At the 2015 Symposium on Excellence in Primary Care [2], Tom Bodenheimer, MD, declared that we already know what good primary care looks like. Dr. Bodenheimer then challenged the participants to consider why systems still struggle to provide the best quality primary care. While there are “bright spots” that provide hopeful examples of what is possible, too much of primary care remains mired from a lack of sufficient resources, high rates of clinician burnout, and failures to provide the highest quality of care to patients.
The symposium brought to light bigger-picture issues in providing quality primary care as well, like the inherent tensions that exist while trying to provide high quality primary care within a free market system. Kristen Dillon, MD, FAAFP described this tension as trying to simultaneously function as a highly regulated utility, a social service, and a free-market business. These three roles are often in direct conflict with one another and place an undue burden on primary care systems attempting to satisfy the demands of contradictory forces. The remainder of the symposium was dedicated to addressing those challenges and looking for lessons to learn from bright spots around the country.
Burnout
Not only are clinicians within primary care settings required to address often conflicting needs, there is also a call to increase primary care capacity. Inevitably this places stress on the system and often leads to individual clinician burnout. Participants in this symposium discussed a variety of ways to increase capacity while also addressing issues of burnout. One strategy highlighted was the use of robust interdisciplinary primary care teams in practice settings. The Center for Excellence in Primary Care at UCSF is particularly fond of the notion of “teamlets [3]” or small partnerships of clinicians with other staff members within the context of a larger primary care team. Dr. Bodenheimer underscored strategies such the use of “scribes” to lessen the administrative burden on clinicians as well as the importance of reallocating some key responsibilities to non-clinician team members. Research done in San Francisco by Dr. Bodenheimer and others demonstrates that the teamlet model increased both primary care capacity and clinician satisfaction.
Meeting all needs
Participants also engaged in an interesting discussion of the concept of the “medicalization of suffering,” defined as reclassifying a non-medical problem as a medical problem. On one hand, primary care is often the only mechanism by which some of the neediest patients interact with a system that can provide them with support. On the other hand, if primary care is forced to address all the issues that plague human society, then the focus on physical and mental health issues can be diluted. Fundamentally, most participants seemed to agree that primary care cannot be the only source of services, and therefore must think expansively about partnerships. Just as there are teams within the primary care setting, primary care must think of itself as a critical member of a community-wide team where many needs can be met if organizations work collectively.
A number of stumbling blocks still stand in the way of expansive practice transformation, key among them being a dysfunctional payment system for health care in the United States. However, as the symposium illustrated, there are bright spots that give us the possibility of hope that primary care can reach its full potential. Fundamentally, the symposium presenters and participants asked a series of critical questions. If we do know what good primary care looks like, then how can we scale up the bright spots? If we know that primary care relies on a sense of intimacy, then how can we recreate that intimacy in a system that requires complexity? And on the very large scale, what can we do at the policy level to address the fundamental challenges of our health care system?
Speakers at the symposium discussed strategies for many of these issues, although critical issues remained unaddressed. The health care system remains geographically static, while our patients are increasingly mobile. Even if the best care team is in place, without tools and support at the ready, primary care can quickly leave behind patients like mobile workers, when they need the care the most.
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