Primary care doctors, the way things are organized in this country, perform three kinds of services. If we don’t recognize very clearly just how fundamentally different they are, we risk becoming overwhelmed, burned out, inefficient and ineffective. And, if we think about it, should we really be the ones doing all three?
SICK CARE
Historically, people called the doctor when they were sick. That service has, at least in this country, become more or less viewed as a nuisance in primary care offices. We keep a few slots open for sick people, in part because the Patient Centered Medical Home recognition process requires us to. But our clinics may worry that those slots go unfilled and lead to lost revenue.
Instead, sick people scatter toward emergency rooms with crowding, high overhead and liability driven testing excesses or to freestanding walk-in clinics that only sometimes are integrated with the primary care office but universally staffed by providers who don’t know the patient. These providers, due to staffing cost strategies, are sometimes the least experienced clinicians within their organizations, doing what I feel is the most challenging work in health care – sorting the very sick from the only moderately ill or even completely healthy but worried patients.
In the worst case scenarios, the walk-in clinic is freestanding, operating without any access to primary care or hospital records, starting from absolute scratch with every patient. Some of these clinics are well equipped, with laboratory and x-ray facilities and highly skilled staff. But some are set up in a room in the back of a drug store and staffed by a lone nurse practitioner with minimal equipment and no backup.
Because health care in this country has no master plan, this is what has emerged. If we had a national strategy for health care services, does anybody think it would look like this?
CHRONIC DISEASE MANAGEMENT
More and more people suffer from chronic diseases like diabetes, hypertension and autoimmune conditions. This is where the bulk of primary care work is done. Much of it is straightforward and predictable: Diabetics get their glycosylated hemoglobin checked every three months, hypertensives get their blood pressure logs and blood tests reviewed at certain intervals. And, sadly, much of it is ineffective. Few people lose weight, improve their blood sugars or change their lifestyles. Our visits follow the same tired routine from one time to the next – “I’ll do better this time, Doc”.
The more our country’s chronic disease burden increases, the more clinician time and effort this kind of work will consume. And the more we need to question whether there isn’t a better way to deliver chronic disease management.
We already know that group visits can be very successful, because of the power of peer support. And even when they are limited to Zoom, they can be effective. They are certainly more efficient than speaking with patients one by one, again and again, like a broken record. Quite frankly, that is getting antiquated.
Besides through group visits, this aspect of primary care is also easily done or at least supported by technology. There are already apps for tracking blood sugar, blood pressure, exercise and sleep. I’m sure there are more applications out there already and even more in development. The feedback from all this data can easily be managed by artificial intelligence, leaving just the final decision making and personal touch for the medical provider. (More on why the personal touch is still necessary in an upcoming post.)
DISEASE PREVENTION AND SCREENING
You don’t need a dozen years of professional education to tell people to have their routine immunizations, to offer screening colonoscopies or to administer standardized questionnaires for anxiety, depression, alcohol or domestic abuse or whatever else the politicians and bureaucrats think we doctors should do.
My professional opinion is that this work is too routinized to require a medical license, but could safely be done by non-providers or even by computers with very rudimentary programming.
I also question the logic of bombarding patients with these when they come in for a sick visit with many worries and questions they hope to have time to address. In fact, I question why these things aren’t done outside the visit, through outreach via our patient portals, newsletters, phone calls, email or even printed letters.
What I do think, is that these screenings can and probably should be done under the umbrella of patients’ primary care “medical home”. But I strongly object to the misinformed assumption that this data collection is doctor work. The doctor should however be available in the loop to manage positive findings.
(In my EMR the doctor has to sign off even normal screening tests in a most cumbersome work flow as part of an office visit. Why not have a standing order and an automated process to only flag the provider for scores above a certain value?)
Prevention and screening services to 331,000,000 citizens, one by one and face to face, for innumerable diseases and risk factors is not the best use of our 209,000 primary care physicians. At least not if we want to be fiscally responsible. It is definitely not a good idea if we want doctors to also have time to treat the sick. And it is a very questionable strategy if we don’t want them to burn out and leave the profession as soon as they can afford to.
A Country Doctor Writes: 
i like how you put it! Though I made commentary on my Linked In post with link to this blog.
Excellently written! Agree 100%!
I find that perhaps the most important component of what I do as a primary care doc is Quarterback: Calling the shots, often executing the play myself, and making sure the various specialists are coordinated in what they do for MY patient. I also try (in vain, most of the time) to utilize a consult as just that: a request for consultation, not a pass-off of care to a specialist. This is how I learned in a military FP program, as specialists were very happy to spend 10 minutes talking to me about one of my patients, that I would then manage (and document) as that was one less patient that they had to see (with no marginal benefit to them) and document on. In fact, that system worked very well in that trust developed between me and the specialists, so they knew that if I did need to send them a patient, they really needed to see that patient and they didn’t just go into the queue with every other patient that had not had good assessment and management up to that point (i.e., they weren’t starting from scratch, nor were they behind the eight ball)
In today’s world, specialists have no incentive to provide consultative services to primary care docs. The way reimbursement works, they have no marginal benefit to taking the time to talk about patient management with a primary care doc and if they do take that time, then they lose the reimbursement that would come with accepting that patient for “evaluation and management” of whatever the issue is. Family Physicians and Internists are perfectly capable of managing a much larger proportion of the issues that their patients face, but the entirety of the system, from reimbursement, to privileging, to patient expectations, to liability assumptions, is geared to shifting care to specialists and relegating primary care docs to the same practice set (and, increasingly, reimbursement) as mid-levels. With this in mind, it’s no wonder why primary care is not attracting physicians.
I really appreciate the organization and analysis in this article. Unfortunately, I am not certain that some of the recommendations will help my patient population: uninsured, and the majority who don’t speak English. As both a Nurse Practitioner and public health professional, I am constantly asking how can I do better, how can we do better for this group? I have been doing telephone and some video visits for 10 months now. It has been hit or miss, with frequently missed appointments, language and economic barriers that have been significantly exacerbated by the pandemic. The uninsured were not being reached before coronavirus, and many are now hanging on, fortunate if they still have work. Nevertheless, this article gives a lot of food for thought and some ideas that may be adaptable for the underserved.
This is a great framework for considering opportunities for process improvement in basic primary care, but I think you’ve missed one glaring component of our practice: mental health. We asses, diagnose and manage the psyche – and it’s impacts on the physical body – in every visit (whether or not we plan to, or have time to). Depression is often a key barrier to medication and appointment adherence; anxiety causes fatigue and pain; substance use disorders underscore everything. Primary care is the first – and often the only – mental health resource patients have. Exploring new models, like integrated behavioral health teams, is going to be crucial if we ever want to see quality measures really sustainable improve.
I certainly practice a lot of mental health care and I’m fortunate to be in an integrated practice myself. I count that as sick care that requires a level of expertise beyond that of practicing public health.
After 34 years in Family Practice, I retired early (in my opinion) at age 62 feeling burnt out. The article brings up some very valid points. I felt exhausted trying to “do it all” managing preventative care, assuring all screening tests and immunizations were performed appropriately, ordering recurrent tests for chronic disease management, refilling medications and filling out all the scut work paperwork, AND diagnosing and treating acute illness ALL IN THE SAME ONE VISIT. We are presently setting ourselves up for failure. The EHR is a work in progress which will take years to improve rather than impede our care. As an “old timer,” I really miss feeling part of a team and instead felt isolated from my other specialty colleagues compared to years ago. I could have probably continued except IF, like most of us, I didn’t expect myself to always provide superlative care at each and every visit. I was proud of the care I provided, but certainly feared making mistakes or not being perfect at all times was a real concern and decided it was time to leave medicine.
Have been a PCP for 45 years and am 73. I practiced in the “golden years” when physicians could be the one making the decisions without having to request a PA for labs, medications, imaging studies, etc from insurance co and/or some government agency. I understand very well the economics but where does the patient’s interest come in. Is it truly between the patient and his provider or are there other players with all the power and the check book?? I feel our lobbies, national, state and local organizations have pretty much gone with the tide and have not been nearly aggressive enough to stem the tide or at least to shape our future as is affects our patients outcomes and our own mental health.
Well said Dr. Duvefelt! I’m a physician assistant who is very passionate about prevention and lifestyle modification to address chronic disease progression. I’ve left traditional medicine to open my own health and wellness clinic. Time constraints imposed in our model of primary care preclude the abiity to adequately address patient education, motivation, prior failed attempts, accountability and obstacles unique to each patient presentation. It leads to “the same tired routine from one time to the next – “I’ll do better this time, Doc”. I hope to fulfill this widening gap to SUPPORT the traditional 3 primary care components you’ve outlined.
Maybe I am too old. I still subscribe to the “antiquated” way to treat patients with chronic illness. I can’t possibly agree to evaluating several patients at one time over ZOOM. They loose privacy and most probably wouldn’t provide very important information. This “modern” way to evaluate and treat chronic conditions does away with a proper physical examination. Only God knows how many new murmurs, atrial fibrillation, PAD, skin cancers, etc would be missed so that we are more “efficient”. I would never abdicate my responsibility to my individual patients to satisfy societal trends. While I don’t know of studies to justify “telemedicine” I suspect that it it is not necessarily cost effective and, to me, it is an aberration, except in cases when the patient can’t possibly be evaluated in person. There is nothing wrong with measures that lead to saving money, as long as it does not reduce quality of care. It saddens me to see how social trends are trampling quality of care in the name of savings.
Aristides M. Estrada MD.
I am sadly agreeing with you doctor. We, as “old school doctors”, can barely fit in this new corporative- computerized medicine which prioritizes numbers of coding and billing way above the quality of care. As you said, not doing physical exams is like dismembering the art of this profession. It is so contradictory to me; on one hand they cluck about reducing costs and practicing “Evidence Based Medicine” and on the other hand they delete the physical exam in just “one click” hahahaha. So as you mentioned before, they will realize about an aortic stenosis only once the patient becomes a Class 4 CHF, which at that point the only effective solution will be a heart transplant (if he/ she is lucky to afford it) instead of a simpler TAVR. That same murmur would have been detected with a simple stethoscope by a pair of well-trained ears. High Tech folks have even dreamed of not only deleting the PE out of the care, but also reaching the point in the future where primary care physicians wouldn’t be as necessary after inventing all of those algorithms of care. God bless/save our future generations!
I started practice seeing mostly acute care 30 years ago. Chronic disease management and our pharmacopoeia as well as standard of care were much more limited then and I would sometimes see 50 patients a day. Then came a plethora of SSRI’s and boom, I’m a psychiatrist. The trend seemed to be that the more drugs we could use, the more chronic disease we treated. Now I see 28 patients a day, I always run late because I do believe in teaching lifestyle change, counseling about stress as well as disease education. If you want to change the system, pay doctors to manage populations, set up automated systems to draw labs and schedule immunizations and screenings and flag abnormal results and non compliance for the doctor to schedule a call. By the way, reimburse physicians for phone medicine! Make dietary and exercise classes mandatory for insurance coverage and reward compliant patients with drug and premium discounts. There’s a lot we could do to change the system. But face it, were just doctors, what do we know?
I see nothing in the above post that suggests a need for a dozen years of training. Which is why the primary care physician is becoming a relic, irrelevant in the world of the ultra specialized. The only places we are not that are in the places where no one else wants to work. I have realized this after being coerced into a specialty that is more suited to managing the administrative BS of medicine in the military. Which is why I plan on practicing medicine as little as possible to make a comfortable living—not why I became a doctor. What’s funny is I became a doctor to avoid sitting at a computer all day! HAHAHAHAHAHA
You need training to diagnose and treat new symptoms. Not to follow protocols or do public health.
Mid levels are entirely capable of recognizing the signs and symptoms that are abnormal and warrant referral to a specialist. They wouldn’t be gaining so much traction if diagnosis, treatment, and referral required so many years of training.
Not always true. I work in an area with very few specialists so we see a wider range of pathology. Nurse practitioners need experience to handle the variety we see here. Physicians are needed to mentor them. So with no neurologist, gastroenterologist, dermatologist, rheumatologist etc. , primary care IN MY OPINION demands a great deal.
One reason they are getting “traction” is they earn less. Another is that primary care doctors are getting burned out by all the non-doctor work they have to do and the specialty is less attractive lately.
Well put. Too bad we have no say in this “for profit” industry.
I trained my track of rural medicine with an outstanding rural family physician in Luverne Alabama, Dr. Tompkins, who is for that population, the hospitalist for acute care admissions, GI doctor doing Colonoscopy, Dermatologist removing all kind of skin cancers, the Psychiatrist treating all kind of mental disorders, the pediatrician, and the geriatric doctor. The closest specialist was 45 miles away. A truly primary care physician with his stethoscope hanging from his neck and of course away from the computer most of his time. Our specialty is beautiful and highly rewarding, they have just messed it up.
What a well thought out article. I found myself bored to tears checking off boxes in a Medicare wellness visit or routine yearly physical. I love the sick visits, and even took care of my patients in the hospital. That eventually was too stressful and didn’t pay enough to drive to the hospital 15 minutes away, once or sometimes twice in a day. I’ve moved to doing hospital work now. There, I get to negotiate the complexities of a medical problem, instead of the complexities of an insurance company’s prior auth system.
IN my 51 years in medicine, I have found that management of acute illness (especially infectious) is the easiest part of my practice, and the best use of physician extenders like PAs and NPs. Juggling those with multiple problems including renal disease or liver disease, so medication use becomes more complex, requires a lot more awareness of physiology and pharmacology. And doing the screening stuff could be mostly scheduled by the computer without me if the computer could convince the patient and explain the processes and risks. But what takes med school is dealing with the hypertensive diabetic with heart disease who had elevated transaminases on statins and now has joint pain and a GFR of 40. And I am often dismayed that some practitioners, including some with MDs in their titles, seem unable to keep these people safe but help them.