Is Primary Care Actually Effective?
In the field of emergency medicine, there is an idea called “door-to-balloon” or “time-to-cath”, which is the amount of time that has elapsed from the moment a patient who is having a specific kind of heart attack walks into the emergency department to the time that a catheter enters the occluded vessel. (There are two general types of “heart attacks”, or myocardial infarctions (meaning death of the heart muscle); one requires immediate surgical intervention with a catheter to open up the blocked blood vessel – the definitive treatment – while the other can be treated with medicines initially. It is the first kind to which the “door-to-balloon” idea relates).
An enormous amount of energy and resources from a myriad organizations have gone into systematic efforts to reduce this “door-to-balloon” time, and subsequently reducing the number of deaths after the onset of a myocardial infarction. The American College of Cardiology launched a large national “initiative” and the American Heart Association launched a complementary “mission” to standardize and reduce time-to-cath; emergency departments have received incentives over the years to make this an ordinary practice, it has become a core measure for healthcare accreditation, and it is now common vocabulary within the healthcare field and among the public. Over the last decade, because of its success, it has become a common topic of medical research and direction for scientific inquiry.
And the results are impressive. At the foundation of this idea is a set of hospital procedures and protocols, a collection of ready human and technological resources, an algorithmic approach to diagnosis and management for the ED team, and a mechanism for administrators to identify and eradicate delays in the process. Whatever means are needed to bring door-to-balloon to under 90 minutes is supplied.
And none of that involves the patient. In fact, the system probably runs smoothest when the patient is unconscious…one step from dead…as passive as possible while still able to be kept alive.
Because of its tremendous success, and coupled with society’s event-oriented mindset and infatuation with instant results, the concept of attaining a goal within a certain time has become common in health care. More and more, time parameters are set on objectives, which dictate reimbursement structure, staffing needs, research practices, and overall resource allocation.
What the health care system does well is simply a reflection of what society does well – eliminate the will of an individual and let the system’s will force short-term and end-oriented results. We can miraculously prevent a patient from dying if their heart stops receiving blood, yet we can’t seem to do anything about the rising incidence of the need to do this.
So it seems that primary care is the answer. Manage disease before it becomes an “event”, before it requires “immediate results”, before it necessitates life-saving measures.
But it’s not that simple. Let’s take an example with diabetes management in primary care. Common in the discourse now is “time-to-goal-A1c”. A1c is a great blood test that measures the average amount of blood glucose over 3 months, let’s say. It has now become the standard for diagnosis and monitoring of diabetes. Below 7.0 is good control; so ambitious primary care proponents are pushing the idea of lowering a patient’s A1c to 7.0 within 3 months of their first visit to a clinic. Time-to-cath, 90 mins. Time-to-goal-A1c, 90 days. Makes sense. It works in the emergency setting – the only difference between emergency and primary care is time, right?
Unfortunately, there has been little to no success. Despite the enormous amount of energy and resources from a myriad organizations, despite the incentives offered to clinics, despite the core measures and accreditation criteria, despite the research, the prescriptions, the counseling, the protocols, the ready human and technological resources, the algorithms, the mechanisms, despite all efforts by the will of the medical system, there is no success.
Because, this time, the patient isn’t unconscious.
The reason why our healthcare system – and, indeed, our society in general – is excellent at drastic end-of-life situations is because the variables are in the hands of the system itself; the patient doesn’t factor. Emergency situations, albeit outwardly chaotic, are very controlled by those in charge. Simply, the more the system is empowered to act, the better will be results. And the same reason explains why primary care is unable to parallel such impressive results: because the power to act still is being locked within the clutches of the system, yet it is the patient who is the primary actor. It mistakenly thinks that if it becomes more empowered, it will deliver health better. However, while a patient may encounter the system’s will for 15 minutes every week, and be given prescriptions in the broadest sense of the word, this does not account for the other 6 days, 23 hours, and 45 minutes he is alive. Delivering health is not the same as delivering a service or good that is needed in an immediate or life-threatening situation; in fact, health is not something delivered, it is something of which a patient is empowered to take charge. Instead of focusing on the system as the deliverer of health, real healthcare means focusing on empowering patients to take charge of their own health care.
Empowerment, like health, is also not something delivered from the empowered to the unempowered; it is something fostered through the creation of environments and relationships. It occurs through the generation of knowledge, through selfless service, and through humility. It draws on the powers of the human spirit and the capacities of the soul. It is a process that demands the active participation of the protagonists of social transformation – all of humanity.