Maggie's Farm

One of the authors is a highly respected and experienced classmate of mine. That is to say we're both close to being old codgers. However, he has a meme to sell that is important to maintain his chosen career track. I am not so sure that electronic medical records, "evidence-based" medicine and computer based order entry coupled with rigorous government oversight is going to improve things.

One point ignored here is that about 3/4 or more of Primary Care medicine is really all about mental and emotional health. And despite all efforts, behavioral medicine is no fixed science with established double-blinded studies without bias to back up recommendations. Not yet. So whatever efforts a provider makes in these areas is likely to not meet a cookie cutter standard of care no matter what the "experts" and "current literature" proclaims is the only way to appropriately deal with a problem. Set in a milieu of toxic economic, culture and legal factors poisoning the practice of medicine, it is a wonder providers get it right at all.

When a patient goes to their primary care physician with a complaint of back pain, and they are not treated for their back pain, but alcohol and tobacco abuse, obesity, poor physical endurance/flexibility/ergonomics and depression, they really are getting quality care.

Most docs simply write a pain pill and a muscle relaxer, neither of which are indicated and often aggravate the underlying problems. Their motivation USUALLY is because this is what the patient requests or demands from the outset of their visit. Also its an easy way to make money for the visit with minimal effort, and at least initially results in a satisfied patient. The patients are not motivated to change their lifestyle or attitudes, their insurance is not motivated to have them approach the problem in a behavioral manner with repeated visits and counseling, physical retraining and coaching, and they usually complain loudly if that is what is offered to them.

After repeated visits and an unsatisfactory outcome, the frustrated practitioner refers the patient on elsewhere, often at the patient's insistence, for a "surgical solution" and expensive imaging. Thus they avoid the anger (which can proceed to tort) and dump the patient into someone's lap who can only make money if they perform procedures on the patient, who is demanding a procedure (to fix what their obesity/tobacco addiction/depression/lack of fitness/physical abuse of the body has engendered). Poor outcomes are fairly predictable.