Friday, June 17, 2011

21st Century Medicine, Part II

 

“The Revolution will Not be Televised” (Gill Scott Heron).

The Black Panther video from the late 1960s is just the opposite of what is taking place in America in the 21st Century. Although much of the proposed changes appear to be transparent, all of medicine wonders what is really happening in committees in congress, behind closed doors of insurance company lobbyists and our representative as well as hospital negotiations for CMS reimbursements.  What is the AMA doing? Is what happening, The revolution will not be televised?

Over the past 20 years there have been many recommendations to alleviate the shortage of primary care physicians.  The term itself is worrisome and casts a shadow which belies the nature of family practice in the present setting of medicine beginning in the last quarter of the 20th century.

The advent of managed care, HMOs has also deepened the divide on the landscape of family practice and general medicine.

There are internal factors within the educational system, and also extrinsic factors involving reimbursements, referral patterns, authorization for services,

Central to the issue is a relative shortage of “Frontline Medicine” to Consultative medicineFrontline medicine indicates the first stop on the Health Train.  This point is where the patient enters the non-system. The provider may or may not be a ‘pcp’. It may even be a specialist a pediatrician, an Ob/Gyn, a cardiologist, an ophthalmologist, a chiropractor or a nurse practitioner. 

Some say that primary care is what takes place as an outpatient, or not in the hospitals. Or that only specialists should admit to hospitals. This  is what is practiced in the U.K.  In fact, the general practitioners are called ‘Mister’ rather than Doctor which is reserved for specialists. The GPs do not admit to hospitals.

As a matter of fact there are many hospitals that now employ “Hospitalists” who care only for inpatients, whose care is transferred to them upon admission by a GP and then returned to the GP on discharge. The practical result is that it is easier for the GP to remain in his office and work efficiently, not  losing time travelling to and from hospital, and also not requiring a disruption on the office schedule. Yet there is a disruption in continuity of care, and it takes special measures to ensure communications for the transfers.  Patients often feel abandoned.

Numerous plans have evolved to attempt to correct the shortage of PCP.

Preferential acceptance of students from poorer communities, and incentives for returning to those communities to practice by forgiving medical student loans. At times this is enabled by the use of the  USPHS or Federal grant block funds to community clinics and Indian Affairs.

Medical schools were mandated to increase their class size, increase diversity of the incoming classes,  and adding residency programs for family medicine specifically, tied to continuing federal funding, with the threat of losing federal grants if they did not do so.

Some medical colleges, such as the new University of Central Florida, have enrolled a charter class with a four year scholarship free tuition for students with limited assets.  The emphasis is on multi-culturalism. Their stated goal is, “The UCF College of Medicine was established in 2006 by the Florida Legislature and the Florida Board of Governors to address the growing physician shortage nationwide and provide economic benefits to Central Florida and the state”

This in a state with a relative abundance of physicians.

The Revolution Will Not be Televised.

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