Andrew Bazemore | Visionary Leader in US Family Medicine

Andrew Bazemore: I came into medicine with a liberal arts background and an undergraduate training in history and political science.  Instead of working in a place like the U.S State Department towards medicine, it came through work in the early 1990s with a former Minister of Health in Bolivia who unbeknownst to me, was practicing something that Sydney and Emily Kark had called ‘Community Oriented Primary Care’.  And really showing how you could take a -by the people for the people- approach to Primary Health Care, emerging public health community medicine stakeholder and grassroots engagement, and the primary clinical care that we know together, and take care of about 28 Villages , predominantly Quechua speaking and some of the most Indigent populations in a country that was the poorest in South America, and achieve major healthcare achievements.

Family Medicine was the home that I found at the University of North Carolina that most resembled what I’d known.  I eventually added a Public Health degree, some work in travel and international global medicine, and 25-30 years of going back mostly to Honduras.  I often learn as much about how you can do the most with the least in Primary Health Care as I ever have in the States.

Eventually, after working in settings like community health centers and academics, I was drawn to something that I had initially resisted- research evaluation and even policy- because it just didn’t feel like I could go to work every day in the clinical setting that I was in, frankly, a somewhat broken and fragmented health system, without trying to work upstream, and work on the bigger problems.

DMacA: Before we go into policy aspect, you’ve said something that’s very interesting and contrasts with many people’s views of medicine in the US. You described your experience in South America, almost a socialized medicine, but that’s a huge contrast to U.S Healthcare.

AB: One thing we’ve never done terribly well is to collectively declare something as simple as Primary Care to be basic or essential.  I should say that, in this case, health care is a fundamental right, a social good. We have built a system around capitalist economy and a market approach and left higher level collective thinking out of many of our frontline implementation and systems, and so we spend an awful lot on health care.  But as VCU colleague Steve Woolf and the committee that wrote a mid-2010s report called “Shorter lives poorer health” note, we probably spend twice the developed nation average on health care per capita and we lag in almost every major statistic from life expectancy to healthy life years, to quality adjusted, or disability less than life years, to how we perform across various chronic diseases and, even increasingly, maternal infant child mortality which is rising again. We’re actually one of only three countries on the planet that have had two consecutive periods of reversal in life expectancy over the last decade.  And the other two are a failed state, Venezuela, and one that’s been embroiled in civil war for the last decade, Yemen.

DMacA: If you think about primary care and getting more doctors into primary care, that’s another challenge.  How do we create that workforce who are prepared to take that risk of working in Primary Care?

AB: It’s a great question. If you look at the U.S Primary Care Workforce it is, by most estimations, a team sport in this day and age, has been forever.  But, we’ve not always performed very well as teams or trained in teaming.  And we’ve also created, over decades, an increasing gap between the highest and lowest paid disciplines.  And among the lowest paid disciplines across fields are the primary care disciplines.  So whether you’re a physician, and you’re comparing the general pediatricians, general internists, and family physicians that make up the core, not all, but the core of our U.S primary care physician workforce, or a Nurse Practitioner, or a Physician’s Assistant, or an Allied Health Professional, the best way to have the same amount of training and achieve less lifetime return on investment or annual compensation, is to enter primary care.  We also need to change the composition to look more like our population- so, more diversity and inclusion.  We need to figure out how to take those who are trained- like family physicians across a really wide scope – and allow them to work to the top of their scope and that’s true, not just for Family Physicians, that’s true for any of our trainees.  And we do have to figure out a persistent maldistribution problem.

DMacA: How can we change the policy at the top.

We need to look at National priorities so stated, which include the 1978 Declaration of Almaty,  where the nations of the world got together and said  Primary Care is the central feature of an effective Health System. Participation, universal access, affordability, all mentioned as components.  We have gathered about every 10 years and again Primary Care is at the center.  We just haven’t gotten there yet.  That would be the first priority.  And, in 2019, the nations of the world including the U.S Under Secretary or the Assistant Secretary for Health, all gathered together and said back at Astana back in Kazakhstan, that we reaffirm the principles of that original Declaration of Almaty;  we put Primary Care at the center of our health system and specifically, we had an Under Secretary state that Primary Health Care, which as I mentioned, is that merger of primary care clinical teams with community organizations and public health enterprises to affect population health, the Under Secretary said that this is what we believe in, we affirm this. 

We had a report that came out in 2021 from our National Academies of Science, Engineering and Medicine on high quality primary care, and it wasn’t just a rehashing of its importance.  If anything, it looked back to another report, the 1996 Institute of Medicine report on primary care and said- what didn’t we do to achieve the goals and realise the recommendations of that report. It created a road map and categories or five different groups of recommendations.  One that was particularly notable, and notable right now, was the absence across a series of U.S health and human services of agencies and bureaus, of a Primary Care Central Council or feature or place where one person or a group of people at the secretary’s level like a Ministry of Health level was waking up every day thinking about-  how do I advance primary health care,  this integrative notion. 

Right now we’re having conversations about birthing just such a council, about having a permanent group at that National Academies of Medicine, the place that advises Presidents and Congress, on the direction that we should take in our health system and its various features that is dedicated to Primary Care. Implementing that is a critical first step.

From there, getting back to your questions about workforce and payment and training,  and how we take public expenditures and use them to advance these various features,  suddenly primary care has a voice and a central voice.  The real critical element beyond birthing is giving it some authority to help direct the health systems resources.

DMacA:  In terms of policy and policy changes, one of the factors that drive policy change are data and, when you have office-based practice which is very much the case in the U.S, how do you manage the data sets, how do you acquire the data sets?

AB: Excellent questions.  In an age of what we’ve labelled ‘big data’ it’s also notable that too many of our big data sets are derived from hospital and acute care and owned by hospital systems.  It is no fault of the hospital systems, it just means you’re probably not getting a full range of views and information emerging from the largest and most widely distributed component of your delivery system, Primary Care. One thing that we’ve tried to birth at the American Board of Family medicine is a registry, PRIME, to speak to the information that comes from caring for populations in small and solo practice in rural and underserved settings. Getting information from PRIME and from another group in Oregon, which is trying to capture info from the 14 000 safety net clinics the federally qualified Health Centers. What’s coming out of their electronic health records, who’s curating this?  Oregon is at least taking a very laudable crack at that and turning it into meaningful research and research that informs policy.  We have been very deliberate in our own group in trying to make the most out of, not only claims data -our U.S Medicare and Medicaid, but also how we can integrate that and intersect what we learn from claims with what we learned from registries like the PRIME registry and also a national survey.  Go in and ask for any family physician in our board, and we see this across some of the other U.S boards,  an ability to tap into what’s happening in their practice; demographic, economic and,  even questions about burnout in U.S Family Physicians,  because we have a unique opportunity, every time they sign up to take their board certification or renew any of their board activities, to ask them these questions again.  It gives us a veritable census on a serial rotating basis for U.S Family Physicians.  You can only make so much sense out of large secondary data so, building on your qualitative resources, not just surveys but doing good informant and focus group information gathering, has been the way that we round out what we think is a fairly robust series of data sets and sources of information on primary care.

In the US, this is a place that we’ve actually done fairly well.  I’ve travelled enough to see that many other countries have not been able to build as much of a robust network of information, particularly around primary care, but we still have a long way to go.  Primary Care is always the laggard.  It shows up when we’re doing artificial intelligence machine learning work. We’re trying to really understand how you can take large information and bring it back to clinical practice in ways that new technologies and methods allow.

DMacA:  We’ve talked about policy, and we’ve talked about data, and there’s a third pillar of primary care.  That comes down to the personal relationship, of which you’ve written about, and that’s a big challenge for all of us in primary care. The two areas that you’ve written about are continuity of care, and the second is narrowing the focus with generalists narrowing their breadth of practice.  Where do you see those challenges?

AB: Specific to continuity and comprehensiveness, since you mentioned those two, we have seen over the past two decades in particular in the United States factors such as limiting work hours as a good thing for our physicians who were probably working too long and probably into spaces that weren’t entirely safe.

We’ve watched a continued reductionism in the kind of work that we do: Primary Care clinicians becoming hospitalists, or laborists, or pure outpatient specialists, begin to fragment what we historically benefited from – a continuous relationship with patients.  It’s a bygone time where one single GP or family physician was able to see all of their patients and all of the possible settings of care but, there still needs to be some way to maintain at least team continuity, and individual continuity using technology to our advantage.  We know from Starfield and other evidence that longitudinality, that relationship, that administrative record-keeping, that we’re all able to hold in the primary care setting, grows trust, allows patients who are facing what they think are difficult decisions, whether it’s about to get a vaccine or a certain lab test or not to get studies that they don’t need, that they have a single source of information that they trust over time.  While I do think that there is a personal and individual continuity that’s valuable in this day and age, it has to include the team.  The comprehensiveness we have documented declines in both settings of practice so, working in hospitals or nursing homes or in emergency rooms and acute facilities in family medicine for years, doing less care of children, less care of certain types of diseases, as we get more and more complex in the range of things that we’re supposed to have excellent knowledge in. We haven’t taken full advantage of technology, artificial intelligence, decision support tools, ways that a family physician does not have to singularly track all things about all aspects of knowledge in clinical Primary Care. We haven’t taken full advantage of our teams and so we’re beginning to lose this breadth and we’re narrowing in a space that doesn’t benefit the patient or the populations we serve. It’s pretty clear that those who have higher levels of comprehensiveness tend to have lower overall costs of care and tend to have more trust. The patients who come to those clinicians tend to value information across a wider range and seek less undesirable or low value care,  tend to have less utilization of hospitals and ERs. So, finding a way through teams and technology to retain the comprehensiveness of general practice, family medicine, primary care, is really crucial if we’re going to bend our cost curve and maintain high value care for whole populations.

DMacA: There’s something I must ask you because you have worked with one of the legends of general practice in the UK, in the Outer Hebrides.  Tell me about that experience.

AB: I’m so glad you brought it up.  It was another deeply, a seminal and deeply shaping experience for me to work with Dr John MacLeod, a third generation GP who worked in Lochmaddy on the island of North Uist in the outermost Hebrides of Scotland. and to see what true continuity, comprehensiveness, coordination, and first contact look like.  That meant anything from John driving the ambulance, sometimes an hour south to Benbecula where we hoped the tide was out so we could get a patient with gallstones or not necessarily an acute MI but possibly unstable angina off to Glasgow.  Or reaching the end of a day, where we travelled all over the island with most of the work being outside of the surgery to take care of respite patients, and then put on our rubbers got in the boat, went fishing, pulled out mackerel, haddock, crustaceans, and then my job as the medical student was to make sure that all of the older community members, who were no longer able to fish and who John worried if they were getting enough protein and good fish in their diets, got a knock on the door for me as the medical student dropping off whatever we caught that night.  And then inviting me back to his house where he and his wife would break open a good bottle of Burgundy or Bordeaux and eat whatever was left. So, seeing what it looked like to do full spectrum general practice in a community setting, as an icon.

His longitudinality was three generations deep.  He was using records that went back to his grandfather on some folks, to do a truly unique form of what general practice can mean for populations. It was a fabulous experience.

DMacA: Finally let me ask you about the future. When we talk the future, it seems a bit of a contradiction to mention personal care and artificial intelligence in the same sentence.  Is there a role for artificial intelligence in good quality primary care?

AB: Absolutely.  We’ve seen new technologies and what we’ve labelled disruptive Innovations, as somehow anathema to old-fashioned comprehensive coordinated continuous primary care. Optimally they would enhance that.  Artificial intelligence, machine learning, is a space that the ABFM is investing in.  We think primary care should be at the table and not on the table, and should be part of designing fair and equitable algorithms that use data sets representative of real US populations and all their diversity, to answer questions that affect us on the front line and not be further fragmented, not be cherry picking single elements of care away to apps or online services at the expense of broad spectrum comprehensive continuous care.  We think that if you use design thinking in proper engineering, and you create the kind of economic nudges that behavioral economics points us towards, you can use technology to enhance all of those 4Cs features and imagine a much brighter future for primary care.

 I’m actually optimistic as a generalist that my many deficiencies in an ever-expanding world of medical knowledge can be better covered if we design the right algorithms and create the right training environments where we’re incorporating new tools and technology, same as we have for centuries, to allow the primary care clinicians to do more to broaden the scope.  But we do have to start with the right technologic design and we have to incorporate it in training.

DMacA: You said something that’s really very interesting and that’s the importance of Family Medicine being ‘at the table’ and not ‘on the table’ and U.S Family Medicine is very lucky to have you ‘at the table’.

It’s been great talking to you. Thank you very much indeed.