Aug 9 2013
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Medical Innovation Should Not Overshadow Primary Care

Katherine Vickery, MD, is a family medicine resident and a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Vickery and her coauthors, both affiliated with the RWJF Clinical Scholars program, as well as others from RWJF programs to respond to the question. Vickery’s response follows. Read all the blog posts in this series.

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Before I joined the Robert Wood Johnson Foundation’s Clinical Scholars program, I trained in family medicine at a federally-qualified, or community health center, United Family Medicine, in St. Paul, Minn.

Many of my patients, and the struggles they faced in trying to access health care, motivate the work I’m doing as a scholar. At the top of this list is “Juan,” a 35-year-old Mexican man working as a day laborer to support his family. 

I became Juan’s doctor after a hospitalization where his toe was amputated due to advanced infection resulting from his undiagnosed type II diabetes. He had no insurance and had not seen a doctor in years. The preventability of Juan’s amputation and treatability of his disease was always a frustration to me, and I began to wonder, “What kind of backwards system do we have that ensures a man’s access to a costly hospitalization to remove his toe but bars him from the primary care which can prevent or diagnose and easily treat his disease?”

I knew that the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) ensured Juan was able to access care in the emergency room and hospital, which likely saved his foot, leg, and perhaps his life. And I am grateful for the standard society set with its widespread support for EMTALA, which made emergent care a right. 

But it puzzles me…with our health care system’s out-of-control costs and failure to improve the health of Americans…how can there be so much debate about the 2010 Affordable Care Act’s (ACA) extension of a right to comprehensive, preventive and primary medical care to U.S. citizens?! 

Together with another scholar, Kori Sauser, MD, and Matt Davis, MD, MAPP, co-director of the RWJF Clinical Scholars program, I explored this apparent disconnect in a commentary published earlier this year.[1] I think the crux of the issue is that, in the United States, we have such deep reverence for innovation and medical progress that we cannot see past the failure of this approach to make America healthier. The bells and whistles of modern medicine have distracted us from the need to extend access to the basic, life-saving foundation of primary care which has, to date, remained a privilege in the United States. 

A Fascination with Innovation

America developed a focus on progress and innovation early in our country’s history. This helped make doctors very successful in their work to establish the “superiority” of laboratory science and medicine above public health and natural healing.[2]

Popular media has captured this fascination well. Covers of Life magazine across the decades are filled with backlit images of medical discoveries, miracles, and advancements. [3] For example, the September 10, 1965, cover features a woman getting an obstetric ultrasound, beginning a series on the “Profound and Astonishing Biological Revolution: Control of Life,” intriguing readers with descriptions of “Audacious experiments [that] promise decades of added life, superbabies with improved minds and bodies, and even a kind of immortality.”[4]

At the same time, the role of doctors was elevated from that of traveling salesmen in the 1800s to heroic, omniscient, often god-like figures. Time magazine’s cover for its special issue from Oct. 1, 1997, features a dramatic photo of a surgeon in front of his OR spotlight and describes, “A cast of talented innovators [who] employ new and exciting techniques to become the latest HEROES of MEDICINE.”[5]

America became fascinated with innovative, technical medicine and its ability to extend and enhance life through the hands of doctors. In such an environment, perhaps it shouldn’t surprise me that EMTALA was so widely supported…it emerged from the fabric of American medicine and extended the right to highly technical, dramatic, life-saving, emergency care to all people.

America’s palate for primary care and prevention has never been as strong. The intrigue of a medical discovery to prolong life has outweighed the knowledge we’ve had for decades (if not centuries!) that eating right, staying active, and having strong relationships leads to good health and long life. The ACA faces these types of long-standing biases with its offer of primary care—life-saving in a different, less visible way than emergent care.

What Juan, and Other Patients, Want and Need

But these views of U.S. society stand in conflict with the individual experience of most Americans I know who relish a doctor who gets to know them…someone who takes the time to “really listen” and cares for them personally. In spite of our fascination with technology and intervention, most of us prefer the old-fashioned model of a doctor who knows us well, who we can get to know, and perhaps who will even make a house call when needed.

With these preferences, often at the heart of modern measures of “patient satisfaction,” we acknowledge the power relationships hold to improve our health and our lives…relationships with health care providers which grow out of the continuity offered by primary care. Relationships transform a building offering medical treatment into a “medical home.”

By forming a relationship with Juan over a series of medical visits, we worked together to improve his diet, begin an exercise routine, and start medications to control his blood sugar.  Working with nurses, Spanish interpreters, and outreach workers we helped him learn to take his medications, check his sugars, find safe boots to protect his feet from his manual labor jobs, and find someone to talk to about his emotional concerns about his new diagnosis.

This type of comprehensive, primary care built the foundation upon which Juan can avoid or at least delay future complications. And when complications inevitably arise, he will have a team of trusted providers ready, willing, and able to ensure he gets the treatments he needs in a timely manner from people who know his children’s names and what baseball team he roots for.

We are in the midst of a much-needed transformation of the U.S. health care system. At the root of this transformation is correction of our current system’s over-dependence on procedures, technology, and emergent care at the expense of prevention and public health. While innovation will remain an important component of the American medical establishment, it cannot continue to overshadow a solid foundation of primary care. Without this sturdy base, our lopsided system will continue to generate uncontrolled costs without the ability to improve our country’s health.

[1] Vickery KD, Sauser K, Davis M. EMTALA and the ACA as Responses to Public Demand for HealthcareAccess: Necessary But Not Sufficient.  Journal of the American Medical Association, 2013; 309(7): 665-666. doi:10.1001/jama.2012.96863.
[2] Starr, Paul. The social transformation of American medicine. Basic Books, 1982.
[3] Hansen, Bert. Picturing Medical Progress from Pasteur to Polio: A History of Mass Media Images and Popular Attitudes in America. Rutgers University Press, 2009. Print.
[4] http://www.ob-ultrasound.net/project/life_c2.jpg
[5] http://www.time.com/time/covers/0,16641,19971001,00.html

Tags: Access and barriers to care, Health care delivery system, Primary care, Affordable Care Act (ACA), Human Capital, Voices from the Field, Clinical Scholars, Emergency Care