Health for life

Years ago, the Disease Management Care Blog had a pediatrician colleague who was widely admired for his diagnostic acumen, attention to treatment detail and personalized attention. As further testimony to his reputation, every physician wanted him to be their childrens doctor. The DMCB was one of those lucky docs. The luck ran out, however, when the DMCBs spouse quickly realized that she couldnt get any appointments and even if she did, the physicians clinic routinely ran two hours late.

Persons who read this New England Journal Perspective testimonial on the joy and frustrations of a primary care career should keep that physician in mind.   That reality contrasts with Dr. Finegolds fantasy world of dedicated physicians with limitless time where 1) the personal physician individually guides complex patients through a complex health care system and 2) the doctor patient relationship is fountainhead of professional satisfaction and patient well being. Thats why insurers should pay anything and policymakers should do everything they can to support this vision.

The DMCB sadly disagrees.

Primary care physicians are a precious resource. Theyre not only expensive, they are becoming more rare over time. As a result, use of their time and effort has to be restricted to circumstances when there is no one else who can deal with the paper work, make medication adjustments, work to increase treatment compliance, maximize the insurance benefit, deal with the social issues and provide psychological support. The DMCB thinks there are non-physician professionals who are better at these activities and do can do it far more cheaply. The solution is not more primary care physicians but more primary care physician support.

The DMCB physician colleagues may argue that the doctor-patient relationship is truly Holy Ground. Unfortunately, it is becoming increasingly apparent that there at too many patients and too few physicians to allow Dr. Finegolds indulgence of being so immersed in their patients lives. The degree of personalized involvement described in this article may be a luxury - like open access to brand drugs, the latest technologies, the priciest specialists or a few extra days in the hospital - that society can no longer afford.

Whats the one issue that drives the most doctors crazy?  The Disease Management Care Blog suspects its persons who use basic vaccinations.  Thats because physicians are inculcated from the first day of their education with triumphant stories of how basic science and public health joined forces to banish many common and fatal infectious diseases. 

Not getting your shots is crazy.

DMCB readers are probably aware of how childhood U.S. vaccination rates are dropping.  While we continue to wonder just how any parent or guardian could let that happen, heres a handy summary on the story behind the story: the New England Journal has an article on Improving Childhood Vaccination Rates:

Total U.S. rates of vaccination remain greater than 90%, but there are some pockets of the country with rates just over 50%. Thats where there have been outbreaks of disease leading to some pointless deaths.

Parents (or guardians) opposed to vaccination are unlikely to change their minds.  Thats why high vaccination rates among the remainder of children are important to create herd immunity.

There are four approaches to achieving high vaccination rates:

1. Make shots free and think about paying parents to have their children immunized.

The DMCB likes the idea but wishes the authors had pointed out that in the context of value-based insurance, this is hardly a radical idea. 

2. Make it really difficult to attend school without proof of vaccination.  Getting an exemption should demonstrate that the parents are serious and not shuffling by on lax enforcement.

The DMCB grew up in New York City and recalls being immunized against polio in the schools cafeteria.  Is it time to bring this back as a first-line strategy?

3. Confront the anti-vaccine community with counter-education campaigns that rely on more than facts and figures.  Anecdotes and trusted public figures should also be used.

Whither social media?  And, at a traditional marketing level, the DMCB thinks that maybe its time to partner with the pharma companies that do such a good job of convincing TV viewers to take lipid-lowering agents and anti-depressants.  Nothing against the colleagues in public health, but theyre not known for their marketing savvy.

4. Physicians need to step up one patient at a time and, while theyre at it, make sure theyre up to date with their shots.

The DMCB did a literature search on "shared decision making" and "vaccination" and found no useful information.  Given the success of aids and engagement strategies that enable truly informed decision-making, the DMCB thinks its time for the population health management community to step up and offer their services.

(One last thought: Newts been lampooned for his moon-base wackiness, but as the DMCB understands it, his recommendation is really based on an X-Prize approach, which he contrasts with the discontinued Shuttle program.  The DMCB wonders if such an approach couldnt work in those areas of the country with critically low childhood vaccination rates: a 5 figure prize to any outfit that can move it to 90%.  Why not?)

Image from Wikipedia