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The Cost-Effectiveness of Family Physicians – Comfort with Uncertainty

June 3, 2013

This post is the 3rd in a series discussing our findings in a recently published study on the ways family physicians deliver better care at a lower cost than a multi-ologist model.

Family physicians told us they are more comfortable with uncertainty than the ologists. For a little history, the Future of Family Medicine project published in 2004 identified this mental attribute as an important defining skill of family physicians (which was listed under the heading of comfort with uncertainty, which I’ll expand on in a future post).

This comfort/skill/psychological ability manifests itself across the entire spectrum of family medicine. An example is reassuring a young mother that her infant with a fever will probably be fine – and ordering no tests or hospitalizations. Another is reassuring a middle-age man, who had a neck CT ordered by an ER doctor after a minor motor vehicle accident that revealed a smooth cystic mass in his thyroid gland, that he doesn’t need to worry about it (and if there is any follow up, it’s minimal and as non-invasive and inexpensive as possible), family physicians make a dozen decisions a day to not order tests or treatments that other physicians would.

This doesn’t mean that family physicians are simplistic in their thinking and don’t understand that in each of these cases rare outcomes happen rarely. Rarely, a child who initially looks mildly ill worsens over the next day or so. Rarely, a smooth mass seen on imaging turns out to be cancer.

It’s just that family physicians also feel that overtesting and overtreating, besides causing great economic harm to society, also  harm patients. Infants indiscrimately prescribed antibiotics experience adverse effects individually, and across all patients bacterial resistance to antibiotics worsen. People who have surgery for benign-appearing masses suffer the predictable risks of surgery, including death. Movements such as the Avoiding Avoidable Care organization and conference have helped spread this message better than the during the fiasco of the managed care era.

And medical schools certainly don’t teach or value this skill. Think about how many times the presentation of a patient with a rare disease in a medical school M&M conference run by one of the bigoted ologists started with a statement that “This patient was referred to us by a local MD (medical school speak for family physician) who discovered an X on one of his patients — the implication being that the “local MD” just doesn’t know enough to know what should happen next. Medical schools teach thoroughness, not judgment or prudence.

Medical students who have poor tolerance of uncertainty find a primary care career too challenging. I also believe this comfort is a huge reason mid-levels can never achieve the efficient outcomes of family physicians. They refer to ologists any patient situation that doesn’t fit one of their cookbook algorithms.

This family physician characteristic is so important that the AAFP should spend much more of its resources on spreading this message: that family physicians provide better care at a lower cost because they as medical decision makers are more comfortable with uncertainty than all other physicians (internists included). This is a huge undertaking. I’m asking the AAFP to make efforts to move the U.S. cultural dial to a different place than it currently is. This means the AAFP will have to fight back against the influence of Dr. Oz and the rest of the TV doctors and health beat reporters.

Because if the family physician is comfortable with the uncertainty that a patient with a classic migraine history doesn’t need a dose of radiation to her head – a CT scan – but she is not comfortable with the inherent uncertainty of this decision — the physician can’t be certain that the CT will find no mass — then conflict will arise between patient and physician. The family physician will  not receive a 10 on the patient satisfaction report card, which some pinhead bureaucrat will interpret as poor care.

And a sustainable well-supported army of U.S. family physicians will continue to only be wishful but delusional thinking. If our patients and the payers don’t support our comfort with uncertainty, we will continue to be an anemic presence in U.S. healthcare system.

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