Wednesday, November 19, 2008

The worst of times for primary care?

Woody Allen once said, "More than any other time in history, mankind is at a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let's pray we have the wisdom to choose correctly."

Replace mankind with primary care and you get a good idea of how primary care doctors view their future. At least, this is the conclusion one would draw from a survey of 12,000 (mostly primary care) physicians released by the Physicians' Foundation:

- 78% believe there is a shortage of primary care doctors in the United States today.
- 49% said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.
- 60% would not recommend medicine as a career to young people.

Other surveys show less pessimism. The Center for Studying Health System Change found that 83.6% of primary care physicians surveyed in 2004-2005 said they were somewhat or very satisfied with their careers, only marginally less than the 84.7% of specialists who said the same. (A new CSHSC survey is in the field, and it will be interesting to see if primary care physicians have grown more dissatisfied).

Still, the Physicians' Foundation survey is a wake up call. Think of the impact on access if half of the primary care physicians in the U.S. reduce the number of patients they see or stop practicing.

It may be a mistake, though, to suggest that primary care is all about gloom and doom. I don't discount the very real concerns, but do we really want to tell young doctors and medical students that primary care is a dying field?

Today, the American College of Physicians releases a new white paper to make the case for primary care. The report doesn't mince any words about the dire circumstances surrounding primary care, but makes the positive case that primary care will improve outcomes and lower the costs of care.

Will policymakers listen? Last week, Senator Baucus aptly called primary care the "keystone" of a high performing health care system and proposed to increase Medicare payment to primary care doctors. During the campaign, President-elect Obama proposed "to expand funding - including loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions" for primary care.

Today may be the worst of times for primary care, but the best of times could still be ahead.

I say this not because I am hopelessly optimistic (I work in Washington, after all), but because I believe policymakers can be shown that primary care offers the best value in U.S. health care. Policies to support primary care will follow suit. Isn't this a better message to give medical students and young doctors than (only) telling them how bad things are?

Today's questions: Do you believe that this is the worst of times for primary care? Do you believe that the best of times for primary care could still be ahead?


Jay Larson MD said...

The Physicians' Foundation study included several pages of comments from primary care physicians. The comments reflect a very disheartened group of physicians. Primary care has several rewards personally and to some degree professionally, but the barriers to providing good healthcare is getting near impossible to get around. Increased non-clinical paper work for primary care physicians is one of 3 major reasons medical students decision to choose a different career than general internal medicine. Over 95% of the physicians in the survey noted increased non-clinical paper work over the past 3 years.

Is it the worst of times for primary care? Probably.

Could the best of time for primary care be in the future? Only time will tell. If the government and insurance companies proceed forward without dramatic action to support primary care... the worst of times are still ahead.

DrJHO7 said...

Not once during my residency did I think to myself, "oh boy, i want to be a primary care provider."
I was very interested, though, in practicing general internal medicine for all of the right reasons: a broad range of clinical problems to keep things challenging and interesting, the opportunity to build ongoing relationships with patients and become an important part of their lives as their personal physician/care coordinator and translator of things medical, to function in a consultative role in and out of the hospital, to pass on important clinical skills to students and residents in a teaching setting.
Yes, part of the job description was "primary care", but that is performed in the context of being an internist.
When we became "PCP's", a designation that was basically dumped on us by the hmo/insurance company boom of the 90's, we lost our identities as physicians. We became providers - and these PCP's were at the bottom of the hill - in terms of income, status/respect within the medical community, and in how we were viewed by the insurance companies, even by some patients.
To paraphrase a quote from Forrest Gump, "It rolls downhill", this became a reality for PCP's with regard to referrals, preauthorizations of drugs and radiology studies, CMN's, care plans, letters of medical necessity, FMLA forms, scooter store forms, DMV forms, routine pre-op H&P forms on healthy patients who were to have surgery, signing orders for home care agencies to justify their care and existence, work notes, disability forms, nursing home forms, and any annoying complaint a patient had that their specialist didn't want to deal with. PCP's were positioned at the bottom of the hill, and It rolled down.
I guess you could say that things are pretty bad in primary care right now, but that depends on how you look at it.
The good things are: business is good. There are plenty of patients. Job security is good. We can straight-arm some of the lower paying insurers because we really don't have to be part of their captive network to attract patients. Information technology is maturing to the point where it may actually be worth it for us to invest in it and use it to improve the care we provide, and improve the organization of our offices and our lives. In the near future (2-3 years), the primary care physician shortage is going to worsen to the point that access to care for alot of patients will be palpably/visibly reduced, enough to capture the attention of even our elected officials at the State and National levels. Policy changes and legislation will be enacted that provide financial support and momentum for PCMH models of care that will bring some money in the front door of these practices, along with financial incentives for students such as structured loan forgiveness programs for those who WANT to commit to careers whose job descriptions include primary care.
Such reforms and resurrection will not occur without the direct involvement and leadership of the stakeholders - US - in the process.
Whining will accomplish nothing and will fall on unsympathetic ears.
I think we should chuck the notion of primary care provider. When we step up and be Pediatricians, Family Physicians and Internists again, we can take back what is rightfully ours: the physician-patient relationship. This always has, and always will be the source of satisfaction in a physician's medical career.

Doctor Tofuhead said...

I'm a primary care doc and have always wanted to be. I'm still new to it- 4 years out of residency. I don't think it's the worst of times for this profession, but I think it's on a downhill slide and the worst of times are a few years away. However, I have to admit that I still find primary care to be fulfilling in the ways that I expected: I have great, long-term relationships with my patients, a broad base of knowledge, and the opportunity to learn more every day. Sure, I don't make a ton of money and I'll be finished with my school loan payments at age 67. But I never wanted to be rich; I wanted to be intellectually challenged. Primary care can still deliver that, but changes are needed soon to prevent burnout, as provider panels become stretched to the limit. Every week as my panel gets larger, I have less time to talk to my patients and less time to keep up with the literature. And that's a real shame.

PCP said...


A more apt question is could you in good faith tell your son or daughter to enter into a primary care physician career at this time.

I know I for one cannot do that. We have heard a bunch of pandering about the value of primary care doctors from the politicians. Seldom is any of it followed by action. There may very well be a few who actually understand this issue, however the collective result of all of our efforts have been next to negligible if we are honest about it. All this while the structural framework of physician manpower is crumbling at an alarming rate, and to the extent that even with immediate changes we will end up with a severe problem as Mass. is now finding out.

I am aware of the value I provide, some of my patients are as well, ACPs paper does a good job encapsulating the case in a good way for interested parties, but as you well know DC is full of such papers, some speak the truth and some are spin. Those in a position to change the situation however, ie joe public, the payers, politicians, the press etc don't appear to be particularly interested in anything more than lip service.

Some of the proposals being put forth are quite simply near sighted, none of them for instance categorically designate the primary care doctor as the captain of the primary care team. When I read about the views of Tom Daschle, the anticipated health secretary, his view of healthcare appears more centrally controlled treatment algorithms with care delivered by NPs and PAs. That sadly is the solution he sees.
I've heard repeatedly about the need for more autonomy and independence for mid level providers, almost always through legislation rather than education. How many of us really beleive that is the real issue here? How do such red herrings come to define this issue? We hear about more consolidation of Insurers, we hear about more funding for CHCs/FQHCs which are inherently inefficient and do nothing about the access problems for tertiary care, we hear about enhanced support for Medicare advantage while our issues are given lip service, the list is virtually endless.
Noone has ever asked the question why is it appropriate for a Nurse practitioner to be reimbursed at the same rate by Medicare for a level 4 visit as a General Internist Physician. Surely that is a distortion? Until such difficult questions are addressed by policy makers, no substantial change can occur. I am not as naive as to feel that these are easy politically, or that we will not stir up a hornets nest if such thorny issues are brought up, but at the core of the career choices of our younger colleagues are such things.
Our younger colleagues take refuge in areas such as Hospitalist medicine and other such careers precisely because of such unjust treatments.

None of this makes me optimistic about the future. I would love to feel more optimistic, but it is more important to be a realist. The evidence of recent years shows ho reason for optimism. I'll whole heartedly acknowledge however it is not for a lack of effort from the ACP.

Dan said...

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. Less than 20 percent of medical school graduates go for primary care as a specialty. 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. Some anticipate a shortage of 60 thousand primary care doctors now and in the future. Most primary care doctors today would not recommend their specialty, or their profession, possibly.
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.