Patient-Centered Primary Care: Getting From Good to Great

Book Title: Patient-Centered Primary Care: Getting From Good to Great

Author: Alexander Blount

Publication Information: Cham, Switzerland, Springer Nature Switzerland AG, 2019, 243 pp., $99.99, hardcover

Asking Alexander “Sandy” Blount to write a book about patient-centered primary is akin to asking Michael Jordan to reflect on basketball. There is perhaps no one better to reflect on their experience and history on the ground. But it may also be true that we then look ahead, we desire something more of a critique and meta-analysis, and in our system of health care there is certainly plenty of room to critique everything, starting with the book subtitle “Getting From Good to Great.” In our system, I am neither sure that we are in fact currently good, nor that we are in a position to be great, but Blount (and Jose Bayona) who coined the term “integrated primary care” in 1994 certainly has the depth and breadth to at least comment on this, as well as to assert and challenge readers.

Blount is a psychologist, a pioneer, and a leader of behavioral science integration in primary care behavioral health. His pedagogic ways have promoted reducing barriers and improving behavioral medicine responsiveness and usefulness in the primary care setting. His primary care behavioral medicine (PCBM) course developed at UMass Medical School helped highlight the use of standardized tools and assessments, and taking a practical approach to what behavioral medicine can offer primary care. I still have his attitudinal PCBM doorknob-hanging message of “Yes, please interrupt, I’m here for PCBM.” Being open to interruption seems a job requirement in all of medicine, but in primary care especially, where the ability to have fractured attention and recovery is a job requirement. During his online courses Blount famously demonstrated this value in action, often interrupting his copresenters to interject something from his experience.

Heath Myers, LCSW: As a new professional in what I have perceived to be a shockingly dysfunctional health care system, I am ambivalent about this text. Without a doubt, I found the repository of theories, interventions, empirical evidence, and professional lexicon highly educational, especially in terms of deepening my working knowledge of how behavioral health functions with a patient-centered model. Yet for a model so focused on the patient experience, the patient experience somehow felt like the most distant aspect of the book. Terminology like “multiply-disadvantaged patients” brought to mind George Carlin’s critique of how relabeling “shell shock” as posttraumatic stress disorder drained the color and meaning from content the label held. The more I read on the more the disconnected I felt from the patient(s), and particularly their emotional experience.

I find framing the efforts to establish the patient-center primary care model as moving “from good to great” highly problematic. In Blount’s book, I hear the voice of a spirited, passionate, technocratic reformer where I deeply desire a broader, more revolutionary voice. Blount appears to accept, almost without questioning, the supposition that revenue generation and cost savings should be one of the primary, if not the primary factor that shapes who gets what care and when. Questions of policy as it pertains to questions such as access or the impact hedge funds shaping care are arguably beyond the scope of a clinical textbook, but I fail to see how. To me, these questions are central to the provision of clinical care. Without more fundamentally confronting current presuppositions about how care is provided, why, and to what end, the suggestion these reforms can move the state of primary care from “good to great” seems to overemphasize how much humanity a patient-centered medical home can bring into the revenue-driven health care system.

Patrick McFarlane, LCSW, MSW, MA: My overall impression, as someone who has been around for a long time, is that the book isn’t stinging enough. It doesn’t challenge the field enough, but maybe that’s what happens when you’re a psychologist in medicine; you may question your standing to really be an effective critic. I’d recommend the book to anyone starting in primary care as it offers a primer on the thinking about primary care, the history of primary care, and models for team-based care. And it’s a tour de force delineating the difference between care delivery and partnership with the patient that empowers. Blount’s mnemonic TEAM stands for Transparent, Empowering, Activating, and Mutuality, and is the center of his argument of how to get “from good to great.” These are important concepts, but leave me thinking that concepts and incrementalism are unsatisfying in the face of a difficult system of care that is only becoming more corporatized with the advent of minute clinics, Amazon Health, etc.

This is meant as a textbook, and its strengths are its history and context of these efforts in primary care, and its concepts for incremental improvement. The chapter on growing and retaining an expert team is a great discussion of the factors that organizational leadership should consider. However, in a nation that ranks middling to low in measures of health, health equity, health outcomes, and cost, and where we fail many people (both clinicians and patients), this kind of book can seem like an apology where radical change is necessary, and disruption is replaced with efforts at online care, public health initiatives, and large corporate challenges to a system that is not good, and thus may not be great.

Overall, the text provides an overview of efforts at patient-centered primary care, which is a valuable read for administrators and clinicians who regularly think about such things. However, it may leave some readers wondering if it provides anything close to the radical reforms necessary to achieve significant gains in health, health outcomes, and patient centeredness in primary care.