Think Globally, Act Locally: What Each Clinician Should Do
Every dollar that is spent unnecessarily in the care of a healthy person potentially leads to further restrictions on reimbursement, further increases in health insurance premiums, loss of health insurance in borderline cases and, ultimately, fewer available resources for the care of the sicker patients who desperately need them. —Raymond J. Gibbons, MD21
Medicine has some very crucial decisions to make in the immediate future involving the allocation of resources, including the appropriate use of antibiotics, screening diabetics for microalbuminuria, screening for osteoporosis using bone densiometry, screening for prostate cancer using the prostate specific antigen test, and the use of routine obstetrical ultrasound. By continuing to provide services that do not improve patient outcomes, we add to the rising costs of health care, which results in fewer patients being able to receive the health care they need.
What can the individual clinician do? Each of us needs to learn about the benefits, harms, and costs of important interventions.22 We need to identify both the unnecessary and underused services and determine with patients if those services are worth the costs. More basic, applied, and practice-based research is needed to determine patient preferences about what information they want or need and how they would like to be included in the decision-making process. In addition, we must take responsibility for incorporating valid POEMs and guidelines into our everyday practice. Finally, we must accept that resources are limited and we can either continue to limit people who receive services, or limit the services themselves.
Practice behaviors this year have a direct effect on the health care budget for next year, both in a fee-for-service and capitated system. Excess spending this year results in fewer patients being insured next year and has a direct impact on how many people can afford coverage or how many individuals a specific company can afford to employ. The money saved by increasing the value of the services we provide (by limiting costs or increasing quality using valid POEMs as a guide to delivering these services) may not result in a direct decrease in the overall cost of health care. It will, however, reduce the yearly increase in health care spending occurring above and beyond the inflation rate. Figure
The role of family medicine
The only thing necessary for the triumph of evil is for good men to do nothing.—attributed to Edmund Burke
The survival of family medicine as an independent specialty is being challenged by competition from other providers and increased control by insurance organizations. These challenges are reflected in the lower number of medical students attracted to the specialty.
What does family medicine have to offer the students who have only the dictatorial dons of medicine or the young, brash hero-docs on “ER” as role models? By comparison, family medicine does not look challenging or sexy. Family medicine must be seen as cutting-edge and patient-centered. To achieve these goals, the specialty must embrace patient-oriented evidence that matters and balance the needs of each individual with the needs of the family and the entire community.