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Building Confidence and Trust in Primary Care (11:31)

Early in Patrick Courneya’s 25-year career as a family physician in a small clinic, he experienced a difficult day, disappointed in himself for not finding the “magic formula” to help one patient with high blood pressure and another with diabetes. Faced with his next patient, he felt determined to apply all his training to that patient’s circumstances and come up with a better outcome.

The next patient was new, a pregnant woman with a chronic disease that complicated her pregnancy and increased the risk of that pregnancy having a bad outcome. “I came at that with enthusiasm. I dove into it. I asked her questions. I came up with a remarkable plan for her care, and I left that room feeling good about myself. But as I walked down the hall to the next patient, my heart began to sink,” says Courneya.

“I realized I that I had applied all of my training to her circumstance in a way that made sense to me, a man at a different stage in life, with a different set of circumstances, and a different day-to-day reality,” he recalls. “I applied my training but failed to let the patient educate me about what was important to her.”

“Being able to understand that difference is a foundation that builds the confidence that any primary care system needs, any primary care provider needs to create sustained relationships [and] the confidence that our patients need in us in order to have the impact that we can have.”

Courneya, who currently serves as Executive Vice President and Chief Medical Officer for Kaiser Permanente’s National Health Plan and Hospitals Quality, reminds the audience of the patient-clinician relationship.

“If we create amazing systems, learning systems, ones that can tackle these amazing problems, but we fail to understand the impact of that relationship at that level, supported by systems, supported by technology, connected across regions, we will build a system that misses the mark,” he says.

“Our patients need to have confidence that the local providers and services are solutions to their specific health needs,” Courneya adds. He’s seen the need to understand both systems and individual interactions — and how these are connected — as a family practitioner at the one-to-one level and at Kaiser Permanente, a health system stretching across eight regions of the United States and responsible for 12.5 million members.

“If you don’t actively earn the confidence of those individuals, families, and communities, you will scale the targets that you’re not going to be able to make,” he says.

When Courneya started his career, it was in the face of competition: working in a small clinic in an environment of large clinics with great reputations. “I knew that every day, every patient who walked out of my clinic could make a choice to go to a different place the next day,” he recalls. “So we were focused on being able to create the relationships, being able to create the confidence, and create the sense that the patient was going to get everything they needed from us.” When the clinic couldn’t provide that, they would connect patients with high-quality specialty care.

Americans tend to turn to primary care to solve many problems, including access to quality care and affordability across all ages. This is a growing burden for primary care and can undermine trust in it, also making the effort to drive that trust difficult to deliver.

“A high-functioning and well-used primary care system depends on well-trained, well-supported, and broadly distributed primary care infrastructure and professionals who have the trust of the communities they’re serving,” says Courneya. “Being able to drive that trust is critically important.”

Workforce shortages are pressuring the U.S. health care system, particularly in primary care. The burden of obligations is having a poor impact on career satisfaction and creating concerns about whether young professionals will want to enter the field.

With the American Academy of Medical Colleges projecting that the U.S. will see a shortage of  between 21,100 and 55,200 primary care physicians by 2032, with a total shortage between 46,900 and 121,900 for all physicians, and a Physicians Foundation 2018 survey finding that 78% of physicians experience burnout at some point in their career, creating a sustainably appealing environment is difficult but critical.

Scopes of practice are changing; having a variety of health care professionals able to independently provide primary care — whether nurse, nurse practitioner, family physician, pediatrician, or internist — is a major aspect of this change.

Early in his career, as the quality movement took hold in the United States, Courneya and his colleagues learned that despite their pride in delivering excellent care, there is remarkable variation and room for improvement in public transparency about the measures used to drive higher performance.

Building trust in primary care, having a well-supported, well-connected network of primary and specialty care workers meaningfully integrated into the patient experience and the health care system, and building new tools and technologies to improve care are all crucial. Also crucial? Accountability — being measured and embracing measurement as an opportunity to improve, along with the courage to be transparent about it so that the rest of the community can understand how well your system is performing and what they should expect, how high-performing health care systems are making a difference in the lives of patients.

Courneya mentions a commission in California that put forth some recommendations for the health care workforce of the future: increase the opportunity for all Californians to consider health care careers, aligning and expanding education and training to achieve that at scale; strengthen the capacity, retention, and effectiveness of those health care workers across their careers; and ensure those professionals are connected to a support network wherever they happen to be, whether urban or rural.

“When we connect with patients, when we gain their confidence, we can do remarkable things,” says Courneya. “When we don’t, nothing that we do will help us to achieve what we hope to achieve.”

The United States, China, or any other country facing these challenges must take concrete steps to establish meaningful connections that are based in respect and value and address provider supply, training, and tools that drive uniform outcomes, less variation, higher quality, and outcomes focused on what’s important to patients. That’s the next evolution of health care.

Courneya’s patient, the pregnant woman with chronic disease complications, gave him a second chance. Two weeks after her first appointment, she saw him again. Courneya dove into her circumstances to better understand where she was coming from, and together they crafted a much better plan to help her enjoy a safe pregnancy and delivery a healthy baby.

Several months later, Courneya helped deliver the patient’s son. Over the next 20 years, partly built off that foundation, he cared for her parents during their end of life, delivered more of her children and provided care for her family, and even delivered her granddaughter.

“That long, sustained relationship gave me the opportunity as a primary care professional to be there for them when I might be able to add the greatest value,” Courneya says. “That long, sustained relationship — built on confidence, focused on their needs — is critical for any primary care system. Primary care systems that are built to scale need to take that into consideration, both the excellent training that you get from your system of education and the incredible learning that you get as your patients educate you about what’s really important.”

From the NEJM Catalyst event China’s Changing Health Care: Global Lessons at Scale, held at Jiahui Health in Shanghai, April 25, 2019.

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