Fragmentation in Primary Care

I spent the last five years of grade school and high school in a town of approximately 122 people in rural North Dakota. When I was growing up, adults in my area described a very messed up situation by saying, “That’s enough to make a preacher swear.” I think often of that tired old phrase today when I see the rampant fragmentation of medical care.

Many doctors practicing today were not around before the fragmentation caused by the takeover of healthcare by corporate medicine. Many independent primary care physicians who used to do daily rounds to see their patients in the hospital have lost their hospital privileges, not because of the quality of their care, but because corporate medicine has replaced patient primary care physicians with hospitalists. Hospitalists, as employees of the hospital, can be controlled more easily than independent primary care physicians.

While independent primary care physicians have been largely shut out of hospitals, physicians labeled primary care physicians also work in the clinics owned and operated by corporate medical groups, but they likely do not practice medicine the same as your family practice physician. First of all, do you see the same family care physician every time you go to the clinic? And how much time does this corporate family care physician spend talking to you about your problems? 

I have a friend who I’ve known since we were 12 years old. He has many serious health problems and stays within one healthcare system. In theory, that one large healthcare system should be able to provide all the healthcare he needs, but the fragmentation of his care, the divvying up of his various healthcare problems to ten or twelve specialists, simply means the right hand doesn’t know what the left hand is doing.

I can’t explain exactly why his care has become so fragmented, but I suspect his four or five doctors see him as a series of illnesses and not as a person. The primary care physician had the advantage of treating their patients for various problems and referring them to a specialist if needed and being sure all the specialists work together to meet the needs of their patients. The primary care doctor managed all patient care and oversaw the care of any specialist a patient was referred to and made sure there was a care plan holding all the specialists’ findings together. With specialists, everybody is taking care of their particular specialty, but the patient goes home without an overall plan for managing all of the various health problems, even if the patient sees someone in the healthcare conglomerate labeled a primary care physician.

I’ll name my friend in this story Steve. Last summer he had four episodes of temporary blindness in his right eye. He went to see a neurosurgeon. The family history recorded by the neurosurgeon shows that Steve has had one episode of blindness, has not had a stroke, and has no family history of strokes. I myself do not understand how this neurosurgeon could have gotten Steve’s family history so wrong. True, patients are not always forthright with their family history. That’s why it’s so important to have a primary care physician who knows you well and spends enough time talking to you that unspoken issues become clear to your primary care physician.  

Steve has had four episodes of temporary blindness in his right eye, not one episode. Steve had a stroke and was hospitalized at age 44. His father died of a stroke at the age of 58. Steve has also had a coronary artery bypass grafting procedure. None of this history appears in the neurosurgeon’s chart.

I have spent many years in primary care and pulling together fragments of care like pieces of a puzzle. I know that temporary episodes of blindness are no joke. As a matter fact, I have always treated them as medical emergencies, and I have never had cause to regret that. Usually these incidents are temporary, at least for the first few times.

Temporary strokes can present in people in various ways. Perhaps you can’t speak for a short time or perhaps you can’t add numbers for a short time.  Usually, these incidents are associated with stenosis of the common carotid artery, the internal carotid artery, or one of the three branches of the cerebral arteries, directly inside the brain skull. Temporary blindness could be associated with stenosis of the posterior cerebral artery.

This neurosurgeon who saw Steve ordered a chest computerized tomography (CT) scan. The scan showed nine nodules ranging in size up to nine mm in diameter in Steve’s right upper lobe. This imaging was combined with an elevated level of alkaline phosphatase of 285 and a low hemoglobin of 12.9. A repeat CT scan of the chest was ordered in three months, but the clinic never arranged for the repeat CT to be done so it was not scheduled and not done. The physicians never told Steve about the lumps in his lung, the alkaline phosphatase, or the anemia. Nobody told him of these critical findings and nobody arranged for his follow up care, neither his neurosurgeon nor his corporately employed family practice doctor.

In addition, Steve has had prostate cancer for over 10 years. He has been assigned by the Mayo clinic group to the active surveillance status. Steve’s urologist, who is also part of his large clinic, is supposed to be checking Steve’s PSA every year. However, the last prostate biopsy and medical resonance imaging (MRI) was done three years ago. There’s also a discrepancy between the biopsies and the MRI which indicates a more advanced cancer than the biopsy does.

It is the job of family practice doctors to keep all of these health care issues pulled together and be sure that they are followed. For some reason, Steve’s family practice doctor who is part of the corporate medical organization has not pulled any of this together into a comprehensive health care plan. His family practice doctor did tell him the last time Steve was seen that he could die any day. But no plans were made for surgery. No plans were made to follow up on his PSA. In reality, Steve has no family practice doctor, but rather a doctor within the corporate organization who goes by the title of a family practice doctor.

Steve took a stool sample to the clinic last summer for a blood test. The test was positive and he had been scheduled for a colonoscopy. A few days before his scheduled colonoscopy, a receptionist called him and said the doctor wasn’t going to be there for his scheduled procedure. Instead of rescheduling Steve’s colonoscopy while she had Steve on the phone, she told him he would have to call and reschedule the procedure. Apparently, no effort was made on her part to reschedule the surgery. In the meantime, Steve’s preoperative exam (they are good only for one month) was going to expire in two weeks. If the colonoscopy didn’t get rescheduled within that two-week window, Steve would have to have another preoperative examination before a colonoscopy could be done.

In an effort to connect some of the dots in Steve’s medical care, I sent him to a nurse practitioner I have known well for many years. I tried this in an effort to help Steve get some kind of coherence to his healthcare. This practitioner was now a part of a large healthcare system which was different than the one Steve went to. So Steve now seems to have a whole new batch of healthcare providers because the nurse practitioner cannot refer her patients to specialists outside the corporate physicians. Unfortunately, the nurse practitioner, now working for a corporate entity, doesn’t seem to be able to pull any of Steve’s health history together to create a treatment plan managing the various results from specialists. Perhaps because the specialists are outside her group. Perhaps because she cannot spend enough time with Steve to gather the information she needs to create a plan for his care.

One recent day when I was talking with Steve about how we could bring some reasonableness to his treatment, he told me that my efforts to help him get a coherent treatment plan for his various health problems had opened his eyes to the kinds of problems I had been dealing with my whole career as a physician. Patients often are unable to see the difficulties primary care physicians have in coordinating medical care for their patients. He told me he hadn’t realized until now what I really had to do to get good, coordinated healthcare for my patients.

Being able to differentiate good personal care from bad personal care is one of the few remaining advantages to being a physician. Many times our patients mistake the chaos of mismanaged corporate healthcare as stemming from a physician’s poor care. I’m here to tell you that most of the problems with coordinated health care result from the lack of a truly independent primary care physician who can spend the time with patients to establish the necessary relationship of trust that cannot be supplied by the way corporate medicine demands physicians practice.

The necessary partnership between doctors and patients is rapidly eroding while millions of dollars are being spent to study the fragmentation problem by government agencies. The good news is that the solutions are obvious, just as they are with obstetrical deserts. The bad news is that rather than repairing the problems of healthcare fragmentation, we will continue studying them as if the solutions are not already obvious. Yes, the inability to see the solutions to the fragmentation of patient care is enough to make a preacher swear.