Primary Care Is In Crisis

Internist explains why the current work flow of a primary care physician is unsustainable and how lower salary and substantial debt add up to little financial incentive to work.

By Lydia Dugdale, M.D.

Don't make me leave primary care. You need a doctor, and I love what I do. But this work just isn't sustainable.

In 2009, I finished medical training and joined a clinical academic practice. For those not in the know, doctors can -- very generally speaking -- work in one of two domains: in private practice, or on faculty at a medical school where they see patients, teach, and/or do research. Some docs manage to keep a foot in both academics and private practice, but for most, it's one or the other.

I stayed in academic medicine for many of the reasons that my colleagues did: to be immersed in the front lines of new knowledge, do a bit of teaching, and care for complex and diverse patients. I chose a salaried position, unencumbered by concerns of paying overhead or running a business. And even though academic physicians tend to earn less than those in private practice, I have no question that I am in the right place. I love my work. And more importantly, I love caring for my patients.

But primary care is broken across the board. The work is unsustainable. I'll tell you why.

For a start, the pace is manic. In our clinic, we see established patients roughly every 15 minutes. This flows well when the patient is a young healthy woman on no medications coming in for the common cold. But what about the 70-year-old man with diabetes, high cholesterol, high blood pressure, and prostate trouble? He sees four specialists and takes 17 medications, is retired and enjoys chatting. Even though he keeps in his wallet a list of his pills, he forgets to update it. We spend six minutes fixing his medication list, eight minutes reviewing the recommendations of his sub-specialists, and he hasn't yet mentioned the reason for the visit. You don't need to be a mathematician to calculate why your doctor is always in a rush.

If the primary care doctor's only task each day were to see patients within a very limited time frame, it might be doable, but unbeknownst to many outside of medicine, the doc does so much more. How much? A recent study in the Archives of Internal Medicine looked at clinics just like mine -- academic general internal medicine practices -- and for the first time ever attempted to quantify "the work no one sees." The researchers found that in a typical clinic day, the general internist completes electronic orders for 70 laboratory tests, images, and consultations; writes and signs 31 prescriptions; responds to seven patient care-oriented messages; and reviews, edits, and signs 19 electronic medical documents. Most of this occurs outside of face time with patients, and -- they postulate -- this estimate is conservative.

But it's not just that time is short and busy work abundant; primary care doctors also increasingly struggle with job satisfaction. Why? Two reasons. First, we primary care doctors take pride in being the "people people" among doctors, but time constraints force us to emphasize strategic decision-making over relationship. As much as I'd like to engage my talkative retiree, an extra five minutes per patient puts me over an hour behind at the end of the morning clinic session and imposes on the afternoon schedule. And yet, I need to talk with my patients, and they need to talk to me. These conversations build trust, clarify patient wishes as well as misunderstandings, and result in improved care all around.

We primary care doctors take pride in the jack-of-all-trades-ness of our specialty, but in practice, we do less and less medicine. Rather than master diagnostician, the internist often feels more like a glorified vending machine. Push enough buttons and you just might get what you want, regardless of whether it's good for you.

I anticipate the response to my observations to be along these lines: Stop whining; other professions have it harder than you do. You chose this. You make a decent salary. You have job security.

Yes, all of those things are true. But when the unrelenting pace, scope, and quality of work leave me so mentally taxed that I am unable to engage my children or spouse night after night, then something must change. At the end of the day, the healers themselves must be healthy in order to continue the work of healing others.

The insufferable pace of primary care combined with the erosion of the doctor-patient relationship deters young physicians from entering the field. In my graduating class of 30 or so internal medicine trainees, only two of us chose to go into primary care. The vast majority picked sub-specialties with a narrower scope of work and a higher salary.

What can be done? I offer two simple suggestions as starting points. First, medical students need greater incentives to choose primary care. Currently, programs exist to help reduce student loans for physicians practicing in certain low-income settings, but individual states need to offer grants to reduce student loans for all primary care doctors accepting state insurance. For my part, as a working mother of two, more than 60 percent of my monthly salary goes to my student loan payments and to child care. There is almost no financial incentive for me to work.

Second, primary care doctors need more resources. More assistance with paperwork and telephone calls translates into greater opportunity to spend time with patients and practice the art and science of medicine. It is for my patients, after all, that I became a physician.

Primary care is in crisis, and I am here to work. Please help me to stay.

Lydia Dugdale, M.D., is a primary care internist and assistant professor at Yale School of Medicine. This post originally appeared on Huffington Post and appears here courtesy of the author.
 

Posted by Sonya Collins on Dec 13, 2012 10:41 AM US/Eastern
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