“Practice at the Top of Your License?”

In my first 30 days on Substack, I published a post that got eight new subscribers and broke my record of how many views it had, 195, more than twice what my budding Substack had accomplished before.

It was a call to reimagine, reinvent and reinvigorate primary care. I re-blogged this post on my original, much older WordPress blog and it got 14 comments, many more than usual. So this was a hot topic and two years later it’s still hot. In fact, personally, six months later, I started transitioning to a different job, the one I now work full-time in, doing housecalls and virtual visits for older and disabled patients.

Many of the comments were saying that Direct Primary Care is the solution to today’s primary care crisis. It’s a great alternative, for sure, but it doesn’t work for everybody. Medicare patients on a fixed income need to use their insurance if they still want to eat and heat their homes. Same thing for most people on Medicaid.

There are a few problems with primary care today. One is that our nation’s lack of a public health system has defaulted most of those tasks to the primary care practices, where we are hard wired (and usually reimbursed) for seeing patients one by one. It is hugely inefficient to do mass education and mass screenings with large populations on a one-on-one basis. This is obviously leaving less time to treat sick people one by one.

Another problem with primary care today is that managers and EMR programmers have basically no idea of what we do, the cognitive aspect of doctoring. They only see the superficial aspects of our work and they create “workflows” (a word that makes me cringe) that emphasize the scutwork aspects of our day instead of creating systems that liberate us from tasks that non-providers could do and free us up to diagnose and treat. This is a dramatic example of what it used to be like to dose the blood thinner warfarin before and after computers (note that the top image is for 4 months’ worth of test values and the bottom “workflow” is for ONE SINGLE test value).