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Fitzhugh Mullan, M'D

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Primary care is the provision of integrated, accessible health ... 1940 - The Present -- The Rise of Specialism. White et al, 1961. The History of Primary Care ... – PowerPoint PPT presentation

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Title: Fitzhugh Mullan, M'D


1

Big Doctoring in America  Primary Care
Essential and At Risk
  • Fitzhugh Mullan, M.D
  • Case Western Reserve University
  • Cleveland, Ohio
  • December 6, 2002

2
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3
Primary Care Defined
  • Primary care is the provision of integrated,
    accessible health care services by clinicians who
    are accountable for addressing a large majority
    of personal health care needs, developing a
    sustained partnership with patients and
    practicing in the context of family and
    community.
  • Institute of Medicine

4
Value of Primary Care
  • Comprehensiveness of Care
  • Coordination of Care
  • Continuity of Relationship
  • Disease Prevention and Health Promotion
  • Bridging Individual, Family, and Community Care
  • Big Doctoring

5
U.S. Health Outcomes
  • Multiple Studies Have Shown That Primary Care Is
    Associated With
  • Lower Costs
  • Better Access
  • Fewer Ambulatory Care Sensitive
    Hospitalizations
  • Better Outcomes for Primary Care Sensitive
    Conditions

6
International Comparisons of Primary Care Systems
  • The stronger the primary care, the better the
    infant and child outcomes.
  • The stronger the primary care, the better the
    outcome for conditions primarily in the province
    of primary care (e.g., postneonatal mortality,
    stroke, suicide).
  • Weak primary care systems do poorly on general
    health outcomes, e.g., overall mortality,
    especially at young ages.

Starfield 11/01
7
Primary Care Score vs. Health Care Expenditures,
1997
8
The History of Primary Care
  • 1900-1950 -- Generalism by Instinct and
    Default, The GP
  • 1940 - The Present -- The Rise of Specialism

9
White et al, 1961
10
The History of Primary Care
  • 1970 - 1990 -- The New Constructprimary Care
  • 1990 - 2001 -- The Best of Times, The Worst of
    Times

11
Primary Care Troubles
  • Managed Care Backlash
  • Genome Fever
  • Hamster Health Care

12
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13
Median Starting Income of New Primary Care and
Non-Primary Care Physicians (in 1,000s)(of
Physicians with Confirmed Practice Plans)
Source Resident Exit Surveys, CHWS
14
Physician PayMedian -- 1999
  • Family Practitioners 128,000
  • Internists 127,000
  • Pediatricians 134,000
  • Invasive Cardiologists 274,000
  • Gastroenterologists 235,000
  • Orthopedists 270,000
  • Ob/Gyns 191,000
  • Source Medical Economics

15
Future Patient Needs
  • Care
  • Interpretation
  • Selection
  • Coordination
  • Navigation
  • Care

16
Primary Care Policy Strategies
  • Systems Reform Putting Primary Care at the
    Center
  • 2) Primary Care Re-engineering
  • 3) Compensation Pay Parity for Primary Care

17
Primary Care Policy Strategies
  • 4) Research Building Generalist Knowledge
  • 5) Education A Core Curriculum for Primary Care

18
Primary Care Policy Strategies
  • 6) Leadership Coalition Building
  • 7) Communication A Better Message

19
The Mandate to Re-engineer
  • The Tyranny of the Urgent
  • The Boundaries of the Brain
  • The Frailty of the Hand
  • The Chaos of the System
  • The Potential to Help

20
Re-engineering Strategies
  • Primary Care Teams
  • EMR
  • Clinical Information Systems
  • Patient Self Management Support
  • Open Appointments
  • Group Visits
  • Hospitalists

21
Evolving Culture of Medicine
  • Resident Work Hour Limits
  • Feminization
  • Decline of the Single Combat Warrior
    Physician
  • Changing Boundaries of Medical Practice
  • Flexner (and Then Some) by the Back Door

22
The Primary Care Challenge
  • Big Doctoring
  • vs.
  • Heroic Doctoring

23
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