Why Do Bad Policies and Practices Continue or ....
Find New Primary Care Leaders that Represent Primary Care Truthfully
At the start of World War II, the RAF Bomber Command effort was failing. This was not what air command indicated. The British public at large was kept in the dark especially when German bombs were raining down and killing British citizens. This could have continued for years.
Eventually the truth had to be told. More British Airmen were dying than Germans on the ground. The Butt Report indicated the sobering truth. The most important industrial targets such as the Ruhr were missed 9 out of 10 times. Over Germany as a whole the rate was 1 in 4 on target. Flying at night often in bad weather without reliable guidance systems and under attack, the methods of the time simply failed. Over in the US the vaunted Norden Bombsight was also great in theory, but woeful in actual battle performance. Air crews were sacrificed with 5 - 10% lost each mission and their efforts were inconsequential.
Once there was understanding of the errors and assumptions, the way was cleared for real improvements in performance - by design changes.
The reality of primary care in the United States is also quite different compared to government indications. Primary care is widely recognized as a neglected area, even by non-primary care physicians. All seem to understand the difficulty of choosing and remaining in primary care, except those who have vested interests. Looking like primary care is important even when primary care yield is actually lower or lowest.
Primary care needs a Butt Report. Primary care needs less theory and more emphasis on practice. Numbers in secondary databases and association reports and government reports do not fit with the reality of shrinking primary care delivery capacity. The war for health access is won by enough front line personnel and experienced front line personnel. The war is not won by pretend primary care, theoretical innovations, or deceptive reorganizations.
No war is won with steadily fewer front line troops remaining leaving rookies and the least experienced. This is the legacy of poor support for primary care resulting in few committing to permanent primary care and ever more departing after graduation. Only sources permanent in primary care result have the most experience and the best primary care delivery result.
A Butt report regarding primary care would emphasize entire careers of workforce contribution rather than the first career and location choices. A proper report would include steady losses from primary care during training, at graduation, and each year after graduation. Studies indicate that dysfunctional primary care training drives medical students and residents away from primary care (Keirns, Academic Medicine). Indeed US policy has been toxic to primary care since 1980. Only from 1965 - 1980 has the US actually increased primary care and the policies that accomplished these were changed over 30 years ago.
A decent report would reveal the truth of one out of three primary care graduates found serving in primary care workforce in the years after graduation with only one out of six sources reliable in primary care result. The reality of failure in primary care delivery from five out of six sources is too important to cover up.
Such a report would not allow those using the name of primary care for training that resulted in a minority of graduates found in primary care. This training is properly termed non-primary care training.
Such a report would recommend that funding for primary care training be specific for primary care result, especially in a nation desperate for primary care. Such a primary care report would question the ability of flexible primary care sources to deliver primary care with so few total graduates entering primary care and even fewer remaining in primary care over the years after graduation – a guarantee of workforce too small and least experienced. Does Primary Care Experience Matter? With short term primary care stays, one could argue that the training was largely wasted with little chance for continuity, little chance to understand patients or populations, and little chance to become a part of the health care team.
Such a report would clearly indicate failed US health policy regarding primary care. Such a report years ago would have led to redesigns of training and support long before the major recessions and cuts of the current time period. Delays in this understanding make it most difficult for the necessary redesign with substantially more spend on primary care – during a time when any increased expenditures seems unlikely.
Such a report specific to the needs of 65% of Americans would have led to understanding that the best answer for the most Americans left behind in health access is permanent, broadest generalist, family practice. Such a report would have prioritized permanent family practice and would have forced any entities planning to deliver health access to permanent family practice outcomes – especially NP and PA where only 1 in 4 is employed in family practice. Generic fails, specific works. Generic funding fails also.
Reports during the age of science commonly indicate technology as great in theory but poor in practice, particularly in people intensive front lines areas – as in soldiers during battle, as in leaders great in theory but failing when faced with actual battle, as in the innovations in torpedoes and bombs that failed during the start of the war.
The US still fails to understand how it fails teachers delivering education, nurses delivering health care, and primary care clinicians delivering primary care. There is always a two way interaction. It is patients that shape the time and place of encounters. It is support that shapes the workforce and the availability. It is personnel at the primary care clinic that shape outcomes before, during, and after the encounter. Too many barriers, too few personnel, too little support, and not enough primary care professionals are all limitations far greater than HIT, software, electronic prescribing, paperless, primary care medical home, pay for performance, and all the other distractions. What matters is too many barriers, too few personnel, too little experience, and too few dedicated front line primary care professionals.
Even with such a report, five sources with 25,000 of 28,000 primary care graduates would not agree because the report would place them in a bad light. Five sources screaming would appear to be more valid, but this would not change the truth of too few remaining in primary care.
The truth is that so much support for non-primary care and so little support for primary care translates to too few entering primary care and too few remaining in primary care.
Family physicians with just 10% of the primary care graduates will deliver nearly 40% of the primary care arising from the six training types. This is entirely about staying in primary care, staying active at highest levels, highest volume, and most years in a career. The gap between family physicians and other primary care sources widens with each passing year as other sources decline more rapidly in primary care delivery.
Permanent stays and flexible flees under US health policies that favor non-primary care.
Thanks to all 12,000 who have visited Basic Health Access in 2011.
Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog
Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
