needs. These companies feel that there is economic benefit from such separation. This is where a competent AGP comes in, on the other end of the health care continuum with inpatient care provided by Hospitalists and outpatient care provided by AGP's. This AGP can deliver the elusive goal of quality and cost-efficient health care. Achieving this goal through the AGP may not mean that we have reached the "Utopia" of health care, but means that we are close enough! The opinions expressed in Perspectives are those of the individual and not necessarily those of the Editorial Board. Jacksonville Medicine / April, 2000
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