Sunday, March 3, 2013

The goals and business of general practice


In the last week I have been involved in the recruitment of a new nurse to the primary care clinic I’ve been working in. (And I should note that the terms general practice, general medicine, and primary care, are been interchangeably here) I suggested that we ask applicants in the job interview what, in their opinion, are three goals of (private) general practice medicine. This is a question that potentially has dozens of answers! To patients, up to 95% of the time it is about helping them deal with immediate, though generally non-urgent, health problems. The rest of the time it is about preventing ill or worse health. To governments, the goals of general practice medicine are to keep people healthy so that they utilize less government-funded health resources. General practice is meant to keep patients out of hospitals. But what are the goals of primary care medicine if you happen to work in a primary care clinic? I think that if you understand the way the business of general practice, the goals of general practice are fairly straightforward - from a business perspective, because this is an industry just like many others.

How does general practice work? Well, patients require a service so they contact the practice’s administration staff to book this service: a medical review with a doctor. Booking appointments is just one of the tasks of the admin staff, and their tasks are fundamental to the proper and smooth running of the practice as a business and also in optimizing the clinical interaction between the patient and the doctor. The doctor takes the patient’s clinical history and requests investigations and treats their condition, etc. To do this more efficiently and effectively, they often enlist the help of the practice nurse. The nurse has a very important part in the running of the practice too. They are there to advocate for the patient, to help carry out a lot of the preventative activities related to medical practice, they administer medications and immunisations, they perform some of the tests the doctor needs to help clarify the patient’s diagnosis, etc. They do all this in the background so the doctor doesn’t need to do it herself – and in this time the doctor may see another patient or take care of another clinical activity. That’s it. At the end, the patient pays one fee to cover the cost of seeing the doctor, the nurse, and having administration staff assist them.
How General Practice Works

Now, how does the money side of general practice work? There is one source of money coming into the practice: patients. That’s right, the only income-generating activity in general practice occurs in the interaction between the doctor and the patient in that room. For example, talking to the receptionist doesn’t attract a fee (as a patient you could theoretically come in and talk to one all day and she can’t bill you for anything as she hasn’t sold you anything).  
Where the money in General Practice comes from.
What then? Well, the money generated by the doctor’s fees is pooled and is meant to cover the cost of paying the practice’s staff, the building rental fees, insurance costs, medical and non-medical equipment costs, etc. And that exactly is why it is important for practice managers, for administration staff, and for nurses to help doctors see more patients and to see them efficiently and effectively.
Where the money in General Practice goes to.
So what are the business goals of general practice? I believe they are so closely related to the duties of general practice that you could be forgiven for mistaking them. The first priority of (any) medical practice are the patients. Keeping them well, that is giving them what they pay us for (assistance with health problems), is and needs to be the first goal. The second goal is to optimize the interaction between the patient and the doctor; the “service” being sold. It is the task of everyone working alongside the doctor to make sure this happens well, smoothly, and in a time-efficient manner. The third priority is to the community in which we work. This makes sense not just in a humanistic ideal but because general practice, as opposed to other medical specialties, often deals with people who are well and healthy – and who want to remain that way! Healthy patients don’t attend cardiologists, for example, to prevent cardiac disease. No, they would go see the cardiologist once cardiac disease is diagnosed or suspected and they need secondary prevention or treatment. But general practice does see well people for this and many other preventative activities.

It makes so much sense from a business point of view to fulfil our duties in general practice, that is to patients, to the staff, and to our community. Patients that are well-cared for and feel/know that they are being prioritised want to continue using that service. If you optimise the doctor-patient interaction (in business terms: time), you make the business more profitable. And if you cater to the local community, that community gets to know and trust your service and seek it out amongst the other dozens of similar practices around. What is there to lose by fulfilling the duties of our jobs in general practice, really?

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