We live in a world of juxtaposed ideas and options: big box store versus neighborhood store; bigger and better versus small is beautiful; mach speed versus stop and smell the roses; just the highlights versus focus on the details; the forest versus the trees. These contrasting ideas and choices confront CAP members at every turn as they move forward with maintaining their practices and caring for their patients. More than half of all CAP members are part of small group practices, and with them we firmly believe that good things come in small packages. In alliance with CAP members in larger and hospital-based groups, small practices are a vital part of the healthcare delivery continuum and, as Casalino and his colleagues observed, there are lessons that might be learned from them.
What lessons can be learned from small practices? Dr. Danielle Ofri, a physician at Bellevue Hospital and an associate professor at NYU School of Medicine in New York,notes, “Medicine is unquestionably harder than it was 10 years ago. Many more doctors I know talk about quitting (an option that is not equally available to patients).” Bodenheimer and Sinsky in their travels observed, “Society expects more and more of physicians and practices, particularly in primary care.” Detsky says, “Patients want their health to be better, to be seen in a timely fashion with empathy, and to enjoy a continuous relationship with a high-quality clinician whom they choose.”
The word that occurs frequently and prominently in the literature is “relationship.” In a time of change and uncertainty — and when were we ever not going through change and experiencing uncertainty — it may be that relationships are our most reliable reference points and perhaps even our anchors. Dorr Goold and Lipkin write: “The doctor-patient relationship has been and remains the keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation and support are provided.”
Dorr Goold and Lipkin were writing in 1999, but their observations about compliance, healing, activation and support are borne out by contemporary studies: Casalino and colleagues in 2014, and Liaw and colleagues and Squires and Blumenthal in 2016. Casalino and colleagues’ study concluded that small practice size was associated with fewer preventable hospitalizations due to stronger relationships among physicians, patients, and staff, and improved continuity. Squires and Blumenthal observed that “many patients and physicians deeply value the personal relationships that smaller settings can cultivate.”
However large or small our organizations are, it is the relationships we form and maintain that make small packages full of good things. As physicians care for patients and their families, and work with staff, it becomes ever more clear that “the relationship is part of the treatment program,” as Savitsky observed. Our challenge here at CAP is to support our members through times of change and uncertainty as practices small and large, urban and rural, primary care and specialty care, continue their vital work of building relationships among patients, families, physicians, and staff that will be deeply rewarding to all involved.
Carole Lambert is Vice President, Practice Optimization for CAP. Questions or comments related to this article may be sent to clambert@CAPphysicians.com.