The Front Lines of Primary Care

In a recent post, Health Beat described the policy strategies that must be employed in order to address the primary care crisis in the United States.  This post focuses on the human side of the primary care crunch by highlighting the personal experiences of doctors. Moving from the policy to the personal adds an all-important qualitative element to our understanding of just why American primary care is in such dire straits. 


The Basics

That said, numbers still help set the stage: in 1990, 9 percent of graduating medical students planned to work in primary care/internal medicine; today just 2 percent are choosing primary care. Meanwhile, we know that primary care can help patients avoid expensive, unnecessary medical procedures; obtain regular preventive care; and manage the chronic illnesses that make up between 75 and 80 percent of our $2.3 trillion national health care bill. We can’t afford to run out of PCPs.

The usual reasons cited for the dwindling ranks of PCPs are money and time. Many PCPs make only 1/5 as much as the best-paid specialists. Lower salaries mean that PCPs need to see more patients to have incomes that are comparable to those of their peers. This imperative creates a “hamster wheel” as PCPs frantically cycle through patients who often are suffering from complex, chronic diseases.

No Time to Learn

It’s generally agreed that primary care is unpopular because medical students see the money/time crunch and tell themselves, “no way is that going to be my life.” But the Over My Med Body! blog, which until recently had been maintained by a medical student named Graham, offers a slightly different perspective. According to Graham, students aren’t necessarily mapping out their whole lives when they select a field and apply for residencies—they just want the chance to develop their analytical acumen and grow as doctors. The hamster wheel doesn’t give them that opportunity.

“In subspecialty outpatient clinics, there’s more time to spend with patients,” says Graham. “Visits are usually scheduled as 30 minutes long,” twice as long as the 15-minute standard for primary care visits. The frenetic pace of primary care makes students a hypertension, diabetes, hyperlipidemia, peripheral neuropathy, prior MI [myocardial infarction], stroke, and liver disease (not to mention learning all the drugs and dosages).” Students and fresh-faced doctors simply can’t get their bearings; so they abandon the field. 

“Of course we like the specialties where we have more time to figure out all our patients’ problems,” says Graham. Time lets residents develop their expertise and feel that they can improve as doctors. As the saying goes, you have to walk before you can run; but with primary care, you have no choice but to hit the ground running.

Another downside to the hamster wheel is that it provides little time for doctor-patient interaction. “[W]e got into medicine to help patients, not just cure their disease,” says Graham. “[Medical students] prefer to have the time to get to know our patients as people, not just as the guy with poorly controlled diabetes with hemoglobin A1C’s in the 10-12 range.” In primary care, they don’t get that time.

This is heartbreaking to acknowledge. With its professional emphasis on patient consultation and care coordination, primary care is supposed to be the most patient-centric field of medicine. But in the eyes of med students it lacks the very human element that—in theory—should be at the center of a family doctor’s practice.

“Assembly Line” Medicine

Sadly, many established pros would feel inclined to agree with this assessment. In a 2006 op-ed for the Boston Globe, an ex-PCP in Massachusetts named Annie Brewster describes how primary care ended up being far less personal than she had hoped. Initially, Brewster “chose primary care because [she] love[s] people,” and because she “wanted to take care of the whole person, body and mind.” But after a few years of practicing, Brewster was “drowning in this overwhelmed state,” in which she lost her “ability to take good care of people.”

To keep up with patient visits, Brewster had to “move frantically from exam room to exam room.” She found it “impossible to know all of [her patients] well, to give adequate focus to each person's unique situation, [and] to sift through the piles of paperwork and lab data daily.” At one point, Brewster—who had long aspired to be close with her patients—“walked into an exam room…and introduced [her]self to a patient. ‘We have met before,’” replied the patient, understandably annoyed. Brewster was “horrified and saddened” that she had become so desensitized to her patients. She left primary care and now works as an urgent care physician.

Like Annie Brewster, Theresa Chan had always loved the idea of being a PCP. According to a recent post on her blog, Chan entered primary care because of what she calls “the Dream of Family Practice”—an ideal where “doctors represent the health of families and the community” and stay with patients “from womb to tomb,” performing functions that are “fundamental to people’s well-being.”

But, also like Brewster, Chan saw her “Rockwellian utopia of medicine” fall apart, albeit for slightly different reasons. One potentially frustrating reality of primary care is that it’s more interactive than other types of medicine. As Beverly Woo, a PCP affiliated with Harvard University, noted in a 2006 commentary for the New England Journal of Medicine, the scope of primary care often requires sensitive interactions: “[b]ecause primary care doctors are often the only physicians whom a patient visits, we must identify problems that are frequently difficult to talk about, such as alcohol and drug use, domestic violence, and risky sexual practices,” says Woo. PCPs also have to keep tabs on “how social factors affect patients who have chronic diseases.” Woo notes that “[one patient named] Mr. S. had a relapse of alcoholism after separating from his wife, Ms. R.'s glycated hemoglobin level skyrocketed when her daughter became ill, and Ms. H. had an exacerbation of her colitis when she lost both her job and her housing.” More than any other type of doctor, PCPs have to engage with the lives of their patients, an often touchy endeavor. When people find themselves in tough times, even simple discussions can become volatile and exhausting.

It was this volatility that eventually drove Chan from primary care. Over time, she became fed up with the pushback she constantly received from patients. They “yelled at the front desk staff when they had to wait half an hour” and “cussed out our triage nurses”; patients “stormed out of exam rooms” and threatened “clinic staff for what most reasonable people would consider minor annoyances.” Ultimately, Chan spent “a disturbing amount of time managing people's expectations and making ‘behavioral contracts’ with” unruly patients in order to continue providing care. Being a referee and a disciplinarian “is not what I went into medicine to do,” she says.

While primary care will always maintain a certain amount of unpredictability, Chan’s experience was made much worse by the volume of patients she received. Difficult patients are one thing, but dealing with difficult patients in 15-minute intervals has a cumulative effect: Chan acknowledges that she would sometimes have to cut short visits with reasonable, amicable patients in order to deal with the difficult ones and still maintain her schedule. The sad truth is that the pace of primary care work leaves little wiggle room, meaning that, when complications arise, something has to give—even if it’s good, decent patients who need help.

Ultimately, Chan left primary care and now works as a hospitalist. Like Graham, who felt that primary care wouldn’t allow him room to grow, and Annie Brewster, who lost touch with her patients, Chan came to realize that she wasn’t living up to her aspirations as a doctor. All three had a similar thought when they observed the realities of primary care: this is not why I wanted to become a doctor.


Today, too many PCPs are burning out as they watch their ideals crumble in the face of the day-to-day realities of their practice. But let’s be clear: none of this is to say that there’s no hope for primary care on the whole. In the past, we’ve talked about how to fix the problems, because they are fixable. But do take these stories seriously; they do more to put the state of primary care into perspective than statistics ever could.

In Part 2 of this post, I’ll talk more about the reality of primary care—including its upsides—and how we can create a health care system that nurtures PCPs instead of breaking their spirits.

Comments

[Annie]

Niko, this way of relating the problems via the stories of those involved is compelling.

With the recent days' events of Tom Daschle's Sec HHS choice, Waxman to take over Dingell's committee chairmanship and the biggest and most powerful stakeholders coming together to commit to fundamental and large scale reform, I'm encouraged that significant change will occur.

But, always the Eeyore, I think that as that golden window of opportunity was open to new ideas, that professional nursing is being permanently shut out.

I foresee the death of nursing as a nascent full profession and a return of it to an externally controlled and directed technician occupation.

THe worst part about that, for me, is that nursing is the sole profession charged with assuring patient safety and advocacy throughout all healthcare settings. Its aims dealt with health and helping patients to achieve peaceful deaths.

As it has regressed to a task dominated occupation with untenable working conditions at the direct expense of therapeutic patient relationships (which is a major dissatisfier in primary medical care, too), patient recidivism rates are climbing, preventable mortality and morbidity rates are rising, and costs are increasing.

Nursing is, in my view, the most undervalued resource with the highest ROI. But it has no exposure. It's viewed through the lenses of 1950s stereotype - a mindless, obedient and subservient physician handmaiden, despite the reality of it being entirely difeerent.

The public will never be fully informed because the media doesn't report about it accurately and completely.

Nursing has abrogated its professional autonomy and authority to external non-nursing power brokers: nurses' employers, legislation (as in legislating nursing patient ratios), insurers and physicians.

If nurse experts had ever been integrated as full members of health policy think tanks, invited to politicians' advisory councils, participated in drafting comprehensive health reform, and in working within the profession to take back the usurped professional autonomy and authority, we'd be looking at a different animal in which the nursing shortage didn't loom as a critical system-wide failure.

But they weren't and it looms ever more ominously over a decimated landscape of needless suffering on a massive scale.

I'll continue to watch healthcare reform. But as ever, it will be from the sidelines, excluded from participation.

Separate and unequal.

What I'll never understand is why this country squandered the resources that nurses bring to bear in the way of patient comfort, outcomes, health attainment, satisfaction with care, cost efficacy and patient safety.

[laura]

I only know medicine from the patient's point of view but my persepctive is similar: the primary care doctor is in a mad rush and can't listen. I feel like I have to have the diagnosis myself prepared ahead to save time! On the other hand the surgeon who cut out six inches from my colon had all the time in the world. Which was nice--I'm not objecting to that!

My point is that the only reason I got to the surgeon who cut out my precancerous cells is that I told my primary care doctor that I needed a referral for a colonoscopy because I thought I might have colon cancer.

My primary just thought I was getting old. Which is true...

[Dan]

So, You Want To Be A Doctor…..

In recent times, others have appeared to express concern about the apparent shortage of primary care doctors in particular- both presently and in the future they speculate that the shortage of doctors will continue to exist or progress to even greater shortages of PCPs. Typically, the main reason believed and speculated by others for this decline of this unique health care profession specialty that historically has been the apex of our health care system is lack of pay of PCPs, which is the second lowest medical specialty next to pediatrics, it has been reported.

Once viewed as a vocation with great esteem and respect, a desire to be a doctor may not be desired as a career path by many. While this profession requires admirable commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of their lifespan, the complications associated with practicing medicine in many situations presently may be why others are not seeking this profession. Such complications may include:

Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction of health care systems for financial security, primarily, as the cost involved with running a medical practice is quite expensive. These regional and nationally created healthcare systems are typically composed of numerous hospitals and clinics in a certain geographical area.

The often monopolizing nature of the business models of these health care systems of increasing growth is not necessarily a desired method to practice medicine as a primary care physician in particular. Often, these often large health care systems employ their authoritarian stance by limiting as well as dictating how their health care providers practice medicine. This is further aggravated by possibly unreasonable expectations of their health care system employer- such as mandating that doctors they employ to see as many patients as they can in a full day. There actually have been cases of physicians being fired by a health care system for lack of patient volume that they have in their practice.

Conversely, there are instances where health care providers receive financial rewards for seeing more patients a day than what is determined as average visits by the health care organization, it is believed. Such requirements likely and potentially affect the clinical judgment that is determined by physicians employed in this manner, as well as the quality of care the doctors provide their patients. Medicine should not be viewed as a profession of speed and volume.

Another reason may be due to the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently due to such factors involved with practicing medicine presently. In regards to malpractice insurance for physicians, many doctors find this type of insurance in need of reform for a variety of reasons. These premiums become more costly for doctors as it relates to their chosen specialty as a health care provider. For example, the malpractice insurance premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. With malpractice cases that are initiated, those who initiate a lawsuit against a doctor win about 25 percent of the time, with monetary awards averaging nearly a half a million dollars for these who sue doctors and win. Around 95 percent of these cases are settled out of court, it has been reported.

In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine. This basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. They are compelled to order perhaps unnecessary diagnostic testing to rule out medical conditions or disease states that likely such patients do not have. This practice of defensive medicine may be encouraged by the health care systems that employ such doctors as well. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients after they see them for treatment. So one could argue that over-treatment is as common as under-treatment of patients in today’s health care system.

Such excess and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility. This may be why this medical profession may no longer be viewed as distinct from other vocations as it once was, or one that has been desired more than apparently it is now. Some claim that doctors are somewhat understandably more cynical and demoralized than they have been in the past, which may be replacing the pride and responsibility that they historically have had with what they believed were their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.

Further complicating and vexing to these restrictions is the usual financial state of the individual physician after their training, as many have debt that may exceed over 100 thousand dollars. This is much more debt than what doctors experienced after their training only a few decades ago, it has been said.
Conversely, there are obviously some others who believe that doctors in the U.S. are over-paid and greedy. In spite of how they are judged, physicians are likely not absent of financial concerns as with many other people, yet the situation with doctors may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations, one could argue. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a doctor, as others are more dependent on their judgment for the restoration of their health.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable, it is also unfortunate for the health of the public in the future, and the perception normally associated with the medical profession which could deter ideal medical care for others.

There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall.

The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.
Again, and for perhaps Primary Care Physicians in particular, the medical profession clearly needed by others to some degree appears to be absent as a desired path of today’s careerist.

The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.

“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero

Dan Abshear (ex-military medic and physician assistant for nearly 20 years)

Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.