In the previous post, I wrote about a resurgence in Primary Care among medical students and how the movement towards primary care at many medical schools is distinctly student-driven. Why is it that medical students are drawn to a renaissance in primary care? After all, we’ve all been fed stories about the declining respect and pay associated with primary care, its coincident increase in paperwork and hours worked.
To a medical student the answer is clear. The health care system is broken and primary care is the best vantage from which to coordinate solutions. Even to say the medical system is broken is a gross oversimplification as that statement is a conglomeration of a dozen intractable problems, each in their own right. These range from healthcare economics (we currently spend 17.9% of the US GDP on healthcare and there exists no greater drag on the economy) to the loss of the patient-physician relationship in our technologically evolving society (at your last doctor’s visit did your provider share more eye-contact with you or the computer screen?). The hit list of quagmires goes on: insurance, emergency rooms, paperwork, preventive care, quality improvement, team-based care…
Who would be excited by this mess? The truth is that medical students are attracted to the most challenging problems. In the 20th century, medicine’s most complicated problems were those of biotechnology: penicillin, heart transplants, and monoclonal antibodies. Those pursuits are still essential and I, myself, have spent the past two years studying a fundamental principle of autoimmmunity in the laboratory. But in the 21st century, medicine’s greatest challenge and opportunity is health care systems improvement: how to make sure process A happens at time B. It’s more complicated than it sounds and that’s why the WHO ranks the US health care system 38th in the world, after Costa Rica. Students now, particularly at research-intensive schools, are hoping to bring the same rigor and creativity of basic science to study and improve healthcare in the US and globally.
The good news is that a foundation for these ideas on which to build is currently being laid. At my institution, “Ambulatory ICU’s” and ” Coordinated Care Clinics” are pilot programs that provide intensive primary care to complex patients to test the hypothesis that preventive care upfront will result in better outcomes and less overall cost. The Affordable Care Act, Accountable Care Organizations (ACO’s) are designed to test similar hypotheses. Each of these programs are scientific experiments and their results will inform how we shape the healthcare system moving forward. Primary care has always been a bastion for humanism, but now it is also a laboratory for some our nation’s most vital scientific research.
If you ask a physician to describe an image of the primary care physician, he or she will often conjure “The Doctor,” an 1891 painting by Sir Luke Fildes. The painting depicts a house call where a pensive physician sits devotedly over a deeply ill child. That mission is still the core of why many of us choose to go into primary care, but the field of primary care has grown. Given the changing landscape of medicine, primary care has become an incubator for the scientific design of health care systems, starting with ensuring that systems are in place so that a child such as the one suffering in that painting has received a full course of scheduled vaccines.