Airport security and hamster wheels: analogies for American primary care

Since having children (two, ages 3 and 1), I've dreaded going through security screening at airports. With carry-on bags, collapsible stroller, car seat, and various prohibited-unless-you're-traveling with-an-infant beverages in tow, it always seems to take an eternity to disassemble ourselves (including removing my toddler's infant size 4 Dora the Explorer sneakers, in case they may be harboring a terrorist weapon) and reassemble everything correctly on the other side of the metal detector before an officious TSA employee, or worse, a fellow passenger, informs us that we're taking too long and are holding up the long line behind us. In our recent holiday trip overseas, I prematurely congratulated myself for managing to move all of our luggage off the belt in a timely fashion, only to be admonished by a TSA employee that our bags were blocking the exit to the departure gates and needed to be moved ASAP. Just 30 seconds to replace our boarding passes in my backpack? Out of luck. Move it along, buddy.

What saved me in this case from having my usual post-security screening explosion (aside from my wife's saying that I take these things much too seriously) was the sudden insight that this undignified process is a near-perfect metaphor for the current state of affairs in American primary care. Primary care clinicians in the U.S. are facing mounting pressure to see patients with increasingly complex medical conditions in less time, for less money, with administrative hurdles that seem to worsen every year. Despite the ample intellectual challenges and emotional rewards of "uncomplicated" primary care, it's no wonder that so few medical students are choosing careers in family medicine, general internal medicine, or general pediatrics. Try as we might, we can't find a way to get our luggage off the belt without making patients, payers, or specialist colleagues unhappy (these days, published scientific papers bemoaning the inability of primary care clinicians to detect this or that rare or pseudo-condition are a dime a dozen).

Another metaphor for the ills of primary care medicine is the hamster wheel, first proposed in the British Medical Journal in 2000:

Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still. ... In the government sponsored, single payer system in Canada; the mandatory insurance systems in Japan or continental Europe; or the managed care systems in the United States, doctors feel that they have to see more patients to maintain their incomes. But systems that depend on everybody running faster are not sustainable. The answer must be to redesign health care.

Of the many innovative proposals put forth in the past decade to redesign health care (a few of which I've mentioned in previous blog posts), the one that seems to be gaining the most traction is the patient-centered medical home, an integrated, team-based approach to providing a set of essential health services to every patient. This new model of care is both a return to family medicine's roots of caring for the "whole patient" with several contemporary ideas added in, including health information technology, patient registries, and proactive outreach to patients with chronic diseases. The current health reform bills being debated in Congress, while not doing nearly enough to support the medical home, are a step in the right direction.

So whether you prefer the metaphor of airport security or the hamster wheel, now is the time to become engaged in the movement to shape health reform in order to banish these metaphors once and for all.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from September and October:

1) Why you should just say no to "routine blood work" (9/13/09)

2) Public option or no public option: that is not the question (10/27/09)

3) Why "patient centered" health care isn't the norm (10/5/09)

4) The "single payer" should be you (9/17/09)

5) Primary care: no next generation? (9/21/09)

If you have a personal favorite that isn't on this list, please let me know. In the future, if enough people are interested, I may set up an "audience vote" function to choose the most popular posts. Happy Thanksgiving!

Guest Blog: Thanksgiving: Visiting My Brother on the Ward

Peter Schmitt is the author of five collections of poems, including Renewing the Vows, in which the following poem (first published in the Bellevue Literary Review) appears. You can find more information at his website, http://www.schmittpoetry.com/.

**

THANKSGIVING: VISITING MY BROTHER ON THE WARD

Behind the thick, crosshatched glass of the cruiser,
my brother, back for the holiday, breathes
more slowly. A phalanx of uniforms
cloaks the open door, murmuring to him
where he sits. The carving knife is somewhere
out of reach, none of us so much as scratched.
Inside, the bound bird cools on the butcher block.

Later that night I move through many doors, each
locking behind me, each inlaid with the same
heavy glass as the squad car. Through the last
I see my brother's face, fixed as on a graph,
ordinate, abscissa. When he sees mine
he retreats from the common room to his own,
a bare cell he shares with a narrow bed.

He will not speak to me, at first. His fingers
move in perpetual chafe, like a mantis,
his lifelong nervous habit, the edges
of a newspaper shredded on the bed.
This time, his eyes say, we have betrayed him
as never before. This time, he seems to say,
he cannot find a way to forgive us.

At last I persuade him to join the others
finishing the meal, their plastic utensils
working the meat, their low voices broken
by stray whoops of inappropriate laughter.
We sit, though, in a separating silence,
my brother's hand already eroding
his napkin, eyes distant with medication.

If only he were faithful to himself
and took his daily pills ... But what is the point
of such a constancy when the world itself
has so profoundly turned away? As tonight
I will leave him here, leave all of them here,
the psychotics and depressives, my brother,
to lie in their beds and stare at their ceilings,

and I know that for at least this visit
he will not come home, where our parents now sit
in darkness, their faces streaked and damp. And when
we drive him to the airport, an unmarked
police car following as an escort,
he might be a foreign dignitary
bearing developments back to his country ...

For now, though, it is just two brothers, beneath
a glaring bulb. The expression on his face
would ask, Have you gotten what you came for?
And again I have no answer for him.
But there, at the floor of the bed, all around
the room, are crumbs of paper, as if he were
leaving a trail by which he might be found.

- Peter Schmitt