What Are the Characteristics of a Good Primary Care Physician?

PCPs like people. This was true of them long before they started medical school and it will have only blossomed further during training. Ask PCPs, as I have with in-depth interviews, and they will tell you that certain types of individuals are drawn to primary care careers; they have common characteristics. They like to converse with people. They enjoy getting to know about a person – their ideals, their goals in life, their ambitions, their cares and sorrows. They are interested in learning from the patient rather than talking down to the patient; their ego can be strong but not as to impose themselves on the patient. They tend to not only want to know their patient but also to understand his or her place in their family and society. He or she is a person who wants to know the “whole story;” they tend to see the patient as a whole person, as part of a family and part of a community. They see the patient as a unique individual and his illness as part of that totality of the person, not just a diseased organ or system. To paraphrase Sir William Osler, a good doctor tends to the person who has a disease rather than just the disease itself.   

PCPs generally like to engage in an intellectual puzzle, a mystery to solve.  They have a “general contractor” mentality meaning that they see themselves as capable of getting much or even most of the job done themselves but are comfortable in drawing in others as necessary and in so doing are committed to coordinating everyone involved in the patient’s care. As with all of us, they wish to earn a good income but money is not the most important thing in their life nor is it what drove them to become physicians.

What are the characteristics of a good physician? The deputy dean for education at Yale Medical School, Richard Belitsky, M.D., talked to the freshman class a few years ago at their White Coat Ceremony about becoming a doctor. Greatly abbreviated, he told them there was much to learn “but so much of what you need to be really good doctors, you already know… Becoming a great doctor begins not with what you know, but who you are. Being someone’s doctor is about a relationship. That relationship is built on trust…Being a great doctor begins not with what you have to say, but your ability to listen.” 

In my interviews, primary care physicians report that listening is the key and most important attribute of being a good physician in primary care. By listening they mean one who listens to the patient’s story without rushing it and without embellishing it. They let the patient develop his or her own story of their situation perhaps with some prompts to help them focus but without unduly narrowing the narrative. The PCP must at the same time be nonjudgmental if he or she is to learn from the patient and develop a strong doctor patient relationship – the third major attribute.  PCPs need to like people and thus like their patients.  The good PCP is well grounded in basic medical science, the latest in evidence-based care and is constantly seeking continuing education. The good PCP is conservative, meaning that he or she will work with lifestyle, behaviors and other measures such as nutrition or exercise before resorting to drugs or procedures. This requires patience; not everything can be “fixed” immediately. They feel that knowing the patient over the long term aids the care process and enhances the doctor patient relationship as does being attuned no only to the physical needs but also the patient’s emotional and spiritual requirements. Knowing the patient’s family not only helps to understand the patient but they will be the physician’s ally if and when needed later. It is important to attend to the patient in the same manner that one would want to be treated by others. Combined, these will develop trust, respect and partnership. Some will not only be very good physicians but also true healers, a desired state that only some attain.

A physician who saw this post previously commented that I forgot two things – leaping tall buildings in a single bound and being a good typist. The problem of course is that PCPs today do not have enough time with their patients so even if they possess all or most of these characteristics they are trapped in a business model that does not value time.

When a general audience on LinkedIn was asked by Paula Stanziani what in one word constitutes a good doctor the answers varied of course but some of the most noted common attributes are these: Listener, commitment, compassion, humanity, attentive, patient, competent, teacher, healer and ethical. A good overview from one respondent, Scot Sturtevant, was “I’ve met many a physician in 36 years of service. Some brilliant, some not so much. The one thing I have noticed though those that were great, truly great, were those who were humble, but confident. They would listen quietly to a patient's story, and were never really rushed nor found themselves panicking in a critical situation. They were stoic yet responsive, and treated nurses, technicians and even field medics as a valued part of the team. To sum it they know who they are, and where they came from... And like all of us, still put their trousers on one leg at a time. There really isn’t a single word to describe greatness, it’s part of the diverse nature of who they are and how they apply what they've learned and what they know.”

That sums it up well for me.

Next post: The frustrations of being a primary care physician.

 

Time - The Impediment to Being a Good Primary Care Doctor

Did you get more than a few minutes with your doctor at your last visit? Probably not. Why not? Not enough time.

The primary care physician (PCP) is the most broadly yet deeply focused care giver and as such is the backbone of the healthcare system. But to do this work effectively requires time – time which all too often is not adequately available. Lack of time is a real impediment to the best possible care.

What constitutes primary care and who are the primary care physicians? They are the first responders, the first line of care, and very frequently the patient’s confidant on all matters related to health and often more. The PCP is often the first physician contacted because of the long standing patient - doctor relationship but also because the PCP tends to be more readily available than a specialist who does not know you. The PCP needs to know a broad and deep range of medicine and at the same time needs to know when it is time to consult a specialist. And if you have a chronic illness, the PCP should also ideally coordinate all of the various specialists, tests, imaging and procedures that you might require. It is this coordination of the care over the long term that will mean better care at a lower cost.

The PCP deals with most problems/ illnesses with a broad yet deep expertise and knowledge and so is able to diagnose and treat most common and many not so common diseases and problems, including most chronic illnesses. He or she is well versed in the continuity of care for chronic complex illnesses, is in the best position to refer when indicated, and to coordinate care of chronic illnesses or referral for an acute issue. The PCP is or should be focused not just on disease but on the person with the disease, on wellness and disease prevention by means of immunizations, screening (recognizing risk- reward rationales)  and behavior modification – diet, stress, exercise, smoking, etc.

But there are serious issues in Primary Care.                                                                                

There are too few primary care physicians, too few medical school graduates choose primary care as a career and there are too few residency slots after medical school for primary care training.

Today the PCP needs to be “efficient.” This means that it is more efficient to just give an antibiotic for a sore throat than to reassure the patient (and perhaps the parent) that it is likely caused by a virus; that the antibiotic will do no good and could even have some undesirable side effects and that time is the best medicine. But it takes time to do reassurance. And if not done thoroughly, the patient likely will go away unhappy that he got “nothing.” So do the quick thing and give the antibiotic. And add in for good measure – “This should do it!” or “It is good you came in today to be treated.” It also means that the PCP needs to see as few Medicaid patients as possible since Medicaid pays so poorly. And although much can be done over the telephone or with email, preventing a trip to the office or even the ER, the efficient PCP wants to avoid both since there is no payment for either.

PCPs are frustrated. Some see the glass half full and many see it as half empty. Those that see it half empty are quickly selling their practices to the local hospital. Others are trying new payment methods. Either way, PCPs know they are not doing just the “simple stuff” as so often portrayed but the very complex. Many patients have multiple chronic conditions, are on many prescription drugs, have various functional incapacities as a result of aging, and often have problems rooted in family dynamics or their own cultural norms and traditions.  The good PCP understands that the essence of care is the bond that they develop over time with each patient. This is the bedrock of the profession. But the current “culture” of medicine expects high technology to be the answer, imposes financial frustrations and is always threatening malpractice litigation. This combination, but mostly payment issues, has led to a fragmentation of care and the overuse of specialists, specialty care without coordination and an over reliance on technology. The good PCP, despite all of the frustrations, still understands that that bond with the patient is key, the very heart of their medical practice, the basis of their own satisfaction in their career and (as stated in a book review  on primary care) “the essence of a well-functioning medical care delivery system.”

PCPs are departing private practice in droves. Traditionally a newly minted physician would borrow funds to start a private practice or would enter an already established practice in town. In 2000, it is estimated that about 60% of physicians were in a private practice. This had dropped to about 40% by 2012 and perhaps to 33% by 2013. It appears that the rate of decline in private practices is increasing with no apparent end in sight. In 2000, about 20% of PCPs were employed by hospitals; today that is up to about 40% and growing rapidly.

Why the rapid change? Some of it is a change in the desires of the new generation of physicians. They have a desire for more personal and family time and a professional life with fewer administrative obligations, no concerns about borrowing large sums to begin a practice, and a steady paycheck. But this change to employed status is also about the current convoluted billing requirements of practice, the administrative complexity of running a business plus being a physician, and the always changing regulatory requirements.

But there are definite tradeoffs. Most important is autonomy. Physicians over the years have valued their autonomy but when one works for a corporation, no matter how benevolent, it will have its own rules and regulations. Autonomy is lost. And although the administrative burdens are lessened the physician is still expected to cover his or her own salary and expenses which means still seeing many patients per day, 24-25 or more to meet productivity standards. So shifting to hospital employment does nothing to gain time – time to listen, to prevent, to coordinate chronic care and to just think.

Your primary care physician requires time – time which all too often is not available. This issue will be a major topic going forward in this continuing series on the Crisis in Primary Care of which this is the seventh installment.

The next post will consider who chooses to become a primary care physician.

 

The Doctor’s Customer Is The Insurer - Shouldn't It Be The Patient?

You the patient are really not the customer of your primary care physician. Since the insurer will determine whether and how much the physician will be paid for attending to your needs, you are largely a bystander in the relationship. The doctor’s customer has become the insurer.  

Our system of care is definitely not customer-focused. Doctors truly believe that they have the patient’s best interests in mind and they do. But their work is not customer focused as it is in most other professional-client relationships. You wait long weeks and sometimes even months for an appointment (the national average is 20.5 days), spend long times in the waiting room and are frustrated that you get just 10-12 minutes with your doctor who interrupts you within less than a minute and who recommends you see a specialist but does not personally call the specialist to explain the issue nor to smooth the path for a speedy appointment. All of this because, in the case of primary care, the doctor must see 24-25 patients per day to meet overhead and achieve a personal income of about $170,000. 

As for the insurers, you are not their customer either. Their customers are the ones who pay them - your employer or your government.  And it shows – by our long waits on the phone, by the complex, often hard to understand paperwork and by the frustration when the insurance you thought you had does not cover your latest tests, x-rays or specialist visit. 

So you are not the insurer’s customer nor are you the doctor’s customer. You are a mere bystander. This is hardly the type of contractual relationship you have with your lawyer, architect or accountant. In those situations, you pay them directly. Want more time? No problem, but you pay for it. Want telephone consultation? No problem, but you pay for it. Not so in medicine. You the patient cannot decide and ask for more time or ask to use of email or telephone. Because you are not paying for the time and your insurance will not do so either. It is just not your choice. 

To be clear. Yes, you are paying the physician directly in the co-pays and the deductibles but it is still the insurer that determines whether and how much the physician gets paid. You just get to contribute whatever portion you are told.  

Who is to blame for the current state of affairs? Each party looks to the other but perhaps each should hold up a mirror and take a close look. Nevertheless, here is what physicians think based on a recent survey. Ninety per cent say the medical system is on the wrong track; 83% are thinking about quitting; 85% think the patient-physician relationship is deteriorating; 72% do not think the individual mandate will lead to improved care; and 70% think that the single best fix would be reducing government intrusion. Further, 49% will no long accept Medicaid patients and 74% plan to stop accepting new Medicare patients. Finally, 80% believe doctors and other medical professionals are the most likely to help solve the mess.  

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery of health care is truly dysfunctional. What is needed is fewer patients per PCP so that each gets the time and attention really needed. The PCP needs time to listen, to prevent, to coordinate chronic care and time to just think. This means increasing not decreasing the cost of primary care per person. An increase in costs, yes, but an increase that will dramatically lower the total cost of care. More effective preventive care. More attention to the complex chronic illness with fewer referrals to specialists.  Better coordination of the care of those with chronic illnesses, enhanced prevention such that many chronic illnesses don’t develop. Spending  the time to listen and become trusted as the healers that they could and should be -- all leading to better care at much lower total cost.  

A new vision for our system must make it a healthcare not just a medical care system. It must recognize the importance of intensive preventive care to maintain wellness. It must address the needs of those with chronic illnesses to both improve the quality of care while dramatically reducing the costs of care. And it must be redesigned so that the patient is the customer that he or she should be. And, critically, to make it work effectively, America needs many more primary care physicians – they are and should be the backbone of the healthcare system – who are able to offer outstanding preventive care, care for the vast majority of complex chronic illnesses, offer coordination for those with chronic illnesses and do it in a manner that is satisfying to doctor and patient alike – with true healing along with expert medical care. It’s doable but it means a rethinking of how our delivery system is structured and assuring that PCPs have fewer patients for more time each.  

It is possible but it will require both doctor and patient alike to demand it. There are many ways to skin the cat but the most promising is direct primary care (membership/retainer/concierge) practices. More on this later.

 

My next post in this series on the crisis in primary care will be about today’s impediments to good primary care.

The Paradox In American Healthcare

We have a real paradox in American healthcare. On the one hand we have exceptionally well educated and well trained providers who are committed to our care. We are the envy of the world for our biomedical research prowess, The pharmaceutical, biotechnology and diagnostic equipment industries continuously bring forth lifesaving and disease altering medications, devices and diagnostics. So we can be appropriately awed and proud and pleased at what is available when needed for our care. 

But, on the other hand, we have a very dysfunctional health care delivery system. A fascinating paradox. One wonders just why it is that Americans tolerate this paradox of incredible medical advances and outstanding providers yet a dysfunctional delivery system. 

Our medical care system works poorly for most chronic medical illnesses and it costs far too much. Chronic illnesses are ones like diabetes with complications, cancer, heart failure and neurologic illnesses like stroke. 

These chronic illnesses are increasing in frequency at a very rapid rate. They are largely (although certainly not totally) preventable. Overeating a non-nutritious diet, lack of exercise, chronic stress, and 20% still smoking are the major predisposing causes of these chronic illnesses. Obesity is now a true epidemic with one-third of us overweight and one-third of us frankly obese. The result is high blood pressure, high cholesterol, elevated blood glucose which combined with the long term effects of behaviors  lead to diabetes, heart disease, stroke, chronic lung and kidney disease and cancer.  

And once any of these chronic diseases develops, it usually persists for life (of course some cancers are curable but not so diabetes or heart failure). These are complex diseases to treat and expensive to treat – an expense that continues for the rest of the person’s life.  

Primary care physicians can deal with most of the issues of these patients – if they have the time to do so. But referrals to specialists is often necessary. Primary care physicians generally do not have the time needed to coordinate the care of those with chronic illness – which is absolutely essential to assure good quality at a reasonable cost. Over time, most chronic illnesses will need a team of caregivers. Consider a patient with diabetes who may need an endocrinologist,  nurse practitioner, podiatrist, nutritionist, personal trainer, ophthalmologist and perhaps vascular surgeon and cardiologist and many others as well. But any team needs a quarterback and in general the person is the primary care physician. He or she needs to be the orchestrator as much if not more than the intervener. This need for a team and a team quarterback for the patient with a chronic illness is much different than the needs of the patient with an acute illness where one physician can usually suffice. It is this shift to a population that has an increasing frequency of chronic illnesses that mandates a shift in how medical care is delivered. Unfortunately, our delivery system has not kept up with the need.  

In healthcare the money is in chronic illnesses. These consume about 75-85% of all dollars spent on medical care. So we need to focus there. 

Since most chronic illnesses are preventable, what are needed are aggressive preventive approaches along with attention to maintaining and augmenting wellness. This would reduce the burden of disease over time and greatly reduce the rising cost of care. Unfortunately, America places far too little attention and far too few resources into wellness and preventive.  Most primary care physicians do not give really high level preventive care. Yes, they do screening for high blood pressure and cholesterol and for various cancers and they attend to immunizations. But this is not enough. Patients need counseling on, at least, tobacco cessation, stress management, good eating habits and a push toward more exercise. They need an admonition to not drink and drive, not text and drive and to buckle up. They need to be reminded that dental hygiene today pays big dividends in the later years of life. And they need someone to really listen closely to uncover the root cause of many symptom complexes as in the story given in the first of this multipart series on primary care. 

When a patient is sent for extra tests, imaging or specialists’ visits the expenditures go up exponentially yet the quality does not rise commensurately. Indeed it often falls. But primary care physicians are in a non-sustainable business model with today’s reimbursement systems so they find they just do not have enough time for care coordination or for more than the basics of preventive care.  And they just do not have time to listen and think. 

So the paradox is that America has the providers, the science, the drugs, the diagnostics and devices that are needed for outstanding patient care. But the delivery is not what it should or could be. The result is a sicker population, episodic care and expenses that are far greater than necessary. The fix is change the reimbursement system to get PCPs the time needed to listen, to prevent, to coordinate and to just think. This will lead to better care and less expensive care.

The next post in this series will be about customer focus.

 

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.

 

 

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.

 

Causes of the Crisis in Primary Care

The Crisis in Primary Care –Part 2

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

In my last post in this continuing series on primary care, I described a patient with a straight forward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, with no resolution of her symptoms and with no physician ever exploring the actual underlying causes of her symptom – stress related to a long ago family issue. Why did this happen? Because the PCP had only 15 minutes, not enough time to listen and to think and from there delve into her psyche.

Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. Medicare has for years set a low reimbursement rate for regular office visits to the primary care physician. Commercial insurance always follows Medicare’s lead and has done likewise. Reimbursement rates have remained fairly steady for a decade or more (Medicare has very recently begun to raise rates a bit as a result of the Affordable Care Act) but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding people, accounting and legal needs, malpractice and disability insurance, health care insurance for the staff, supplies and rent and utilities for the office. With costs rising and income steady, the PCP tries to “make it up with volume.” This means seeing more patients per day, usually about 24-25, often even more. In order to see that many, the PCP has generally stopped seeing his or her patients in the hospital or ER and has shortened the time per visit – most visits being about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat, a quick blood pressure medication check or possibly to diagnose and treat Lyme disease. But it is not enough time to deal with a more subtle problem like the patient described in the last post experienced. It is not time to explore family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness. This lady had a straight forward issue that primary care physicians encounter frequently and those that are experienced know well what it implies. But it still requires time – time to carefully listen to the patient’s story, time to put it into the context of the patient’s life situation, time to do an examination and then some time to think about how to proceed. And once the management decision is made, it takes time to talk to the patient, reassure her and yet explain that she should call should are any further concerns arise – and to come back soon for a further follow-up and attention to the underlying issues.

The situation is compounded when the PCP has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses like diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis by their nature are difficult to manage, persist for the patient’s lifetime (some cancers excepted) and are inherently expensive to treat. These patients need very close attention and often need the benefit of a team approach to care. The diabetic patient for example may need an endocrine consult at some point, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist, to say the least. But any team needs a quarterback and this is or should be the primary care physician. But here again, care coordination by the PCP requires time, the one thing the PCP most lacks in today’s reimbursement environment. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total healthcare system perspective, this is critical because chronic illnesses consume 75 – 85% of all claims paid by insurers.

But with little time to listen and think, the action step of many PCPs, as with the patient described last time, is to send the patient to a specialist. Indeed, according to an article in the Archives of Internal Medicine, about nine percent of all visits to PCPs result in a specialist referral, far far higher than truly necessary. This is up from about five per cent a decade earlier; 41 million referrals per year then compared to 105 million in 2010. Something needs to be done. The push for accountable care organizations, medical homes, population health and a switch from fee for service to a salaried or capitated system are noble but unless the PCP is given time and enough of it, these changes – no matter their apparent utility – will prove valueless.

Meanwhile, fewer and fewer medical school graduates choose to enter primary care. They are smart and see that PCPs are very busy and very frustrated. They know that given the PCP’s average income it will take many years to pay off their high educational debt load.

PCPs are looking for ways out of their dilemma. Many are retiring early. Others are closing their practices and beginning to work for the local hospital. But the hospital wants the physicians to earn their keep. That means high productivity. So it is still 24 – 25 patients per day, albeit without the administrative hassles of a private practice.

It is clear that the resolution will not come from commercial insurers, not from the government insurances (Medicare, Medicaid), nor will it come from the Affordable Care Act. It will likely be in the actions and decisions of the primary care physician himself or herself to change the paradigm to allow and encourage better quality of care with lessened frustrations for doctor and patient alike.

For starters, many PCPs need to look carefully at their practice patterns and determine if they can adjust their own workload by maximizing the talents of their team of nurses, nurse practitioners and others and with better use of technologies. This requires a change in thinking about how to organize the practice and who does what and when.

Beyond that, some PCPs have decided to no longer accept insurance. Instead they expect the patient to buy care directly. And since they no longer have the expense of coding, billing and collection (one estimate of this is $58 per patient visit!) they can charge a quite reasonable amount. This can take the form of a set fee for any visit, a sliding scale depending on the type of visit and its length, or of a set amount for all care for the year, a retainer-based (concierge) approach. In each of these models and others the patient replaces the insurer as the actual customer of the physician and as such has a more appropriate professional-client relationship. The patient also becomes a purchaser of services directly and thus begins to ask questions, to challenge and in general to bring down the costs of care while receiving a higher level of quality along with greater satisfaction and less frustration for both doctor and patient.

These are but a few of the approaches being taken by PCPs today in an effort to overcome the current non-sustainable business model so that they can not only give better quality of care but reduce their sense of frustration and increase their patients’ satisfaction.

In the posts to follow I will review what primary care is all about; the characteristics of a good primary care physician and a true healer; who does primary care and why and why not; the critical role of the PCP in managing chronic illnesses; the need to listen and think – both requiring time; the use of teams in the primary care doctor’s office; the importance of care coordination, wellness promotion and disease prevention; the current non-sustainable business model; what approaches are being taken to overcome the current business model; and finally how primary care can once again take its rightful place as the backbone of the American healthcare system offering superior quality, outstanding service and greatly reduced overall costs.

The next post in this series will address the critical shortage of primary care physicians.