Saturday, March 15, 2008

Another argument to support PCPs

I recently became aware of a very interesting article about malpractice cases related to primary care practices. It is called, "Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims", from the Annals of Internal Medicine, by Dr. Tejal K. Gandhi and several other other authors. (3 October 2006, Volume 145, Issue 7, Pages 488-496).

The authors reviewed 307 closed malpractice claims from four malpractice insurance companies in which patients alleged a missed or delayed diagnosis in the ambulatory setting. I quote from the abstract:

A total of 181 claims (59%) involved diagnostic errors that harmed patients. Fifty-nine percent (106 of 181) of these errors were associated with serious harm, and 30% (55 of 181) resulted in death. The most common breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (100 of 181 [55%]), failure to create a proper follow-up plan (81 of 181 [45%]), failure to obtain an adequate history or perform an adequate physical examination (76 of 181 [42%]), and incorrect interpretation of diagnostic tests (67 of 181 [37%]). The leading factors that contributed to the errors were failures in judgment (143 of 181 [79%]), vigilance or memory (106 of 181 [59%]), knowledge (86 of 181 [48%]), patient-related factors (84 of 181 [46%]), and handoffs (36 of 181 [20%]).

Recognizing that malpractice claims are but a subset of cases that result in medical errors or other patient safety problems, this study to me is nonetheless another indication of an important problem that other observers and I have mentioned. The first line of defense in proper patient care is the primary care system, yet this portion of health care delivery is systematically undercompensated and undervalued in the medical payment spectrum. We have relegated primary care doctors to a triage function, requiring them to see a large number of patients in a short period of time. It should come as no surprise that the kinds of errors mentioned in this article happen when a PCP is expected to spend about 20 minutes with each patient.

Much is often made about the superiority of the health care system in European countries. I believe a big portion of the difference is the relative emphasis put on primary care in those countries compared to our own.

7 comments:

Tom said...

Related article in (of all places) USA Today http://tinyurl.com/2qwkqd Seems that specialist physicians can earn ~$350K/year vs. $150K/year for PCPs. Do you support concept of forgiving medical school debt to those graduates who agree to be PCPs for a set period of time?

Zagreus Ammon said...

Twenty minutes, eh? That's pretty good. If you promise we can get that much time, maybe i can come work in your shop...

:-)

Richard Wittrup said...

Yes, but emphasis and compensation are not enough. There must also be effective systems and disciplined adherence to them. In the reformed health care system of tomorrow, that is what institutions like BIDMC will provide.

Richard Wittrup

Anonymous said...

The statistics mention 181 cases out of 307. What happened in the other 126 cases? Also, what is the total denominator of patient encounters that generated those 307cases, I would guess in the tens of thousands, maybe hundreds. Finally will more time or more money improve "judgement" which was the overwhelming reason listed for a medical error? Maybe it has something to do with the training they recieve in medical school and residency also? After all isn't medicine really a game of trial and error, you first rule out the obvious and then move on down the list. Overall I agree with your point that more time and money channeled toward PCPs would be a good thing. But as long as the system rewards piecework(procedures and the like) will anything really change. Doctors and hospitals are really good at playing by the rules that have been set out.

Anonymous said...

Dr Levy,

As head of a large health care organization with significant influence, what are you doing to help the financial situation for your primary care doctors?

Paul Levy said...

First, I am not a doctor, but thanks.

Second, I do not have significant influence over the private insurers, Medicare, and Medicaid, who set the reimbursement rates for PCPs. I wish I did.

Anonymous said...

Hi Paul,
If you had a magic wand that did give you the necessary influence, would you provide more money to PCPs which would (short term)increase costs to a health care system already stretched financially? Or would you fund the increase to PCPs with reductions to Specialists? If so, I wonder how the Specialists who spend many hours in your hospital (and other facilties) would feel about that redistribution? Is it appropriate based on their levels of skill, expereince, and training when compared to a PCP? Curious to get your thoughts on this.....