The traditional models of medicine are changing. One patient, one problem, one at a time was always the norm. But it was also the norm that your family clinician took care of every bump and bruise. It was a time when you could depend on the same family clinician to be there when you were young with a sore throat or older with arthritis.
Today we have conflicted paradigms. The norm of "one patient, one problem, one at a time", has more value when there is consistent care from the same clinician who knows each patient, each problem and will see you every time. But today care is changing. In many ways the change was inevitable and the trend is both good and bad.
Rarely is your family clinician the same medical professional that admits you to the hospital. Someone else will take care of you in the hospital these days then turn you back over to your family clinician upon discharge. That family clinician may also change over time or even visit to visit. You will see new clinicians as practices grow or community hospitals become large academic centers. You will see new clinicians in communities unable to retain consistent medical professionals or as training centers rotate new trainees in and out of a region. It is simply the sign of the times.
While the one patient, one problem, one at a time model is evolving on its own, the sick model should evolve as well. We simply don't know how to evolve it at the same speed. The reason it is important for the sick model to evolve is disease and treatments have evolved.
The sick model is treating people when they get sick. A well model is keeping people well before they get sick. The reason we need to move from a sick model to a well model is because the diseases that are now prevalent are influenced mostly by prevention. This requires ongoing care from clinicians with whom the patient can build a relationship over time. The well model runs counter to our evolving systems.
For hundreds of years diseases like pneumonia, meningitis and diphtheria were leading causes of death. Antibiotics and vaccines began to mitigate the impact of these diseases. Today, heart disease, cancer and stroke are heavily influenced by genetics we can't fully control but are best addressed with prevention before they occur in terms of what we can control. Preventative care is now more effective than reactionary care.
Controlling blood pressure, blood sugar and proper medical screenings for potential disease has the most value today. That's a well model. Treating someone before they get sick rather than just waiting until they develop one of these diseases is how to optimize care. The problem is, we haven't figured out how to reimburse medical professionals for keeping people well. We only know how to pay them for doing things after someone is sick. Medicine pays for doing things, not preventing things. It's simply easier to measure reaction than prevention. We also are evolving away from the family clinician model who knows the patients' needs best. Everyone is now a specialist.
There is value in a population health model that finds ways to address broad health disparities in a community. It is natural that the one patient, one problem, one at a time approach is evolving as disease has evolved. We now find populations sharing common health risks. The approach has become many patients, complex problems and many focused specialties designed to address emerging disease. But something seems lost in this evolution.
Many patients feel medical care has become too impersonal. We need to find ways to get the best of both worlds within these models. Finding ways to deliver preventative care to a population while maintaining personal attention to individual needs is a challenge. But it is the real model that best serves individual patient needs.
Finding a healthcare home helps. We need a lot of sub-specialists who can provide advanced care for specific problems. But the need for a consistent clinician who knows the patient and understands individual long-term needs is vital to ongoing care.
The evolution of big box healthcare isn't going away. Large corporations consuming community hospitals and smaller practices is inevitable. So, while funding healthcare is always a challenge, maintaining individual relationships and personalized medicine will be a growing challenge as well.
Phillip Stephens, DHSc, PA-C is affiliated with Carolina Acute Care & Wellness Center, P.A.