Opinion

The Great Debate

How to recruit more primary care physicians — for the VA and nationwide

By Davoren Chick
June 11, 2014

A patient has her knee examined by Dr. Narang at University of Chicago Medicine Urgent Care Clinic in Chicago

“Can I give you a hug?” a patient recently asked me, just before breaking into tears and wrapping her arms around me in gratitude.

Hugs weren’t on my list of pros and cons when I chose to become a primary care physician, but they sustained me through some tough years. I am devoted to my patients and my profession. But, like many colleagues, I wonder whether I would choose primary care now if I had to choose again.

Primary care physicians have a high risk of burnout. My colleagues continually announce early retirement, conversion to part-time, and changes of profession.

Compounding the problem, too few physicians are entering our field to meet society’s needs. The situation is worse than studies suggest. Some studies count all internal medicine training as “primary care,” even though the majority of medicine trainees will subspecialize.

The result? Access to primary care has been a national problem for years. Recent attention has focused on access for military veterans, but access has been just as bad — if not worse — for many rural and lower socioeconomic populations. Even in otherwise well-served areas, someone seeking a primary care physician may have few to no options, with visit delays lasting months.

The brightest medical students used to dream of becoming master clinical generalists. Fictional television physicians such as Marcus Welby, MD embodied the kindly manner and clinical acumen so many of us emulated. Idealistic and energized, we entered practice and championed patient-centered care.

So what happened? We outgrew the television fantasy. Explosive growth in medical knowledge increased care complexity. Patients with previously untreatable conditions benefited from new, but often expensive therapies. Ageing and increasingly obese patients required more frequent and extensive visits to manage multiple chronic conditions.

Increased attention to underserved populations exposed the fact that excellent care for some could not excuse insufficient care for many. Psychiatric care was appropriately transitioned from hospitals to outpatient settings. Care guidelines promoted high quality care, but also resulted in new documentation requirements. Time and again, primary physicians rose to each challenge.

To match feature DOCTORS-DUMMIES/As care became more complex, the cost of care rose — unsustainably. In response, metrics arose for clinical value. Cost reduction became necessary, but challenged the autonomy and trust that had long been a part of the primary physician-patient relationship.

Seemingly overnight, patients viewed me as a “gatekeeper.” That word is powerful. You don’t hug a gatekeeper.

Administrative work has continued to escalate. Much reflects well-intentioned cost control measures, but it feels like savings are achieved through increasing my unreimbursed tasks. Forms have multiplied for insurance coverage approvals, physical therapy oversight, equipment authorization, and so on.

As administrative tools, electronic medical records are a double-edged sword. They help us track immunizations, avoid allergic reactions, and analyze data. They can facilitate communication, improve patient safety, reduce duplication of care, and ultimately improve care quality.

But few physicians would have envisioned my electronic medical record system: radial buttons, drop down menus, and a constant stream of non-urgent “alerts.” Data entry tasks challenge my eye contact with patients. My electronic “inbox” fills with items requiring review even if I did not generate or request them. More worrisome to me, charts seem data-rich but information-poor — I struggle to find essential clinical information within templated notes that physicians generate by clicking on predefined content rather than describing each patient’s unique presentation.

Primary physicians don’t expect administrative work to disappear and we support reduction of wasteful spending. We simply desire equitable distribution of administrative work and value-based payment. Currently payment disproportionately rewards procedures and high patient volume, while administrative systems disproportionately burden primary care.

So, what can be done?

First, physicians must change current professional culture to foster medical student interest in primary care. Disrespectful language (calling a generalist “just” a primary physician) devalues primary care, and medical students lose interest. In contrast, engaged clinical mentors increase student interest in primary care. Doers inspire learners; we must select primary care educators who actually function as primary clinical providers. We must support and reward generalist educators who mentor the next generation of primary physicians.

Second, we must increase our workforce diversity by engaging and supporting under-represented minorities and people with rural backgrounds. These populations are more likely to consider careers in primary care and to provide care for underserved populations.

Third, we must reform graduate medical education financing so that hospitals share training funds with outpatient venues. We must increase primary care training positions and support education in community-based settings.

Fourth, to recruit and retain primary physicians, we must address the unjust pay differential between longitudinal care specialties and procedural specialties. Surprising no one, studies show that income potential does affect specialty choice for medical students. We cannot expect young physicians to resist the lure of dermatology or subspecialty practice over primary care when the difference in lifetime earnings can amount to millions of dollars.

Finally, we need administrative reform to mitigate burnout. Electronic records and administrative processes must support the physician-patient relationship, not impair it. Software must reflect clinical reasoning. Subspecialists and generalists must share administrative work, each shouldering tasks related to their services. We must also share work in teams of physicians, nurses and other healthcare workers. To reduce physician burnout, we must choose which tasks truly require primary physician review, and delegate other tasks within the care team.

Primary physicians have extraordinary expertise. As an internist, I make initial diagnoses and treatment decisions on everything from minor conditions to life-threatening diseases. I investigate new symptoms and address all my patients’ concerns. I manage chronic illnesses by partnering with each patient. I balance priorities when multiple conditions compete, and I recognize when care should deviate from standard guidelines. When the news is good, we high five and celebrate. When the news is bad, our hugs are genuine.

My devotion to primary care is sincere. I believe that many young physicians can find joy and fulfillment in this extraordinary profession. Let’s do what we can to encourage, support and value them.

PHOTO: Patient Sharon Dawson Coates has her knee examined by Dr. Narang at University of Chicago Medicine Urgent Care Clinic in Chicago, June 28, 2012. REUTERS/Jim Young

First year Northwestern University medical students Abbie Harts (L) and Michelle Gentile (2nd L) listen as Doctor Perry Kamel (C) instruct them how to perform a pelvic exam on rubber dummies during their human anatomy class in Chicago, Illinois March 15, 2007.

Comments
2 comments so far | RSS Comments RSS

Increased income is the way to get more of any worker. All the rest is secondary.

Posted by zotdoc | Report as abusive
 

The solution begins with a return to sanity and eye contact. The EHR primarily benefits the health insurers and their cronies (pharmaceutical companies, medical supplies, etc.). Return the physician, especially primary care, to patient care. Remove the strait jacket by returning the medical record to its original purpose, a short report for the physician for continuity of care with updates. Start a movement of compassion for the physician and remove the medical legal possibilities from the medical record. True, medical reports (lab., radiology, surgical, pathology) facilitate care and should be utilized, but use the system taxpayers have already paid for (VA, Kaiser systems) and make it free for transparency sake. And finally, remove the health insurers from our midst with single-payer healthcare and finally begin cost controls.
Probably $1 trillion is squandered, sequestered and wasted every year with our present system. Every citizen and legal resident could be covered in the U.S. today with lower premiums,no copays, deductibles and charge for medications with this approach. Cost analysis in California in 2005 (Lewin Group Report) when we were looking at single-payer revealed this. And after the first year alone, we would have had a $20 billion surplus if we only had legislators with the political courage to legislate for the public good.
Do we physicians continue down this dark, narrow path where we lose our patient’s confidence completely? We physicians must be part of the solution and take a stand to save our profession and return it to sanity and safety.
Jerome P. Helman, M.D.
Internist and Gastroenterologist
Venice, CA

Posted by gijerry101 | Report as abusive
 

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