Fix the Foundation

Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

Many of the regular readers of this column will recall that my wife’s family has had a small wooden house on a lake in central New Hampshire that’s been in the family for about 120 years.

It’s a beautiful little house, yellow and orange, perched out over the lake, with a great porch for watching sunsets.

Unfortunately, as you can imagine (and I’m sure you know if you have one of these in your family), old houses need a lot of upkeep.

For instance, many years ago we discovered that a lot of the insulation in the house was made of old mats of horsehair, definitely a fire hazard.

And a lot of the original old electrical wiring was still there, buried in the walls and dangling from the ceiling in the basement, mostly not up to code when we found it, most of which needed to be replaced, also a fire hazard.

Recently, the family has started to do some additional renovation and restoration, and, as you can imagine, every time we look around we find new things that need to be fixed, spruced up, torn down, and rebuilt all over again.

As part of a recent inspection, we were told that parts of the foundation needed to be shored up.

Take a look at this photo:

While that stone has served the house for well over 100 years, this certainly looks like a disaster waiting to happen — one big rainfall and it will slip out of place, and we can’t help but agree with the assessors that this should be a priority to fix.

On a related note, at a recent hospital-wide meeting of our ambulatory network, we learned about a program that was being ramped up to provide more data analysts for our community health workers program. Several analysts were being hired — despite what we had been told was an across-the-board hiring freeze — to start looking at data on the impact of these community health workers for outcomes on our patients’ health.

Population health initiatives are being updated and refined to help address healthcare inequities and spot the negative impacts of social determinants of health, to better focus resources on individuals and communities in need.

Our hospital also has several large and diverse innovation teams that are working on developing sophisticated technology and tools such as artificial intelligence (AI) to probe the data within our electronic health record and help advance the science of healthcare. There are so many places where we’re doing innovative things, rethinking how we do stuff, using data and reports to help spot trends and reveal inequities, to make sure everybody gets the best care they can.

Don’t get me wrong. I’m all for innovation, for looking for a better way — I even run an annual innovations program in primary care. Thinking outside the box for better ways to do things is what this column is all about. Data need to be analyzed, registries need to be built and used to improve the health of populations, and AI holds promise to improve the burden of patient portal messages, note writing, and more.

But as I see all of these things happening, I can’t help but think that we need to fix the foundation. You’ve heard me say it before: primary care is the foundation of any healthcare system. Having a functional and efficient (and not burned out) cadre of primary care providers is the key, I think, to a highly functioning healthcare system with the best shot at taking the best care of everybody. We need a solid workforce of fully supported doctors and other members of the care team who have all that they need to take care of their patients.

Over and over, I’ve written about how people keep coming up with new ways to try and get our phones answered; to try to delegate our referral processing, faxing, scanning, and scheduling; and over and over again people keep trying new things and not listening to those that are affected most: the providers and the patients.

How many times do we have to say, “Just give us more live human beings who know our practice, know our patients, know the rules of how our scheduling works, know us, and work within our electronic health record system, and we’ll be fine”?

If they have to be off-site to save the finance people money — if that’s a better business plan — then let them sit somewhere else. Don’t have rotating groups of people sitting in our offices performing randomly assigned tasks that change every day. Instead, give us our own specialized small team that knows our patients and knows how we do things. Having a strong relationship between the staff and the doctors makes all the difference in the world. It makes everyone feel like they belong and makes things more efficient. There is less back and forth, and less opportunity for people to say “not my job.”

To attract and retain primary care physicians, to encourage them to pick this incredible career that we all chose because of our desire to take care of people, we need to build a work environment locally that works for all of us — the doctors, the nurses, the staff, and our patients.

Listen to us. We’re here, showing up to work every day, on a shaky foundation that’s trying to hold up a crumbling healthcare system. Ignore all this, and us, at your peril.

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