Thursday, September 6, 2012

Primary Care vs. Complementary Care

Naturopathic medicine is a work in progress. I’m not saying that it’s in need of significant improvement, or that it’s lagging in some way, but rather that it’s a profession undergoing evolution. I’ve written in the past about how the terminology of naturopathic medicine has reflected the shifting focus of the profession. The latest, and most recent shift, has been a move from strictly complementary or alternative care to primary care – NDs, who used to be doctors of last resort when all else had failed, are now emerging as the entry point into the medical system, the doctor who keeps you well and prevents illness.

That the nation is facing a shortage of primary care providers is not news. More and more medical students are electing to go into specialties rather than primary care, leading to a significant lack of primary care providers. This shortfall, which was in place before the passage of the Affordable Care Act (ACA), will probably become worse as 30 million previously uninsured Americans will enter the insurance market.

Many groups are scrambling to fill this shortfall. Physician’s Assistants (PAs) have been working to fill the void, and the expanding role of Nurse Practitioners (NPs) has been partly motivated by the need to get primary care providers in the field. There have even been efforts to design 3-year MD programs (a year shorter than traditional medical school) with a strict focus on primary care. In addition, of course, there have been efforts to woo medical students back to the practice of primary care, which can be a hard sell to newly minted students with $250,000 in student loans to pay off.

Naturopathic physicians have also been entering the fray, and practice as primary care providers in a number of states. In Washington state, NDs are licensed as PCPs, and can be designated as such on a variety of insurance plans. Vermont and Oregon have both passed recent legislation that provides for NDs to head medical homes, organizations that serve as one-stop-shops for primary care. Other states include language in licensing laws that specifically designates NDs as primary care providers.

This all makes me excited because of the potential that NDs offer the healthcare system.

While different people will have differing opinions on the ACA, we can all agree that we need to save money in order to maintain our healthcare system and serve the American people. A lot of wrangling has gone on about cutting reimbursement to doctors, trying to save money on pharmaceuticals, and a variety of other cost-cutting measures, but I don’t think nearly enough time is spend discussing the importance of preventing people from getting sick in the first place. While not all disease is preventable, a significant portion is; just a few months ago, I blogged about a study which suggested that 40% of cancer cases were due to lifestyle factors and therefore preventable.

In the  20th century, we’ve managed to stem the tide of infectious diseases, which used to be the main emphasis of healthcare, but have seen grow up in their place a large number of chronic, lifestyle-related diseases. This is exactly the type of disease that naturopathic physicians are trained to prevent and manage. While MDs get a precious few hours of training in nutrition and lifestyle medicine (exercise, stress management, etc.), NDs get this from day one, and it’s drilled home in every class an ND takes. At the same time, unlike a nutritionist, an ND knows how to diagnose and treat disease, integrating the diagnosis with changes to the patient’s diet and lifestyle.

A very interesting study came out this summer on the topic of primary care and naturopathic medicine. The Puget Sound Health Alliance is an organization that tracks healthcare results in western Washington state in order to provide information to consumers. Every year, the PSHA publishes a Community Checkup, which tracks the performance of healthcare institutions (both clinics and hospitals) in meeting healthcare goals in areas such as prevention, management of certain conditions, and patient experience. The survey covers everything from small clinics to high volume institutions, and includes high profile institutions such as Virginia Mason, the University of Washington, and Swedish Medical Group. While the Bastyr Center for Natural Health (the teaching clinic of Bastyr University) is a smaller clinic and, like many smaller clinics, didn’t service enough patients to be ranked for outcomes measures, it hit the top of the rankings for patient satisfaction, coming in first place for timeliness of care and quality of doctor-patient communication, and in the top three for customer service and overall provider rating. This is an important verification of quality from a well-known third party that naturopathic primary care offers great promise in modern healthcare.

This study highlights two essential features of primary care that NDs excel at. The first is that, in primary care, the role of the physician is partly to ‘do’ science, but primarily to communicate science, connecting lab values and physical exam findings with the personal experience of the patient. That providers at the Bastyr Center ranked so highly in the study indicates that the school is providing excellent training in this regard. The second is that, in primary care, it is crucially important that the patient feel cared for. It’s right there in the name primary care, and yet this is often lost in the modern medical experience. The Bastyr Center’s excellent performance in this study again indicates that NDs are excellent healthcare providers.

Other research will be necessary to bring naturopathic medicine fully to the forefront of primary care, but it’s clear to me that as the nation moves from a disease-care model to a wellness-promoting model, naturopathic physicians will have a vital role to play in keeping our nation healthy and happy, while saving us money.