Primary Care Transformation and Doctor Engagement

One of the themes of this blog has been to critique the idea that “physician engagement” can be achieved through management techniques alone.

As Donald Milliken writes in the Canadian Medical Association Journal “… ‘physician engagement’ can sometimes seem like code for ‘managing physicians,’ which creates polarity.”  Insofar as doctors are viewed by management as objects to be arranged and controlled then all the different ideas about transforming the health care delivery system through ‘physician engagement’ and ‘buy in’ will fail.

But once we accept that there is no way to “manage” physicians into engagement, then the literature on primary care transformation can be read as a celebration of precisely the form of cooperation that Doctors Council believes in.

The Rocky Mountain Health Plan’s recent policy brief on primary care transformation “Ten Lessons for the Path Forward” highlights important and thoughtful ways of achieving the massive changes in primary care delivery that are occurring the United States.  When we read them not as lessons in how to manage, but rather in guidelines in how to work together they can be very useful.

We will focus on three of their lessons:

LESSON #3 Spark physician enthusiasm

Emily Kivlehan, a medical student reflecting on her decision to be a doctor wrote on KevinMD “Recently, while walking out of the hospital, I felt such excitement that I can do this with my life.”  That excitement is the same excitement that must be part of any transformation of the health care system.

Lisa Letourneau, M.D., executive director of Maine Quality Counts, is quoted in the Rocky Mountain Health Plan’s report on how to connect with the enthusiasm of the doctor.  She explains: “Clearly communicate a vision for practice transformation that both supports the clinician’s sense of professionalism and identifies high-quality patient care as its primary goal.”

Of course we hope that the vision for transformation would not simply be communicated to the physicians, but would be born in their enthusiasm for medicine.

LESSON #8 Embrace team-based approaches that extend beyond the practice

The transformations that are discussed in the literature are not easy.  For example the team-based model of care, which is at the heart of the medical home idea, requires different skills and roles than many doctors are used to.  A recent study by Helfrich, et al of the Patient Centered Medical Home at VA hospitals among all primary care employees (not only physicians) found that ”participatory decision making and having recommended staffing levels for primary care teams were associated with significantly lower burnout after adjusting for a variety of characteristics of respondents and clinics.”

This conclusion is a good summary of the physician experience in team-based models. When doctors are included in the decision making process and the listened to, the experience is a good one.

LESSON #10 Obtain timely, accessible and useful data

The use of data is at the core of health delivery system transformation.  But too often we hear from physicians that data is being used not to transform the system in the interest of the patients, but rather to discipline and manage the work force.

Data, especially when it is a question of what needs to measured, must also be collaborative.

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Transformation is possible when the physicians, staff and patients lead.  No trick of management will take the place of real conversation and engagement with the professionals who do the work.

And that point is one of our central themes in our White Paper on doctor engagement: “Putting Patients First Through Doctor, Patient and Community Engagement.“