In a previous post about how health reform will change your doctor's visits, I mentioned that you're likely to see your future primary care delivered by a "team" of health professionals rather than your doctor. You might be surprised to hear that "team" is a relatively new concept in family medicine. I once had a colleague who told me, only half in jest, "My definition of good teamwork is that when I tell my office nurse to do something, he or she does it." Personally, I've always favored nurses or medical assistants who excelled at anticipating my needs: those who would prepare a suture tray when a patient showed up with a laceration, for example, or open a urine specimen container for a patient complaining of flank pain and chills.
In contrast, a high-functioning health team doesn't require doctors to issue orders all the time—or expect nurses to read their boss's mind. These medical assistants can read charts and test results to determine if a patient, say, needs a referral or isn't up to date on an immunization. Medical degrees aren't required for these things, according to a 2004 commentary on health care teams that was published in the Journal of the American Medical Association. If doctors can hand off some of their responsibilities to others on their medical team, this would solve two tough problems in today's medical system. First of all, we're facing a primary care physician shortage that's only going to get worse when nearly all Americans get health insurance in 2014. Massachusetts and California, which already have universal health care systems, have seen severe shortages in pediatricians, family physicians and obstetrician-gynecologists. Medical teams could allow doctors to expand their practices, seeing more patients each day. They could also solve the time-crunch problem where appointment slots in some offices have been reduced to 12 minutes per patient. Nurse practitioners and physician assistants can set aside far more time to discuss lifestyle changes and the side effects of various medications than doctors rushing from room to room.
Effective primary care teams delegate responsibilities so that each staff member does only what he or she is trained to do, rather than wasting time and energy on tasks that can be performed with less training. I recently introduced a group of clinicians and staff to an electronic tool that uses a patient's age, gender, smoking status, and sexual activity to determine what screening tests and lifestyle counseling needs should be addressed at a preventive health visit. Under the traditional primary care model, only the doctor would use the tool, advise patients, and order tests and immunizations. Only when the doctor emerged from the examining room would other staff members—who did little more than place patients in rooms and take weight, temperature and blood pressure—have any idea what the patient needed to have done.
In the primary care team model, the receptionist or a medical assistant could ask each patient to fill out a form with the necessary information. The medical assistant could then input this information into the tool and create a customized list of preventive recommendations. A medical assistant or nurse could then counsel patients about exercise habits, dietary practices, and smoking cessation before they even saw the doctor. They could also provide basic information about screening tests and immunizations, leaving the doctor to answer any remaining questions. If a referral was needed to obtain, say, a mammogram or a colonoscopy, the assistant could start the necessary paperwork while the doctor performed the examination. The physical exam, which requires years of training to perform, will continue to be the exclusive domain of doctors or those certified to do them like nurse practitioners.
Primary care teams are already being implemented in some practices throughout the country, and they've been shown to improve patient satisfaction levels as well as a practice's efficiency and finances, according to some recently published case studies. Efforts are now underway to teach teamwork skills in medical school and residency training programs. For many doctors, who have historically trained in super-competitive environments with rigid lines of authority, being able to work in collaboration with other health professionals may not come easily. But I'm sure, with time, they'll learn.
So what does this mean for your next visit to the doctor's office? Practices will vary, of course, but as more medical groups reorganize themselves into primary care teams, you may start to have more meaningful interactions with nurses and other office staff instead of sitting alone in an exam room waiting for your doctor to arrive. And since staff will relay your specific needs and concerns to your doctor before he or she walks into the room, you may find your concerns addressed more to your satisfaction.