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Does a Medical Home Still Truly Exist?

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Not much is new about an emerging concept in medical care — the “medical home.”

There was a time when a single physician or a team of doctors cared for a patient regardless of the situation or setting — from routine checkups in a doctor’s office to acute care in a hospital. But as medicine has become more specialized, and the dollar — not the doctor — dictates care, the relationship between the patient and physician has been fragmented.

The “medical home” model seeks to reforge that relationship through patient-centered care that is coordinated, accessible, and open to improvement.

But does a medical home truly exist today? That question was the subject of a dialogue recently between two Texas physicians: Retired obstetrician-gynecologist Robert Frischer, MD, and internist Sue Bornstein, MD.

Dr. Frischer questioned whether the medical home is still a reality, while Dr. Bornstein demonstrated how the model can work.

Their thoughts are published below.

If you want to learn more about ways to enhance the care you deliver, plan to attend the upcoming Texas Primary Care and Health Home Summit. The Texas Medical Association is a founding sponsor of the sixth-annual summit, which will be held April 5-6 at the Renaissance Hotel at the Arboretum in Austin. 

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Robert Frischer, MD:

As a retired physician I really have to wonder what a "medical home" is. 

It is a concept that does not really exist anymore, as far as I can tell. 

You see your primary care physician for your entire life. But if you get sick and are in the hospital, you are no longer under the care of the doctor that knows you (he/she doesn't go to the hospital). Instead, you see a hospitalist on one day, a different one on the next day, you have a million lab and x-ray procedures done based on symptoms without hands on by a physician. 

I have been called for "vaginal bleeding" for women with hemorrhagic cystitis. I have been called for pelvic masses as large as a basketball easily palpated by abdominal exam, but only picked up after a CT scan because no abdominal exam was done.

Once upon a time general practitioners (GPs) and family practitioners (FPs) followed their patients in the hospital. 

That is when we had a medical home. That no longer exists. So what is the concept of a medical home now? As long as you are not sick and hospitalized you have a "home," but it is not there when you need it most. Maybe it exists in really small towns where there are only GPs and FPs, and they are the only hospital staff, but it is not this way in most hospitals.

Maybe Texas Medicine will do a survey and see how many hospitals have GPs and FPs on staff. If GPs and FPs are still delivering babies, you probably still have a medical home. The downside with that is that you have GPs and FPs sometimes over their heads doing obstetrics. But at least you have a doctor that knows you.

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Sue Bornstein, MD:

Dr. Frischer,

Your post sums up the feelings many doctors and their patients have about our current medical system: That it is fragmented, inefficient, and at times, bewildering. 

I recall how my own mother, the wife and mother of physicians, was greeted by the hospitalist who assumed her care on one of her admissions. She was a frail 80-year-old woman, and the concept of a hospitalist was foreign to her. When he said to her, “Hi, I’m Dr. S., your physician,” she replied: “The hell you are!” 

This is not a knock on hospitalists who, like all physicians, do the best they can to care for their patients every day. It simply points out the complexity of the system. 

As medical science and technology have advanced, it’s difficult for any physician, no matter how hard-working and dedicated he or she is, to keep up with all the latest treatments. Combined with the pressure to get hospitalized patients discharged as quickly as possible, and also to “check the boxes” for quality measure, it’s increasingly difficult for the office-based primary care doc to do both inpatient and outpatient medicine.

Your question about what is a medical home is a good one. In my mind, it’s a place where you, your medical and social histories, and family dynamics are known by the doctors and their team. If you must be referred to a specialist, the team helps arrange that and follows up on the results. You are reminded to have screening exams like mammograms and colonoscopies on time. The physician and his/her team may not be directly involved in your hospital care, but they are informed on a daily basis of your status, and when you’re discharged, the treatment plan is shared with your medical home.

You need look no further to find a true medical home than the practice of our TMA President-Elect, Douglas Curran, MD. Dr. Curran is a family physician in Athens who not only delivers babies, but does C-sections and other abdominal surgeries. He takes care of multiple generations of families and is beloved and respected by all. He is a partner in a large family medicine practice and still delights in teaching residents and students, as well as his new colleagues. Dr. Curran works long hours, but is still filled with the joy of caring for his patients after 30 years in practice. 

So there is hope — medical homes do exist!


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