Tuesday, May 30, 2006

Stateside Healthcare: Art, Science, and Commerce?

(Last April 17-May 12, I rotated in an off-campus Family Practice elective at the Kelsey-Seybold Clinic Copperfield in Houston, TX, USA. My output included a paper on Primary Care and Family Practice as observed at the site, submitted to my UP Preceptor Dr. Josefina Isidro-Lapena and to my KSC Preceptor Dr. Peter S. Halvorson. I'm posting the same in full here at my blog, in installments.)


I. Introduction
II. Generalist versus Specialist
III. Kelsey-Seybold: the McDonald’s of Medicine
IV. Family Practice
V. Allied Forces
VI. To Choose, not just to Consent
VII. Medical Informatics: Streamlined Efficiency or Rigid Technology?
VIII. Legalities
IX. Health as Wealth: Managed Care



In a healthcare system, the interplay of factors such as practitioners, patients, facilities, government, and economics can be used to illustrate how the system works. Rather than attempt to discuss public health in general, this paper chose to scrutinize the five factors mentioned above at the micro level, with emphasis on the day-to-day patient encounter and the working relationships of healthcare professionals at the point of service. This paper involves a small snapshot of the United States of America (USA)’s primary healthcare system – both at the outpatient and hospital settings as practiced within the Kelsey-Seybold Clinic/St. Luke’s Episcopal Health System (KSC) in the city of Houston, State of Texas. Its perspective is that of a fourth-year foreign medical student from the Republic of the Philippines.

The highlighted specialty is Family Practice, with consideration for its main role as a primary care specialty. However, to better appreciate the norms of primary care, two other generalist areas were observed: Internal Medicine, and Pediatrics. The three did not differ much in coverage except for an age-dependence in triage. As expected, Pediatrics handled no one over eighteen years of age, while Internal Medicine preferred approximately forty years old and up. Family Medicine’s patient age, on the other hand, was dependent on the individual practitioner’s choice.

Generalist versus Specialist

It was observed that generalists have regained significance in the United States of America (USA)’s delivery of health services. Primary Care Practitioners (PCPs) – generalists in essence – provide close-in personalized healthcare and act as gatekeepers to the various medical specialties and vast health resources.

Health-seeking behavior in patients also shows a demand to be seen by PCPs. As may be discussed later, however, this preference may be mostly due to the health insurance requirement that the insured must seek treatment by a PCP first before a specialist comes on board. Still, to most of those interviewed, it really didn’t matter; what works for them is what they return to. With the ability of the PCP to be flexible in scope as a generalist and because of more frequent contact, the tendency is for rapport to be established mostly between the patient and his/her PCP rather than a specialist. This may allow an improved therapeutic relationship that provides for ease of treatment.

PCPs as gatekeepers could not be emphasized any more than it as being an established phenomenon. Acting as coordinators of the professional team that cares for a patient, the PCP often has the over-all view of a patient’s health. This allows for him/her to sufficiently recommend to the patient what course to take or choices to make as regards the treatment plan, and gives specialists the convenience of truly focusing on their particular field of interest rather than bother in-depth with patient co-morbidities not related to the disease for which they were consulted.

It is also of importance to cite this early in this paper that the PCP saves the whole healthcare system a significant amount of money (to be discussed in detail later). The PCP’s use of wellness checks and focus on preventative medicine may indeed have an impact on future spending, assuming satisfactory patient compliance with advice given. Furthermore, with the PCP coordinating the specialist team and acting as gatekeeper, resources are saved by making educated and appropriate referrals to the correct specialists.

Notable also is the fact that as observed, PCPs attend not only to the physical concerns of patients but also to their mental health. This is not to say that the Psychiatrist has no role; rather, the PCP unburdens the Psychiatrist and allows the latter to focus on more complex mental diseases as befits his/her specialty training. Common psychiatric diagnoses such as depression and anxiety are successfully managed by the PCP, and in the course of management the PCP is not hesitant to use the appropriate psychotropic pharmacotherapy.

Next: Kelsey-Seybold, the McDonald's of Medicine