Monday, April 14, 2014

Lack of Listening is the Core Problem in American Health Care

The Crisis in Primary Care – Part 4
There is and will be a need for many more primary care physicians (PCPs).Why? There is a shortage now and it will be exacerbated in the coming years for at least four reasons. The population is growing, the population is aging and there will be more individuals with health care coverage as a result of the Affordable Care Act (“Obamacare”). I believe that the need will be much greater than the estimate of 52,000 in 2025 as proposed recently in the Annals of Family Medicine. The authors did not address this fourth and particularly important reason driving a need for more PCPs.  If PCPs actually cared for only a reasonable number of patients, perhaps 500 to 1000 (depending on demographics) rather than today’s common 2500+,  such that they no longer were seeing 24-25 or more patients per day in their offices, then the need for more PCPs would be much greater. With fewer patients seen per day, the PCP can then spend the time needed to listen, to prevent, to coordinate and to think – four key activities that they often are not able to do effectively today. This drives a need for substantially more PCPs.
The need is not to graduate more total medical students but to make primary care desirable as a medical professional career. This means overcoming the current non-sustainable business model so that graduates once again will select primary care.
Here is an example of the value of a primary care physician being able to take the time needed to thoroughly listen to a patient and assess the situation. The PCP saw a lady one day that he had known for many years. She was always very enthusiastic and very articulate. One day she came in for a routine visit. The PCP noticed that her speech patterns were slightly different than he remembered from the past. No one who did not know her well nor anyone who had only a brief conversation would have recognized her speech as changed. She was unaware and felt fine. The changes were subtle but they were clearly changed in his mind. The rest of the history was unremarkable. He did a neurologic exam which was also unremarkable. But he was certain that something was amiss. So he ordered an MRI of her brain. Her insurer refused because she had no specific indications with an otherwise normal history and examination. He had to call multiple times and explain his rationale; finally the insurer relented. The MRI showed a primary brain lymphoma – treatable, probably curable. 
The message is simple. The PCP knew his patient well and because he had the benefit of an extended visit time he was able to notice the subtle changes in her speech pattern. His skill combined with a long history with his patient and adequate time made all the difference and probably saved her life. 

Compare that experience to the following story sent me recently.  

“My mother's "real world" story is mostly about a cardiologist but touches on the very problem you describe about PCPs in a brief but pointed way.  

“I took my mother to the cardiologist this week. He spent a good amount of time with her, mostly listening, trying to figure out her medical issue. Once he thought he'd hit upon what was causing the problem and the solution (which happily, did not involve a drug or surgery but behavior modification), he said he'd call her internist who she has been seeing for many many years to tell him about the discussion. My mother waved her hand dismissively and said, "He doesn't know me." The cardiologist looked surprised and a little confused but I understood. My mother was saying that her internist had not spent time listening to her and getting to know her unique situation like this cardiologist had done. 

“My usually non-compliant and defiant mother called me the morning after her appointment to report she had done what he recommended and would continue to do so. His unhurried gentle questioning, sympathetic listening and obvious desire to figure out how to help her is what made my mother trust him. I felt that my mother had actually consulted with a physician - a healer.” 

There is both a good and a not so good side to this story. The good is obviously that the cardiologist listened to her and then developed a plan of action – with her and her daughter - that she could accept and follow. The not so good or even most unfortunate is that she felt her PCP that she had visited for many years didn’t really know her – because he did not listen.  

When doctors do not have enough time to really listen the result is that they do not listen. A study from 1984 of primary care physicians observed throughout patient visits revealed that the doctor interrupted the patient within 18 seconds on average. Relating to this article, Koven commented on KevinMD “In only 17 (23%) of the 74 visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement.”  This is not only remarkable but a sad commentary on the short visit and the lack of attention by physicians to actually listening to the patient.
This lack of listening is the core care problem in American healthcare today. It is prevalent, pervasive and getting worse, not better. It is the inadequate income per patient (by whatever payment system – fee for service, capitation, etc. -- is used) that is driving the lack of listening. Today the PCP sees too many patients for too little time each. Until the payment system is corrected and, in return, doctors get back to listening, healthcare will not be true care and certainly not healing. Call this a future combination of shared rights and responsibilities – the doctor earns a decent income in return for offering superior care to a reasonable number of patients. This would be a good balance all around. And although primary care would cost more, the total cost of care would come way down. 

My next post in this series will address the “paradox” inherent in today’s American medicine.

Monday, April 7, 2014

Why Is There A Critical Shortage of Primary Care Physicians?

Primary care physicians (PCPs) are becoming extinct.  It’s true. Not many medical students choose primary care as their career path. Older PCPs are retiring early. Many others are closing their practices or seeking employment at the local hospital. And there has always been a shortage of primary care physicians in rural and urban poor areas. Today only 30% of all physicians practice primary care (compared to about 70% in most other developed countries and about 70% in the United States fifty years ago) and this percentage is shrinking at a steady rate.  

This my third post in this continuing series  

Estimates in the Annals of Family Medicine indicate that America, which today has about 210,000 primary care physicians in active practice, will need an additional 52,000 PCPs by 2025. Good luck. This is based on growth of the population (requiring 33,000 added PCPs), the aging of the population (10,000) and the added number of individuals that will have health insurance as a result of the Affordable Care Act (8000). The number needed almost undoubtedly is substantially higher. And if you accept my premise to be detailed in a later post that a primary care physician (or nurse practitioner or physician assistant) should be caring for only about 500-1000 individuals rather than the current typical 2,500+, then the need is truly much, much greater.  

About 25,000 new graduates enter medical practice each year. This represents an increase of about 3% per year while the general population has been growing about 1% per year. Today there are about 29 physicians for every 10,000 population although they are not necessarily distributed evenly across all population areas or groups.
With these numbers one could argue that there is no shortage of doctors. Indeed with the opening of new medical schools and many others increasing class sizes, there should be another 3000 added to the graduating class each year rising to 5000 by the end of the decade. But most graduates enter specialty care rather than primary care training driving the ratio of PCPs to specialists of 30%-70% ever wider. Adding further to the specialist roles (except those with known shortages like general surgery) will only add to health care costs rather than increase quality.
There is good data to support the notion that a primary care-based delivery system increases quality of care and decreases costs compared to our current specialist-based delivery system.
Critical to how many PCPs are trained are two key factors. One is how many trainee (residency) slots are available to train primary care physicians. Medicare pays hospitals to train medical school graduates during their residency. Currently, Medicare pays teaching hospitals $9.5 billion each year to subsidize the training of the next generation of physicians with residency programs that range from three to seven or even more years after medical school graduation. Medicare has kept these “slots” it will cover flat since 1997 and has given no indication of raising this as of yet. But even more importantly are the absolute numbers of PCP vs. specialist slots available. There are simply many many more specialist slots available. Medical centers want to train specialists. They represent assistance to the faculty or staff physicians and they bring an aura of quality to the hospital. No good professor and chief of, say, neurosurgery at an academic hospital would not want to have his or her own training program. It is a matter of pride. Absent a training program, the best will not chose to work for that medical center and will choose to practice elsewhere. This is a serious conundrum for the medical center that needs the specialty program to drive more revenue. And Medicare has been willing to pay for these specialty training programs over the years while not increasing funding for primary care training.
There is a recent study covering 2006-2008 residency training and Medicare payments. Lin, commenting on the article on KevinMD, noted by separating out those 20 hospitals that trained the most and the 20 that trained the least PCPs, respectively, among all teaching hospitals in the USA, “the top primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates of their hospitals (41%) and received $292.1 million in total Medicare graduate medical education (GME) payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates from their hospitals (6.3%) and received $842.4 million.”  In other words, the hospitals that got the most money trained a larger proportion of specialists; perfectly logical if that is where the money is. But this makes little sense in an era of serious primary care physician shortages that will certainly worsen in coming years.
The other problem is that primary care is not seen as a desirable career path today. There are multiple reasons. Primary care physicians earn about one half of what a specialist earns. Specialists are generally seen to have a higher level of prestige in the community – “I was sent to Dr Jones, the surgeon.” Most medical school graduates have large debt loads so earning more means paying it off sooner. And with a large debt, it is harder and scarier to take out a loan to start a practice that brings in fewer dollars. But the primary reason is that medical students realize that PCPs are in a non-sustainable business model, one in which they must see far too many patients per day, accept unpleasant burdens with insurers, be on call many hours and yet not be able to offer  what they know would be better care. They see it as a no win situation and so avoid primary care even if that might otherwise be their preference.
Less prestige, high debt loads and a knowledge that PCPs work in a non-sustainable business model forcing them to see an excessive number of patients per day in order to meet overhead and still garner an income about one half that of the specialist is, combined, enough to discourage medical school graduates from selecting primary care as a career.
The next post in this series will focus on the PCP’s need for time – to listen, to think, to prevent, to treat, to coordinate.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).