Nov/Dec 2005 Annals of Family Medicine tip sheet

December 06, 2005

In a compelling essay, Woolf and Johnson argue that as a society, we should spend less on technological advances and more on improving systems for delivering care. They make the case, supported by mathematical arguments, that technological advances must yield dramatic, often unrealistic increases in efficacy to do more good than improving fidelity - the systems that ensure the delivery of care to all patients in need. They point out that our society channels most of its resources into the race for new drugs and devices, even though medical advances do less good than closing the gap in the quality of health care delivery. The authors conclude that our huge investment in technological innovations, which only modestly improves efficacy but consumes resources needed for improved delivery of care, may cost more lives than it saves. They assert that the misalignment of priorities is driven partly by special interests (e.g., blockbuster earnings for industry) and by the public's appetite for technological breakthroughs. Ultimately, however, health outcomes suffer. They urge society to confront the price we pay - in human lives - by maintaining a health care system that is not designed to deliver care well while investing vast wealth in technology.

Two accompanying editorials further the debate about the appropriate balance between investing in new technologies vs. devoting resources toward improving systems of care to deliver services already known to be effective. Steven M. Teutsch, M.D., M.P.H., with Merck & Co., Inc. concedes the American health care system fails to deliver the health benefits commensurate with our investment. He agrees that the American free enterprise system has its weakness in channeling resources into innovative technologies that can be successfully marketed at the expense of other, more effective translational or population health initiatives. But he also cautions we should not assume that closing the treatment gap will be easier or less costly than developing new health technologies. Teutsch calls for a national dialogue to discuss the goal of public health and health care enterprises. He proposes that all parties' success must be measured in units of health, not simply dollars, publications and services. Teutsch argues that such an effort cannot move forward without strong leadership from the federal government.

In a second editorial, Richard L. Kravitz, M.D., M.S.P.H. with the University of California, Davis, challenges several of Woolf and Johnson's assumptions and the logic behind some of their arguments. Nevertheless, he concedes that the main point of their article - that we spend far too little putting research into practice - is irrefutable. He calls for those involved in improving the delivery of health care to be fierce advocates for doing things better even as those in the laboratory continue to search for better things to do.

The Break-Even Point: When Medical Advances Are Less Important than Improving the Fidelity with Which They Are Delivered
By Steven H. Woolf, M.D., M.P.H., et al
Misaligned Incentives in America's Health: Who's Minding the Store?
By Steven M. Teutsch, M.D., M.P.H. and Marc L. Berger, M.D.
Doing Things Better vs Doing Better Things
By Richard L. Kravitz, M.D., M.S.P.H.

Physicians in independent practice report higher quality of work life than physicians employed by health care organizations, according to a survey of 584 Wisconsin-based family physicians. Specifically, independent physicians report better working relationships, more satisfaction with family time, more influence over management decisions, better satisfaction with being a physician, better perceived quality of the care they provide, greater ability to achieve professional goals, and lesser intention to leave the practice. Given the trend toward more physicians working as employees of large health care organizations, these findings have important implications for retaining and enhancing the effectiveness of our current primary care work force.

Quality of Work Life of Independent vs. Employed Family Physicians in Wisconsin: A WReN Study
By John W. Beasley, M.D., et al

With as many as half of all American adults lacking the literacy skills required to function adequately in the health care environment, clinicians are in need of a tool that can rapidly assess patients' literacy. Following rigorous evaluation, this study finds that a new screening tool, the Newest Vital Sign (NVS), holds promise for use in the busy primary care setting. A brief, six-question assessment based on the ability to read and apply information from a nutrition label, NVS was found to be a reliable and accurate measure of literacy. The NVS has advantages over currently available instruments, which are either too long for routine use or are available only in English. The NVS is the first literacy screen available in both English and Spanish, and it NVS can be administered in an average of only three minutes. The authors assert that these advantages, combined with the instrument's high consistency and validity, make NVS very appealing for use in primary care settings.

Quick Assessment of Literacy in Primary Care: The Newest Vital Sign
By Barry D. Weiss, M.D., et al

In the first of two studies in this issue to examine how family physicians spend time outside the examination room, Gilchrist and colleagues find that family physicians spend 23 percent of their office-based time providing medical care outside the traditional face-to-face visit. The most common medically-related activities are charting (32.9 minutes per day) and dictating (23.4 minutes per day). Other undocumented responsibilities include reviewing reports, consulting medical resources, consulting colleagues and communicating with patients, all of which have a direct bearing on patient outcomes and physicians' abilities to manage their practices. Using direct observation of 27 family physicians' office-based activities, researchers found when out-of-exam room medical care activities were figured into the amount of time spent on each patient encounter, the visit time increased by approximately seven minutes, or 40 percent. They point out this does not include the additional, considerable responsibilities physicians perform outside the office. While consistent with the increasing complexity of primary care management, the authors assert patients and payers often do not recognize this care. The authors suggest that models of health care delivery and reimbursement must more accurately reflect health care professionals' work.

Physician Activities During Time Out of the Examination Room
By Valerie Gilchrist, M.D., et al

In a related study also using direct observation methods, Gottschalk and Flocke find that primary care physicians spend nearly one half of their workday on activities outside the examination room, predominantly on follow-up and documentation of care for patients not physically present. These findings shed light on the seeming discrepancy between primary care physicians' experiences that face-to-face visit time continues to decrease and data from the National Ambulatory Medical Care Survey indicating that visit duration has increased in the past decade. The authors assert it is possible face-to-face time has diminished through the past decade, while patient-related demands outside the examination room have increased, however additional studies are necessary to further evaluate this. They also suggest that office systems, such as electronic prescribing, electronic health records and telephone call triage protocols could help streamline the physician's role and increase the efficiency of information management and decision support.

Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room
By Andrew Gottschalk, et al


In a thought-provoking essay, Buetow argues that true "care" is defined by "coprovision" in which clinicians and patients each contribute expertise in their domain. He explains that while clinicians contribute clinical expertise, patients may be experts on their own bodies, life situations, values, beliefs and preferences. Buetow's analysis provides an alternative to medical paternalism and patient consumerism, which prevent and preclude care by disempowering patients and devaluing clinicians' professional training and role, respectively. Alternatively, coprovision is characterized by mutual responsiveness and responsibility.

To Care Is To Coprovide
By Stephen A. Buetow, Ph.D.

In a randomized controlled trial of 52 primary care physicians, researchers found that physicians who used DynaMed, an online clinical reference resource designed to answer questions that arise at the point of care, answered more of their clinical questions and found more answers that change clinical decision making than physicians who did not have access to the tool.

Physicians Answer More Clinical Questions and Change Clinical Decisions More Often with Synthesized Evdience: A Randomized Trial in Primary Care
By Brian S. Alper, M.D., M.S.P.H., et al.

*Conflict of Interest: Dr. Alper is the founding principal of Dynamic Medical Information Systems, LLC and the editor-in-chief of DynaMed.

In a qualitative study of 24 primary care patients who lived through a preventable medical problem, Elder and colleagues find that anger, mistrust and resignation are common. This analysis classifies patient responses into four categories: avoidance, accommodation, anticipation, and advocacy, each with different implications for subsequent health care.

How Experiencing Preventable Medical Problems Changed Patients' Interactions with Primary Health Care
By Nancy C. Elder, M.D., M.S.P.H., et al

A pair of studies examines suicidal ideation among depressed patients. In an assessment of 405 patients with uncomplicated depression, Schulberg and colleagues find a low risk of suicide, which remains fairly stable through six months of follow-up. A randomized study by Nutting and colleagues shows brief training of primary care clinicians to improve depression care can double the rate of initial detection of suicidal ideation.

Suicidal Ideation and Risk Levels Among Primary Care Patients with Uncomplicated Depression
By Herbert C. Schulberg, Ph.D., M.S.Hyg., et al

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care
By Paul A. Nutting, M.D., M.S.P.H., et al
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site,

American Academy of Family Physicians

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