Primary Care Has a Dirty Little Secret

We are like restaurants that charge handsomely for sit down dinners but give away food for free at the takeout window. And we pay our providers only for serving the dining room guests. If traffic gets backed up at the drive-through, we hold our providers responsible, even though we never planned for our ever increasing demand for takeout.

In simpler times, patients went to the doctor when they felt unwell, and doctors didn’t claim responsibility for what patients did on their own time between visits.

Now, doctors are working just as hard taking care of patients in the office, but they are also expected to, on their own time, handle all sorts of ongoing hand-holding between visits. This happens through phone calls, electronic messaging and reading and commenting on endless streams of reports from case managers, specialists, hospitals, emergency rooms, walk-in clinics, pharmacy benefit managers, insurance companies and medical supply companies.

There is talk about how all this extra work will some day generate income streams from cost savings and improved outcomes, but today, the very foundation of how doctors get paid is how many patients they see in the office on a daily basis. Few health care organizations have the cash on hand to schedule provider time for what isn’t going to bring money in during the present budget year.

The dirty little secret we all deal with in primary care is that we make our doctors, PA’s and NP’s see as many patients as they possibly can, with ever increasing demands on the complexity of care they deliver, and on the comprehensiveness of their documentation and quality reporting, and then we quietly assume they will be able to do all this extra, unscheduled and uncompensated work without falling behind, making medical mistakes or simply burning out.

Imagine a CEO who spent all day in meetings and never had any time to himself or herself available to think, plan or write.

Imagine an average office worker, who is said to spend 25% of their time on business related email, suddenly being told that all company emails from now on have to be done outside working hours.

Imagine a judge, presiding over case after case at the bench from 8 am to 5 pm, without any scheduled time to read briefs or write judgements.

Imagine a TV anchor, broadcasting 8 hours a day, never taking any time to study the issues of the day or to speak with colleagues or newsmakers.

Imagine an orchestra, constantly performing, never practicing, never studying the sheet music.

And we are now offering resilience training to our medical providers to help them not burn out…

7 Responses to “Primary Care Has a Dirty Little Secret”

  1. 1 jmccarty3 November 23, 2016 at 2:29 pm

    I have a dirty little secret, too. Specialty care isn’t any different. We are all suffering from the nonsense described in this excellent post.

  2. 2 meyati November 23, 2016 at 3:19 pm

    Admit it, physicians’ pay is tied to doing these things and having stupid life goals-often supervized or it doesn’t count toward the doctor meeting his quota.
    I don’t understand why my physicians care for me-I’m a money losing proposition. I did try to go to cancer support exercise, but the ladies couldn’t understand that head radiation can cause balance and other problems when the head is bent-and they wanted me to do yoga. Then the battle of the bulge. I was told to gain at least 20 lbs to survive cancer treatment, and to keep it on. This interferes with other physicians meeting their quotas in the battle for obesity, diabetes, cholesterol, and CVAs.

    I have a dear PCP and radiology oncologist, and they fight for me to be left alone.

  3. 3 Lenny Husen M.D. November 24, 2016 at 3:09 am

    So well said and sadly, 100% true. I’m the Chair of our Medical Group’s Well-Being Committee. I wish I had the power to change this but I do not. I am a Hospitalist and have it SO good, compared to Primary Docs. If Primary Care Providers aren’t paid for ALL their services and if they don’t have enough time to recharge, Burn Out is inevitable. Thanks for posting this. I just posted it on FB and Twitter.

  4. 4 Jaime November 24, 2016 at 4:31 pm

    Well only take enough patients that you can balance work against down time for R&R in your life. Stop trying to be the big $$$ generator and focus on the number and type of patients you can care for in a quality environment.
    Need for more consumer self help education on maintenance and self care as well as preventive Healthcare 😎😎😎😎 Get rid of Insurance for Profit Healcare providers.😎😎😎😎

  5. 5 Aletha Cress Oglesby, M.D. November 25, 2016 at 3:00 am

    Perfect analogies. And why do we wonder why our health care costs so much with so little benefit to show for it?

  6. 6 Allen W. Ditto, M.D. November 30, 2022 at 11:56 pm

    I survived 40 years in primary care (including 3 years of residency). It was unusual for me prior to 2005 to work less than an 80 to 90-hour week. In solo practice, from 1982 to 1994, I occasionally worked 110 hours a week, and one time, when two of the doctors in our call group were away at the same time, I put in a 120-hour week. As soon as they returned we had a meeting where we established a rule that no more than one of the call group could be away at the same time. In 1994 three of us formed a group practice and quickly added two other doctors and an N.P. I would finish up with patient appointments by 6 pm. Then there would be two to three hours of phone calls, records review, documentation tasks, preauths, labs review, and communication with patients (in writing) about lab results. Some labs warranted a phone call to explain their meaning, answer questions, and formulate a plan. Then it was back down to the hospital to finish rounds, finish up and check on the admissions from the day, and meet or call inpatients’ families and loved ones. I would eat a “late plate” at 11:30 pm. Then it was back up at 6 am for morning rounds. One time on roster call (call for the ER to admit patients who had no primary care doctor) I had 12 admissions overnight. That was one of the most difficult days (and nights) of my career. It was worse than any day in residency. In December of 2005, our group started to use the newly set up hospitalist program that our local hospital had started the year before. The first week of using the hospitalists to see all of our inpatients and admissions was the first time in 23 years that I was not physically in the hospital between 12 midnight and 6 am at least 1 or 2 times a week. At the end of that first week, I came home from the office that Friday and broke down in tears of guilt and relief. Guilt as I was not there for my patients, but relief that I could now have a whole weekend without going to the hospital and I could be assured of not having to get up out of bed to go to the hospital to see a desperately ill patient at 3 am or have my sleep disrupted by calls from the medsurg floor, nursery, or ICU. Then the relief of not going to the hospital was replaced by the grief and stress of learning to use the electronic health record. That nearly killed me. I seriously considered quitting medicine. My health system boss (our group joined the local health system in 2009) came up with the proposition of me being assigned a scribe to assist me with the EHR. That scribe worked wonders for me and saved me for the last 6 years of my career. Unfortunately, after a 6-month trial, I was responsible for paying the scribe. That was $44,000.00 off my pay. That hurt but was an absolute necessity for me to function with the EHR. I retired in January 2019. Looking back on it I did my best, avoided becoming cynical, and had a very satisfying career. I don’t see how I was able to do it. Actually, I did it with the support of my wonderful spouse and colleagues. Now, I don’t miss practicing primary care for one second. My retirement is a gift I feel I’ve earned.

  7. 7 Sanjeet Narang December 8, 2022 at 8:33 pm

    Your logic is irrefutable and the examples are spot on. Telemedicine is being paid for, which is an advance on the gray bleakness. House calls are still mostly gratis.
    Should doctors unionize?

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