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Thoughts on Community Oriented Primary Care David E. Rogers During the intense and productive 2-day conference, discussion focused on the emergence of community oriented primary care (COPC) as a concept. The definition of COPC was refined, and its applications to a variety of settings in both developed and developing nations were described. Atten- tion was also given to the roles various health professionals must play in developing effective systems of community oriented care, as well as to how physicians might be educated and trained to be more effective in furthering such programs. Summarizing what has transpired during the conference is an unenviable task. It cannot be done adequately in one short commentary, but I will try. I have done so by playing a somewhat unusual role. I have tried to pretend that I am an observer from another planet, increasingly convinced of the wisdom of the concept, impressed by the almost religious fervor of its advocates, but puzzled by its apparent lack of contagiousness among many health professions. What are some of the roadblocks that impede progress and what, if any, are some ways of surmounting or circumventing these roadblocks? Answers to these questions might lead the way to a better agenda for the coming decade. To put first things first, the evidence seems to me overwhelming that organizing care on a thoughtful multidisciplinary community-focused basis makes good sense. Community oriented care programs seem to me to be the rational way to deliver the fruits of biomedical and behavioral scientific knowledge effectively to those who need them. No thoughtful person can argue with the logic of this approach. How can one believe that improve- 198

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[noughts on COPE 199 meets in health can occur without thorough epidemiologic knowledge of health problems that exist in a community or a society? How can preventive, rehabilitative, or curative services be fully effective if one knows little or nothing about the cultural, educational, economic, or psychological factors that can create barriers to care, isolate groups, and increase personal health risks for community inhabitants? No one in modern society can believe that a physician working in isolation, and simply treating those who come tO him or her on a one-on-one basis can produce a healthy society. If this be the case, why can I as an "outsider" ask the following questions: . Why hasn't community oriented primary care swept like a tidal wave over the world and why have not all in medicine embraced the concept as an idea whose time has come? . Why are most of our major medical schools continuing to turn out large numbers of specialists despite enormous evidence that what is needed is more generalists to provide community care services? . Why have schools of public health, in the past such proud leaders of medicine and responsible for so many of the advances that we now enjoy, become relatively quiet institutions often ignored by the medical profession and the larger society? . Why do departments of community medicine tend tO be relatively weak forces in their academic institutions and why do they seem to have so little impact on medical education in general? . Why are medical grand rounds in American medical schoolsa teach- ing exercise that offers a reasonable window on what is and is not believed important by facultyprogressively abandoning patient oriented presen- tations, ignoring psychosocial and epidemiologic factors, and becoming largely lectures on recent advances in biomedical science? . Why have so many developing countries with newly realized resources first opted to build very expensive tertiary care centersoften ignoring basic community services as they attempt to develop a stronger health care system? . Why have the mountains of literature on COPC written over the last decade had so little impact on how medicine is organized or taught or practiced in this country? Although deliberately overstated, these and other unpleasant and difficult questions must be addressed. The overwhelming logic of developing COPC systems to create or maintain healthy people is Inarguable. There must be some compelling nonhealth reasons for their failure to capture the hearts and minds of health professionals, or those who come for care, or the

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200 PART I: THEORETICAL ISSUES communities in which they live. There are such nonhealth reasons, and they bear summarizing. First is the reward system as it is now structured in medicine. Current financing mechanisms do not encourage community oriented approaches to care, or personal physician/patient interactions of any depth. Our reim- bursement system sends strong signals to physicians tO subspecialize, to maintain high-technology practices, and to share responsibilities for patient care with as few others as possible. Practitioners of community medicine do not a cardiologist's income make. Use of high technologies results in far more income than using one's head or hands for the same time spent. This needs changing, and I think it can be done. Second, which perhaps is a part of the first, is the prestige factor. Hospitals and those within them who use high technologies are the reapers of glamour and respect in our society. Both physicians and the public regard tertiary care institutions as the space centers where the astronauts pilot spaceships. Community physicians, on the other hand, particularly generalists, are viewed as those who drive the buses and subway trains. While they are of enormous importance in making the everyday world work, few medals are awarded for the task or for making it efficient, or affordable, or on time. Departments of community medicine are caught in the same bind. At present they are not where the apparent action is. In most of our major academic health centers, departments of community medicine are peripheral. It is rare that they have a well-organized defined population group that they are tending; residents and students seldom see the results of their efforts in human terms; and the major visible glories go to the departments of medicine, pediatrics, and surgery in the tertiary care hospitals, where most of the training of young health professionals is carried out. Training physicians to be the captain of the ship in isolation from other health professions is a third factor that contributes to the problem for the community-based efforts. For physicians to be comfortable in organized communitywide programs that care for groups of people, they must enjoy cooperatively shared responsibilities. In times past, in a less educated society it may have made sense tO put all of the responsibility and all the authority for health affairs in the hands of only one professional, but it makes less sense today. The activities in any modern intensive care unit, the most tertiary of tertiary care, are convincing evidence that the physician is not enough. This is even more true if one examines the needs of those with chronic disease who consume the bulk of medical care resources in the developed world today. But medical education has not kept pace with this reality. Most doctors do not feel comfortable in group endeavors or in working with nonphysicians in nonhierarchical relationships, and the land-

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Thoughts on COPC 201 scape is littered with failed programs because of this fundamental problem of"physician mind set." There are two other basic human problems that have become manifest. They affect both those who would organize, develop, and run COPC pro- grams and those who would benefit from them. One has tO do with the appropriate focus of community oriented programs of illness and disease prevention. Although these programs may be well accepted by us for our children or for others, they often create unease and sometimes resentment when focused on me and thee directly. The human animal is wonderfully contrary. Notwithstanding our being against sin, most of us secretly admit that we either lack the interest or the character to change our life-style if that requires giving up pleasurable habits that are deleterious to our health. This is particularly true when such a change requires sacrifice now for health gains years later. Most of the programs that have vigorously promoted health education, risk prevention, and the like have been disappointing in their results. It is quite easy to educate adults about the hazards of certain kinds of misbehavior. It is incredibly difficult tO change them. It is far easier to resent those who point out the error of our ways. We often try tO kill the messengeror at least belittle him. Those who preach righteousness may be respected, but they are not warmly received by most people in modern society. In short, the preventive element of community oriented programs tends not to be very popular. The other human problem is the lack of appeal of aggregate vital statistics for most people. Such statistics are the basic tools of community oriented programs, but they lack immediacy and emotional impact. It has been said that vital statistics are the story of human lives with the tears washed away. Obviously this is the case, but the erasure of the human element the translation of infant mortality or life expectancy into numbers on a page loosens the grasp on public attention. A community or a nation will willingly and instantly spend millions to rescue a trapped coal miner or the survivors of a downed plane or a sinking ship, but it is much harder to get that same community or nation to spend similar sums to reduce infant mortality rates. Walsh McDermott liked tO emphasize that, tO be effective, community oriented programs had tO attract individuals who have or can develop what he eloquently termed "statistical compassion." By this he meant that people had to gain real personal satisfaction from knowing they had put in place services that would improve the health and welfare of individuals they would never see or know personally. This takes both training and imagination. As with olives or oysters, a taste for vital statistics is an acquired one.

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202 PART I: THEORETICAL ISSUES What can be done to overcome these obstacles to wider and swifter dissemination of community oriented primary care programs? A number of suggestions have emerged. First, efforts to restructure the reward system for health professionals must be continued. If community oriented systems of care are to flourish, there will have to be changes in the way physicians are reimbursed for their services. Although favorable reimbursement for high-technology services has served society well by encouraging technical medical programs, it seems time to swing the pendulum back toward the center. Making financial incentives neutral with regard to the use of technology would, I believe, encourage more physicians to consider how their time and effort might have the greatest effectiveness in reducing human suffering. I use the term "neutral" with purpose. I am not suggesting that neutralization of rewards for use of technology be used as a hidden strategy to reduce physician income. That would neither materially affect the costs of medical care nor promote the change in doctor mind set that I would hope could be en- couraged. But allowing physicians to choose the kind of practice style that seems most appealing without financial penalties would, I believe, promote the community oriented cause. Second, there should be continued exploration of ways in which young people who have well-developed social skills and interests can better com- pete with those who have high science skills for entry into medical school. I do not wish to be misinterpreted here. We need well-trained, scientifically oriented physicians in the medical profession, not merely social do-gooders. But broader interests in human welfare and the ability to work democrat- ically with others do characterize some of our best physicians, and we need more of them. The third suggestion both relates to and bears on the first two. The skills and the prestige of those who would organize, manage, and work in com- munity oriented care programs should continue to be upgraded. Here the private sector can be, and I believe has been, helpful. Examples of such private efforts include the Robert Wood Johnson Clinical Scholars, Nurse Faculty Fellows in Primary Care, Health Policy Fellows, and Family Practice Faculty Programs; the Kaiser Family Foundation and the Robert Wood Johnson Foundation support of primary care physician training programs; the Milbank support of epidemiologic training for established academic internists and the Kellogg support of departments of community medicine. All of these programs have attracted top-flight people. These young leaders are beginning to achieve positions of influence and are adding distinction and more hard science to broader fields of medicine of which community .. . . meOlclne IS a part.

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Thoughts on COPC 203 Fourth, constructive use should be made of what are clearly more difficult times. For good or bad, we are now entering a period in which our methods for delivering health and medical care are under intense scrutiny. The overriding view of one and all is that medical care costs too much. The philosophical importance of the COPC concept during a period of dimin- ishing resources is not tO be underestimated. It can provide the opportunity tO streamline the system. COPC can assist by helping communities think more carefully about how best to organize care, promote disease prevention, and encourage more discriminating use of costly medical technologies. The increasing number of physicians means that in the United States access tO medical care services is not the problem that it was a decade ago. This, coupled with the enormous successes in controlling the major microbial diseases of the past and the steady reduction in deaths due to a wide variety of formerly lethal diseases, now affords the Western world the luxury of expanding its areas of concern beyond simply preserving or extending life. Rich and poor alike now have a commonality in the problems of illness that trouble them. We now can focus more of our efforts on helping individuals to use their full capacities in daily living. This leads to my last point and to what, in my judgment, is the most powerful contribution those who would advance community oriented pri- mary care services could make during the present decade. Stated simply, develop a more vibrant and compelling data base with which tO make a case for COPC and train a small cadre of people tO do it well. The kinds of statistics currently used tO track the progress of the personal health care system do not monitor with any sensitivity the changes that are reflected by most of what is going on in COPC. Death rates as well as other morbidity data and other sets of current statistics simply do not measure the impact of what health professionals do, or the potential ca- pabilities of community oriented health care systems. Let me use a simple example tO expand the point. Thanks tO modern medicine many individuals with serious arthritis can now be helped to remain sufficiently pain free and mobile and to lead independent productive lives. It is this kind of activity that is the major thrust of community oriented programs. But nowhere on the scorecard does this important gift to suffering people or the health professional's role in making this freedom possible come to light. Thus, it sems to me overwhelmingly evident that those who believe in the value of community oriented care must replace the current gross statistics with new and sensitive yardsticks that more accurately reflect what such programs can do to restore people to fuller functioning. Again, using arthritis as an illustration of the kind of scorecard I would like to see developed, it represents a group of diseases that rarely kill but

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204 PART I: THEORETICAL ISSUES has a fairly high incidence. In the United States, more than 18 million are afflicted. Almost 14 million of them indicate they are bothered some or a great deal by their disease. But of most significance, more than 3 million of these arthritics, or about 18 percent, cannot function satisfactorily because . . . . ~ . . Ot pain or imitation ot activity. Today a great deal of biomedical research and most of the efforts in major academic centers are appropriately aimed at unraveling the causes of these joint problems with the hope of eliminating them. This is clearly the goal of the future and it deserves major support. But, until that happy day, what doctors want to be able to do better today is tO further reduce the disability rate. They wish to better identify those most at risk of crippling and concentrate their efforts on them. They would like to drop the crippling from 18 percent tO 4 percent. They would like to know whether some interventions do better at less cost. Society would like tO know which health professionals working in what settings are most effective in reducing dis- ability rates. The value of COPC needs to be articulated and documented in problem areas such as this. If this kind of information could be devel- oped and it can and is being done by community oriented health profes- sionals another kind of box score could be recorded. This seems to be the kind of scorecard against which the personal health care system should be measured. I would be quite surprised if COPC programs could not deliver the data with which to develop that scorecard. Who else can better record the percentage of patients in a community with a particular disease that are really at hazard of developing functional limi- tations because of it? Who is better equipped to tell us how these individuals can best be identified? Who can better collect the data which will show what interventions can best prevent limitations? Clearly it is this kind of informational background against which the effectiveness of medical care should be measured. Such a data base would have enormous payoffs and would enable physicians, other health professionals, and those who seek care to judge how our personal health care system really works best. Some are now beginning to try to address these kinds of issues, but I believe the process should be pursued with even greater intensity. Doctors are a hard-nosed, pragmatic group. They do not respond to preaching or exhortation or anecdote. But when given evidence that a particular treat- ment or way of practice will improve the lot of their patients, they are generally quick to respond. These then are the areas that I believe deserve attention if community oriented concepts of care are to be more swiftly and widely accepted. Developing a better scientific data base to show what community-responsive practice can do tO improve human welfare is a most important first step. On the national and international scene, medicine must get a clearer idea

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Thoz~ghts on COPC 205 about what the ingredientsboth human and technicalassembled in what way can most effectively help people to maintain maximum human function, prevent its breakdown, and/or swiftly restore it. There also need to be ways of taking these statistics and putting them in terms that have real emotional meaning for physicians and other health professionals responsible for one- on-one care, as well as\ for the average man on the street. I am convinced that physicians and decision makers armed with such information can make wiser determinations about how best to allocate precious health and medical care resources. I believe community oriented approaches to the delivery of care will be the winners. My economist colleagues might put other more financially oriented approaches first, but my physician background moves me to put this suggestion as number one, while agreeing that both avenues should be pursued simultaneously. We have made great strides in the past decade. We have more doctors, and more are opting for primary care careers. Many more attractive resi- dency slots are available to them. There are more faculty who espouse community oriented approaches to care, there is more time in the curric- ulum for such concepts, and epidemiology has become an increasingly recognized and respected tool of medical science. To close on a philosophical note, community oriented health profes- sionals are up against yet one other problem not of their making. It is a cultural belief that runs deep in our American heritage. I am coming slowly to the view that in the United States we may ask more of or place more responsibilities for health in the hands of individuals than perhaps we should. It is rarely realized that this is not the case in primitive societies or in nations that have more nationally or paternalistically oriented health care systems. Americans deeply distrust and dislike paternalism or ground rules of any kind that threaten encroachment of individual rights. In our culture we are slow to seek out those unable to handle personal responsibilities for their health effectively and are often inclined to feel that they are reaping their just deserts when they get into trouble. Thus we are often inclined tO view with suspicion any who would appear to meddle with troubled families or their children even when it appears in the best interest of those families to do so. But in a nation so large, so diverse, and so complex, if we are to deal with the health and medical problems of the poor or the culturally isolated or alienated who live in our communities, locally designed community oriented health care programs can perhaps find ways that are less intrusive than any centralized public system might be. In doing so, they can be a potential healing force with effects extending well beyond the delivery of health care.

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