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OCR for page 198
Thoughts on Community
Oriented Primary Care
David E. Rogers
During the intense and productive 2-day conference, discussion focused on
the emergence of community oriented primary care (COPC) as a concept.
The definition of COPC was refined, and its applications to a variety of
settings in both developed and developing nations were described. Atten-
tion was also given to the roles various health professionals must play in
developing effective systems of community oriented care, as well as to how
physicians might be educated and trained to be more effective in furthering
such programs.
Summarizing what has transpired during the conference is an unenviable
task. It cannot be done adequately in one short commentary, but I will try.
I have done so by playing a somewhat unusual role. I have tried to pretend
that I am an observer from another planet, increasingly convinced of the
wisdom of the concept, impressed by the almost religious fervor of its
advocates, but puzzled by its apparent lack of contagiousness among many
health professions. What are some of the roadblocks that impede progress
and what, if any, are some ways of surmounting or circumventing these
roadblocks? Answers to these questions might lead the way to a better
agenda for the coming decade.
To put first things first, the evidence seems to me overwhelming that
organizing care on a thoughtful multidisciplinary community-focused basis
makes good sense. Community oriented care programs seem to me to be
the rational way to deliver the fruits of biomedical and behavioral scientific
knowledge effectively to those who need them. No thoughtful person can
argue with the logic of this approach. How can one believe that improve-
198
OCR for page 199
[noughts on COPE
199
meets in health can occur without thorough epidemiologic knowledge of
health problems that exist in a community or a society? How can preventive,
rehabilitative, or curative services be fully effective if one knows little or
nothing about the cultural, educational, economic, or psychological factors
that can create barriers to care, isolate groups, and increase personal health
risks for community inhabitants? No one in modern society can believe
that a physician working in isolation, and simply treating those who come
tO him or her on a one-on-one basis can produce a healthy society.
If this be the case, why can I as an "outsider" ask the following questions:
. Why hasn't community oriented primary care swept like a tidal wave
over the world and why have not all in medicine embraced the concept as
an idea whose time has come?
. Why are most of our major medical schools continuing to turn out
large numbers of specialists despite enormous evidence that what is needed
is more generalists to provide community care services?
. Why have schools of public health, in the past such proud leaders of
medicine and responsible for so many of the advances that we now enjoy,
become relatively quiet institutions often ignored by the medical profession
and the larger society?
. Why do departments of community medicine tend tO be relatively
weak forces in their academic institutions and why do they seem to have
so little impact on medical education in general?
. Why are medical grand rounds in American medical schools—a teach-
ing exercise that offers a reasonable window on what is and is not believed
important by faculty—progressively abandoning patient oriented presen-
tations, ignoring psychosocial and epidemiologic factors, and becoming largely
lectures on recent advances in biomedical science?
. Why have so many developing countries with newly realized resources
first opted to build very expensive tertiary care centers—often ignoring
basic community services as they attempt to develop a stronger health
care system?
. Why have the mountains of literature on COPC written over the last
decade had so little impact on how medicine is organized or taught or
practiced in this country?
Although deliberately overstated, these and other unpleasant and difficult
questions must be addressed. The overwhelming logic of developing COPC
systems to create or maintain healthy people is Inarguable. There must be
some compelling nonhealth reasons for their failure to capture the hearts
and minds of health professionals, or those who come for care, or the
OCR for page 200
200
PART I: THEORETICAL ISSUES
communities in which they live. There are such nonhealth reasons, and
they bear summarizing.
First is the reward system as it is now structured in medicine. Current
financing mechanisms do not encourage community oriented approaches
to care, or personal physician/patient interactions of any depth. Our reim-
bursement system sends strong signals to physicians tO subspecialize, to
maintain high-technology practices, and to share responsibilities for patient
care with as few others as possible. Practitioners of community medicine
do not a cardiologist's income make. Use of high technologies results in
far more income than using one's head or hands for the same time spent.
This needs changing, and I think it can be done.
Second, which perhaps is a part of the first, is the prestige factor. Hospitals
and those within them who use high technologies are the reapers of glamour
and respect in our society. Both physicians and the public regard tertiary
care institutions as the space centers where the astronauts pilot spaceships.
Community physicians, on the other hand, particularly generalists, are viewed
as those who drive the buses and subway trains. While they are of enormous
importance in making the everyday world work, few medals are awarded
for the task or for making it efficient, or affordable, or on time. Departments
of community medicine are caught in the same bind. At present they are
not where the apparent action is. In most of our major academic health
centers, departments of community medicine are peripheral. It is rare that
they have a well-organized defined population group that they are tending;
residents and students seldom see the results of their efforts in human
terms; and the major visible glories go to the departments of medicine,
pediatrics, and surgery in the tertiary care hospitals, where most of the
training of young health professionals is carried out.
Training physicians to be the captain of the ship in isolation from other
health professions is a third factor that contributes to the problem for the
community-based efforts. For physicians to be comfortable in organized
communitywide programs that care for groups of people, they must enjoy
cooperatively shared responsibilities. In times past, in a less educated society
it may have made sense tO put all of the responsibility and all the authority
for health affairs in the hands of only one professional, but it makes less
sense today. The activities in any modern intensive care unit, the most
tertiary of tertiary care, are convincing evidence that the physician is not
enough. This is even more true if one examines the needs of those with
chronic disease who consume the bulk of medical care resources in the
developed world today. But medical education has not kept pace with this
reality. Most doctors do not feel comfortable in group endeavors or in
working with nonphysicians in nonhierarchical relationships, and the land-
OCR for page 201
Thoughts on COPC
201
scape is littered with failed programs because of this fundamental problem
of"physician mind set."
There are two other basic human problems that have become manifest.
They affect both those who would organize, develop, and run COPC pro-
grams and those who would benefit from them. One has tO do with the
appropriate focus of community oriented programs of illness and disease
prevention. Although these programs may be well accepted by us for our
children or for others, they often create unease and sometimes resentment
when focused on me and thee directly. The human animal is wonderfully
contrary.
Notwithstanding our being against sin, most of us secretly admit that we
either lack the interest or the character to change our life-style if that
requires giving up pleasurable habits that are deleterious to our health. This
is particularly true when such a change requires sacrifice now for health
gains years later. Most of the programs that have vigorously promoted health
education, risk prevention, and the like have been disappointing in their
results. It is quite easy to educate adults about the hazards of certain kinds
of misbehavior. It is incredibly difficult tO change them. It is far easier to
resent those who point out the error of our ways. We often try tO kill the
messenger—or at least belittle him. Those who preach righteousness may
be respected, but they are not warmly received by most people in modern
society. In short, the preventive element of community oriented programs
tends not to be very popular.
The other human problem is the lack of appeal of aggregate vital statistics
for most people. Such statistics are the basic tools of community oriented
programs, but they lack immediacy and emotional impact. It has been said
that vital statistics are the story of human lives with the tears washed away.
Obviously this is the case, but the erasure of the human element the
translation of infant mortality or life expectancy into numbers on a page
loosens the grasp on public attention.
A community or a nation will willingly and instantly spend millions to
rescue a trapped coal miner or the survivors of a downed plane or a sinking
ship, but it is much harder to get that same community or nation to spend
similar sums to reduce infant mortality rates.
Walsh McDermott liked tO emphasize that, tO be effective, community
oriented programs had tO attract individuals who have or can develop what
he eloquently termed "statistical compassion." By this he meant that people
had to gain real personal satisfaction from knowing they had put in place
services that would improve the health and welfare of individuals they would
never see or know personally. This takes both training and imagination. As
with olives or oysters, a taste for vital statistics is an acquired one.
OCR for page 202
202
PART I: THEORETICAL ISSUES
What can be done to overcome these obstacles to wider and swifter
dissemination of community oriented primary care programs? A number
of suggestions have emerged.
First, efforts to restructure the reward system for health professionals
must be continued. If community oriented systems of care are to flourish,
there will have to be changes in the way physicians are reimbursed for their
services. Although favorable reimbursement for high-technology services
has served society well by encouraging technical medical programs, it seems
time to swing the pendulum back toward the center. Making financial
incentives neutral with regard to the use of technology would, I believe,
encourage more physicians to consider how their time and effort might
have the greatest effectiveness in reducing human suffering. I use the term
"neutral" with purpose. I am not suggesting that neutralization of rewards
for use of technology be used as a hidden strategy to reduce physician
income. That would neither materially affect the costs of medical care nor
promote the change in doctor mind set that I would hope could be en-
couraged. But allowing physicians to choose the kind of practice style that
seems most appealing without financial penalties would, I believe, promote
the community oriented cause.
Second, there should be continued exploration of ways in which young
people who have well-developed social skills and interests can better com-
pete with those who have high science skills for entry into medical school.
I do not wish to be misinterpreted here. We need well-trained, scientifically
oriented physicians in the medical profession, not merely social do-gooders.
But broader interests in human welfare and the ability to work democrat-
ically with others do characterize some of our best physicians, and we need
more of them.
The third suggestion both relates to and bears on the first two. The skills
and the prestige of those who would organize, manage, and work in com-
munity oriented care programs should continue to be upgraded. Here the
private sector can be, and I believe has been, helpful. Examples of such
private efforts include the Robert Wood Johnson Clinical Scholars, Nurse
Faculty Fellows in Primary Care, Health Policy Fellows, and Family Practice
Faculty Programs; the Kaiser Family Foundation and the Robert Wood
Johnson Foundation support of primary care physician training programs;
the Milbank support of epidemiologic training for established academic
internists and the Kellogg support of departments of community medicine.
All of these programs have attracted top-flight people. These young leaders
are beginning to achieve positions of influence and are adding distinction
and more hard science to broader fields of medicine of which community
.. . .
meOlclne IS a part.
OCR for page 203
Thoughts on COPC
203
Fourth, constructive use should be made of what are clearly more difficult
times. For good or bad, we are now entering a period in which our methods
for delivering health and medical care are under intense scrutiny. The
overriding view of one and all is that medical care costs too much. The
philosophical importance of the COPC concept during a period of dimin-
ishing resources is not tO be underestimated. It can provide the opportunity
tO streamline the system. COPC can assist by helping communities think
more carefully about how best to organize care, promote disease prevention,
and encourage more discriminating use of costly medical technologies. The
increasing number of physicians means that in the United States access tO
medical care services is not the problem that it was a decade ago. This,
coupled with the enormous successes in controlling the major microbial
diseases of the past and the steady reduction in deaths due to a wide variety
of formerly lethal diseases, now affords the Western world the luxury of
expanding its areas of concern beyond simply preserving or extending life.
Rich and poor alike now have a commonality in the problems of illness
that trouble them. We now can focus more of our efforts on helping
individuals to use their full capacities in daily living.
This leads to my last point and to what, in my judgment, is the most
powerful contribution those who would advance community oriented pri-
mary care services could make during the present decade. Stated simply,
develop a more vibrant and compelling data base with which tO make a
case for COPC and train a small cadre of people tO do it well.
The kinds of statistics currently used tO track the progress of the personal
health care system do not monitor with any sensitivity the changes that are
reflected by most of what is going on in COPC. Death rates as well as
other morbidity data and other sets of current statistics simply do not
measure the impact of what health professionals do, or the potential ca-
pabilities of community oriented health care systems.
Let me use a simple example tO expand the point. Thanks tO modern
medicine many individuals with serious arthritis can now be helped to
remain sufficiently pain free and mobile and to lead independent productive
lives. It is this kind of activity that is the major thrust of community oriented
programs. But nowhere on the scorecard does this important gift to suffering
people or the health professional's role in making this freedom possible
come to light. Thus, it sems to me overwhelmingly evident that those who
believe in the value of community oriented care must replace the current
gross statistics with new and sensitive yardsticks that more accurately reflect
what such programs can do to restore people to fuller functioning.
Again, using arthritis as an illustration of the kind of scorecard I would
like to see developed, it represents a group of diseases that rarely kill but
OCR for page 204
204
PART I: THEORETICAL ISSUES
has a fairly high incidence. In the United States, more than 18 million are
afflicted. Almost 14 million of them indicate they are bothered some or a
great deal by their disease. But of most significance, more than 3 million
of these arthritics, or about 18 percent, cannot function satisfactorily because
. . . . ~ . .
Ot pain or imitation ot activity.
Today a great deal of biomedical research and most of the efforts in
major academic centers are appropriately aimed at unraveling the causes
of these joint problems with the hope of eliminating them. This is clearly
the goal of the future and it deserves major support. But, until that happy
day, what doctors want to be able to do better today is tO further reduce
the disability rate. They wish to better identify those most at risk of crippling
and concentrate their efforts on them. They would like to drop the crippling
from 18 percent tO 4 percent. They would like to know whether some
interventions do better at less cost. Society would like tO know which health
professionals working in what settings are most effective in reducing dis-
ability rates. The value of COPC needs to be articulated and documented
in problem areas such as this. If this kind of information could be devel-
oped and it can and is being done by community oriented health profes-
sionals another kind of box score could be recorded.
This seems to be the kind of scorecard against which the personal health
care system should be measured. I would be quite surprised if COPC
programs could not deliver the data with which to develop that scorecard.
Who else can better record the percentage of patients in a community with
a particular disease that are really at hazard of developing functional limi-
tations because of it? Who is better equipped to tell us how these individuals
can best be identified? Who can better collect the data which will show
what interventions can best prevent limitations? Clearly it is this kind of
informational background against which the effectiveness of medical care
should be measured. Such a data base would have enormous payoffs and
would enable physicians, other health professionals, and those who seek
care to judge how our personal health care system really works best.
Some are now beginning to try to address these kinds of issues, but I
believe the process should be pursued with even greater intensity. Doctors
are a hard-nosed, pragmatic group. They do not respond to preaching or
exhortation or anecdote. But when given evidence that a particular treat-
ment or way of practice will improve the lot of their patients, they are
generally quick to respond.
These then are the areas that I believe deserve attention if community
oriented concepts of care are to be more swiftly and widely accepted.
Developing a better scientific data base to show what community-responsive
practice can do tO improve human welfare is a most important first step.
On the national and international scene, medicine must get a clearer idea
OCR for page 205
Thoz~ghts on COPC
205
about what the ingredients—both human and technical—assembled in what
way can most effectively help people to maintain maximum human function,
prevent its breakdown, and/or swiftly restore it. There also need to be ways
of taking these statistics and putting them in terms that have real emotional
meaning for physicians and other health professionals responsible for one-
on-one care, as well as\ for the average man on the street.
I am convinced that physicians and decision makers armed with such
information can make wiser determinations about how best to allocate
precious health and medical care resources. I believe community oriented
approaches to the delivery of care will be the winners. My economist
colleagues might put other more financially oriented approaches first, but
my physician background moves me to put this suggestion as number one,
while agreeing that both avenues should be pursued simultaneously.
We have made great strides in the past decade. We have more doctors,
and more are opting for primary care careers. Many more attractive resi-
dency slots are available to them. There are more faculty who espouse
community oriented approaches to care, there is more time in the curric-
ulum for such concepts, and epidemiology has become an increasingly
recognized and respected tool of medical science.
To close on a philosophical note, community oriented health profes-
sionals are up against yet one other problem not of their making. It is a
cultural belief that runs deep in our American heritage. I am coming slowly
to the view that in the United States we may ask more of or place more
responsibilities for health in the hands of individuals than perhaps we should.
It is rarely realized that this is not the case in primitive societies or in nations
that have more nationally or paternalistically oriented health care systems.
Americans deeply distrust and dislike paternalism or ground rules of any
kind that threaten encroachment of individual rights. In our culture we are
slow to seek out those unable to handle personal responsibilities for their
health effectively and are often inclined to feel that they are reaping their
just deserts when they get into trouble. Thus we are often inclined tO view
with suspicion any who would appear to meddle with troubled families or
their children even when it appears in the best interest of those families to
do so.
But in a nation so large, so diverse, and so complex, if we are to deal
with the health and medical problems of the poor or the culturally isolated
or alienated who live in our communities, locally designed community
oriented health care programs can perhaps find ways that are less intrusive
than any centralized public system might be. In doing so, they can be a
potential healing force with effects extending well beyond the delivery of
health care.
OCR for page 206
Representative terms from entire chapter:
health professionals
