There are two main ways of thinking in today’s medicine. One is the mentality of Obamacare and the use of business techniques – specifically from manufacturing – to improve throughput of the system and reduce cost. The goal is to improve ‘justice’ in the system by proving care to the most people possible. The quality of the care is measured by population metrics – cost, number of infections, mortality, etc. Doctors and patients are essentially interchangeable widgets in this system, and all medical problems can be reduced to a basic set of algorithms that will dictate care. Actually, because thinking is no longer required in this algorithmic, guideline driven system, the role of the doctor is not that important, and physician ‘extenders’ may be used as interchangeable parts. If some patients fall through the cracks and are misdiagnosed, mismanaged, or ultimately die, that is the cost of increasing ‘justice’ throughout the population.
The second way of thinking is ‘old school’. Each patient is considered unique, and every doctor/patient interaction is precious. Time must be taken to get a good history, which will then guide a hands-on physical exam, lab tests, and ultimately diagnoses and a plan of care. The process cannot be rushed, but takes the amount of time needed to come to a good outcome. Extensive training is required to be able to consider the multitude of possible diagnoses. This way of thinking is clearly better for the individual patient (and for the doctors) but is resource intensive.
If I were to devise a health care system for this country, I would take a cue from business and the way technical support is handled. This approach would maximize the benefit of both approaches above. Young and/or generally healthy patients would use a ‘level 1’ system which is the first option above. NPs, PAs, and primary care MDs would handle the vast majority of complaints (URIs, UTIs, minor injuries) in an urgent care type setting. Patients with multiple problems or who have failed treatment at ‘level 1’ would then be elevated to ‘level 2’ where experienced general internists would see the patients, optimally no more than ~8 per day, and take time to go through all of the medical problems, take time to educate, and diagnose more severe problems. ‘Level 2’ internists would then consult specialists as needed.