Primary Care: New Opportunity for Heroism

Atul Gawande argues that investment in primary care has an enormous but unappreciated return on investment in promoting and sustaining health. (“The Heroism of Incremental Care”, The New Yorker, January 23, 2017, pp. 36-45. http://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care ).

Gawande contrasts heroic medicine—like the surgery he practices —to incremental care provided by primary care physicians.

He is now convinced of the value of primary care: “Primary care, it seemed, does a lot of good for people—maybe even more good, in the long run, than I will as a surgeon.” (p. 40).

Heroic medicine along with other procedure-focused specialties like dermatology, gastroenterology, and radiology command more respect and resources than primary care. Gawande sketches the historical causes: in the twentieth century, medical research focused on “rescue.” Rescue--acute care interventions--took place in acute care institutions (hospitals), which dominated planning and spending in health care.

As a consequence, procedural specialties like orthopedics and cardiology command double the salary of family practice physicians and pediatricians; the procedural specialties typically have more equipment and staff to carry out care for patients.

Here’s a simple example of resource disparity recently reported by colleagues at the University of Wisconsin--Madison: orthopedic surgeons and cardiologists are much more likely than primary care physicians to have scribes to manage electronic medical records of patients seen by the physicians. Family practice physicians work many hours after clinic to maintain patient documentation without scribe help (see this post). 

Gawande describes primary care physicians along with geriatricians and palliative care specialists as “incrementalists”; “they produce value by improving lives over extended periods of time, typically months to years.” (p. 44)

The dichotomy between rescue/heroic medicine on the one hand and incremental care on the other has a parallel in management: special quality improvement projects that aim for major jumps in performance in contrast to incremental improvement that emerges from effective daily quality control.

This is exactly the point made by my teacher and friend Yukihiro Ando in his discussion of Daily Management (Y. Ando and P. Kumar (2011), Daily Management the TQM Way: The Key to Success in Tata Steel, Productivity and Quality Publishing Pvt. Ltd, Madras, chapter 2).

The authors distinguish ‘Big improvement’ projects from incremental improvements that emerge from daily quality control.

“‘Big Improvement’ can be achieved by a limited number of people within a short time span. Once it happens, the people involved with the ‘Big’ change will be identified and worshipped as heroes [emphasis in the original text].” (p. 35)

They explain:

“The ‘Big Improvement’ is dramatic, and draws attention by virtue of its magnitude. Many top management also appreciate ‘Big Improvement’ activities and recognize the achievers with awards.”

“While appreciating ‘Big Improvement’, if you lose sight of the ‘Keep stable, improve progressively’ activities, all your ‘Big’ efforts, improvements and resources will go [to] waste. Obviously, ‘Big Improvement’ unaccompanied by the activities of the ‘Keep stable, improve progressively’ variety, result in huge losses to the company as a whole.” (p. 35)

Just as incremental primary care is properly viewed as heroic, incremental improvements from effective daily quality control also deserve our deep respect and appreciation.