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By Deborah J. Cohen, PhD
I recently sat in a virtual primary care leadership meeting with probably 40 people attending. (There were too many little Zoom boxes to count.)
I watched a PowerPoint presentation in which a table outlining what primary care clinicians do was shared. The people presenting had boiled down “primary care provider clinical activity” to things that could be counted: individual direct clinic sessions, consults for things that I consider to be specialty care that live in our primary care clinics (but that is another story), time spent reviewing charts, participating in huddles, typing notes, answering portal messages, etc. This list of activities was intended to account for “providers’” productivity to help leaders in our system understand, value, and account for the work our clinicians do.
To me, primary care is a function that is at the foundation of peoples’ personal health and the health of our communities. By the end of the presentation, with its accounting list, my heart was aching.
Primary Care and the Personal Clinician
The function of primary care is to provide whole-person care. Primary care clinicians are generalists who address the majority of people’s health needs throughout their lifespan, not just for a set of specific diseases. The function of primary care is to ensure people receive comprehensive care: prevention, treatment, rehabilitation, pre- and post-natal care, including the birth of babies, as well as end-of-life care.
This function is inseparable from the function of a personal clinician who is also a generalist. A personal clinician has a committed trusting relationship with patients. It is in the context of a patient’s relationship with a personal clinician, preferably over the course of a lifespan, that whole person, comprehensive care health care is realized. As described by T.F. Fox in 1960:
A person in difficulties wants in the first place the help of another person on whom [they] can rely as a friend—someone with knowledge of what is feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for [them], and, knowing how [they] live, will keep things in proportion—protecting [them], if need be, from the zealous specialist. The personal doctor is of no use unless [they] are good enough to justify [their] independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help [their] patients not because of the interesting medical problems they may present but because they are human beings in need of help.1
From Accounting to Accountability
I spoke up in the meeting to explain how I was feeling in response to the accounting list devoid of the foundational functions of both primary care and the personal primary care clinician. My comments, while eventually appreciated, were initially dismissed as “qualitative” wh(ich was the ideal way to dismiss me, a qualitative researcher).
The system in which I work is not the only one where primary care clinicians are being pushed toward accounting for what they do. But what is needed instead is a focus on clinician accountability to the people and communities they care for as healers. I stole the title of this blog post from someone I greatly admire, Carlos Jaen, who recently made a similar point about this on a national listserv.
This suggests to me that my system and the clinicians I work with are not alone in struggling with accounting versus accountability. But why was I – the non-clinician in the virtual room – the only one who spoke up? Why did I watch as my clinician colleagues put additional countable items in the chat? How do we help our primary care clinician leaders, who I respect and value greatly, shift their way of seeing and thinking about their work so that they can lead our health systems in a new direction, one that moves away from accounting and toward accountability and responsibility?
1. Fox TF. The personal doctor and his relation to the hospital. Observations and reflections on some American experiments in general practice by groups. Lancet. 1960 Apr 2;1(7127):743-60.