Someone to watch over me

Abstract

Millions of Americans are without the medical oversight and continuity of care that is provided by primary care doctors. Numerous US physician organizations have called for the development of a “medical home” model of care delivery that links patients to personal primary care physicians. These pleas have been made by, among others, the American College of Physicians, the American Academy of Pediatrics, and the American Academy of Family Physicians. They have been largely unheeded and have not led to changes in the reimbursement and administrative barriers that make primary care unattractive to US doctors. As a result, in many areas of the US the supply of primary care physicians is not adequate to meet demand. A recent Boston Globe article reported that “all, or almost all” of Massachusetts General Hospital's 178 primary care physicians are not taking new patients. “There is no ability to get anyone in except as a favor,” says one doctor (“Few doctors at Boston's teaching hospitals accepting new patients.” Boston Globe, November 12, 2006). Another describes the exodus of US doctors from primary care as “a waterfall, not a trickle.” The failings of the US primary care system detailed in this week's issue of the journal by Bindman and colleagues (doi: 10.1136/bmj.39203.658970.55) thus will come as no surprise to beleaguered US primary care doctors. The study compared the characteristics of primary care practice in the United States, Australia, and New Zealand. The US has the lowest percentage of primary care physicians, the highest percentage of population uninsured for primary care, and the lowest mean number of primary care visits per person per year. The mean annual exposure to primary care physicians in the US was only 29.7 minutes, compared with 55.5 in New Zealand and 83.4 in Australia. The authors conclude that this “severe shortfall of available time in primary care” might be one reason “the US does not have health outcomes that correspond to its overall investment in health care.” Other things also bear more watching. Susan Mayor (doi: 10.1136/bmj.39244.725810.DB) summarizes a recent study showing that survivors of early breast cancer require close monitoring for recurrence beyond the now-standard three to five years after diagnosis. Dhruv Kazi (doi: 10.1136/bmj.39245.502546.BE) reviews the latest drug safety controversy (rosiglitazone) and concludes that more care is needed in postmarketing surveillance, which currently “falls short of the standards the agencies set for themselves.” He endorses recommendations from the Institute of Medicine for a “life cycle” approach to safety monitoring that would guard against a false sense of security after a drug is released. Finally, Ben Goldacre has been watching over the British media and its reluctance to “mention the data” when reporting on dubious medical conditions such as “electromagnetic sensitivity” (doi: 10.1136/bmj.39245.510718.59). He notes the “monastic silence” of disease “lobbyists” and the press when it comes to reporting scientific evidence debunking disease claims, and considers their possible motives, none of them savory. All of this will be depressingly familiar to US readers. “Electromagnetic sensitivity” may not be as popular a disorder on the US side of the Atlantic as it is in Britain, but we have chronic Lyme disease and multiple chemical sensitivity disorder. And on both sides of the pond the apparent collusion of the popular media and disease lobbyists is dismayingly common..