On the shoulders of giants

Dr. Barbara Starfield died in 2011.  For many people, her name will not stand out.  For those of us looking to improve our healthcare system, however, her work is of critical importance.

Dr. Starfield is best known for her work emphasizing the importance and the value of primary care.  Primary care (usually focused on family medicine, but including general pediatrics and internal medicine) is the segment of our health care system that focuses on long-term relationships, addressing medical problems from a whole-person perspective, and addressing undifferentiated problems and illnesses.  Dr. Starfield wrote in the New England Journal of Medicine that “[i]mportant functions of primary care include serving as the first point of contact for all new health needs and problems; delivering long-term, person-focused care; comprehensively meeting all health needs except those whose rarity renders it impossible for a generalist to maintain competence in them; and coordinating care that must be received elsewhere.“  This as a concise definition as I have seen for the role of primary care.

In the same article, Dr. Starfield notes that “[r]obust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents in better health at lower costs. Health is better in U.S. regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well. In addition to features promoting effectiveness and efficiency, there are fewer disparities in health across population subgroups in primary care–oriented health systems

The article noted above goes on to summarize the evidence that backs up her claim, and I will not post all that evidence here.  Similarly, Dr. Starfield authored many, many other articles that provide additional insight on the key roles of primary care in an efficient and effective health care system.  I encourage you to review some: if you have taken the time to find this site and read this post, then I presume you have an interest in these ideas.  Dr. Starfield’s work is a good place to start.

I would like to make myself look smart, and recite all the ways in which our healthcare system fails us on a daily basis.  And I would like to pretend that I came up with these ideas on how to fix the system on my own.  But, as with so much of life, these ideas are not mine.  I try to contribute what I can, but I am building on the work of those who came before–physicians and scholars such as Dr. Starfield.  So I would like to present her suggestions (from this interview) as to how we can reform our healthcare system to make it stronger and to improve our nation’s health:

For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.

Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples’ needs, professionals define the needs — usually in terms of having a specific disease — and then forget about the people while dealing with the disease. We know from evidence that if you don’t deal with people’s problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.

The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for — the less common and complicated things — and take much better and more care of most health needs within a primary care setting.

The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.

We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don’t do it.”

Accessible care, person-focused care, comprehensive care and coordinated care.  Simple concepts, and core ideas, that have been lost in our hospital-focused and specialist-heavy system.  This is how we change healthcare: identify the beliefs and practices that matter and that work…and then start finding ways to make our system honor and be accountable to them.  We don’t do it, but we should…and we must.

Posted in healthcare, Innovation, medical education