Nearly three years ago, we began training as primary care doctors in two residency programs at a Harvard-affiliated teaching hospital. We understood the value of longitudinal patient-doctor relationships and wagered that primary care would be the bedrock of this nation’s health care system.
That was even after hearing the warnings: predictions of a national shortage of more than 44,000 primary care physicians (PCPs) by 2035, rampant physician burnout, and a workforce saddled with two hours of required documentation for every hour of patient care.
Nevertheless, we felt inspired to join the front lines of health care.
Yet when we finish our residencies on June 28, neither of us will be practicing traditional primary care. We are not alone in turning away from this field: Approximately 80% of internal medicine residents, including nearly two-thirds of those who specifically chose primary care tracks, do not plan to pursue careers in primary care.
We get it. The day-to-day practice of primary care feels daunting and unsatisfying. Primary care physicians need an estimated 18-hour workday to complete their various responsibilities. The much-maligned electronic health record inhibits PCPs from fully connecting with patients and creating the very patient-doctor relationships that once brought meaning to the work — the relationships that lured us into this type of medicine. Instead, our interactions with patients now feel transactional.
And despite the long hours and increasing demands, compensation in primary care trails behind that of specialty care. After four years of drowning in medical school debt and three years barely keeping afloat on a resident’s salary, the preference for becoming a specialist is entirely rational. The prospect of scrounging for reimbursement for our services from insurers and clicking through cumbersome electronic health records all day isn’t a tenable way to offload heavy student debt.
The practice and financial realities tell only part of the story, however. Primary care training is also complicit.
Primary care residencies based in academic medical centers do little to promote or incentivize careers in primary care. These residencies uphold the hospital-centric health care system. Outpatient training is often an afterthought, and dysfunctional experiences in the clinic taint trainees’ impressions of primary care.
Internal data from our hospital show that residents have a higher percentage of Medicaid patients in their panels than their preceptors do. Not only is it unfair for these patients, who often have complex needs, to be mainly seen by new physicians, but such clinical experiences can feel impossible and overwhelming for trainees. Because most primary care programs demand many more than the mandated 12 months of inpatient training, primary care residents struggle to fully integrate into their clinics, to build confidence with outpatient medicine, and to create longitudinal relationships with patients.
Our experiences belie a deeper existential crisis in primary care. The pressure on primary care is mounting: to coordinate care for an aging population beset by chronic disease, to improve the overall wellness of the population, and to control costs and eliminate waste, all the while ensuring a satisfying patient (and supposedly clinician) experience.
Is it reasonable to expect primary care to do all of this? To be all things to all patients? It seems like today’s primary care is being defined less by what it is and more by what the rest of the health care system isn’t — or doesn’t want to do.
As the demographics and cultural values of the U.S. change, traditional primary care is struggling to define its value proposition. Office visits to primary care doctors declined 18% between 2012 and 2016. Patients are increasingly choosing urgent care centers, smartphone apps, telemedicine, and workplace and retail clinics that are often staffed by nurse practitioners and physician assistants for their immediate health needs.
Millennials are choosing solutions that circumnavigate physicians, accessing direct-to-consumer diagnoses and prescriptions for conditions like hair loss, erectile dysfunction, and skin care.
Or consider frail elders, a growing subset of patients who require interventions to prevent falls, manage multiple comorbidities, and plan end-of-life care. Much of their care is being outsourced to geriatricians. Even when they are hospitalized and are at their most vulnerable, they are treated by anonymous hospitalists rather than their familiar primary care physicians.
And then there are patients with complex behavioral needs, ranging from mild anxiety to full-blown substance use disorders, often complicated by trauma, lack of housing, and food insecurity. Caring for this fragile population demands a high-touch collaborative effort by a team of social workers, community health workers, nurses, and doctors. Organizations like Cityblock Health are placing the community health worker — not the primary care physician — at the center of the care team as it works to address the social determinants that are driving health outcomes.
Solutions that exploit the inefficiencies of traditional primary care and fill in the gaps leave us uncertain about the future role of primary care physicians. We wonder whether it’s right or realistic to insist that primary care be the same thing for people of all ages across all demographics, geographies, and incomes. While we still believe that coordinated care that is longitudinal and based on relationships must be the foundation of a healthy America, traditional primary care is simply stretched too thin to provide it and is being eroded, circumvented, and replaced.
It is time we reimagine the role of the primary care physician.
While retaining its core value proposition — longitudinal, relationship-based, coordinated care — primary care must differentiate into narrower, more manageable scopes of practice. The doctor managing opioid use disorder alongside a community health worker is just as much a primary care physician as the one doing intensive behavior counseling patients with prediabetes, the one coordinating care and preventing hospitalizations for high-risk patients, or the one designing balance training programs for the elderly. Given the variety of expertise required in such care models, the primary care physician may no longer be the sole — or even the most valuable — player on the team. This counterintuitive “specialization” within primary care will reduce the current burden on current PCPs and better achieve primary care goals like prevention, efficient resource utilization, and population health.
How primary care physicians are trained must also change. That needs to start by ensuring that future PCPs are entering a profession with reasonable demands and loan forgiveness. During training, they should rotate through high-functioning patient-centered medical homes, hospital-at-home programs, telemedicine units, Teaching Health Center programs, and concierge care practices to experience different models and explore various versions of primary care.
Training in management, leadership, and advocacy skills is also a must — we can no longer separate the clinical practice of primary care from the practice model and the community in which care is delivered. Senior trainees should have access to scribes and technology-enabled support tools to maximize learning and patient interactions. And clinical experiences in cutting-edge primary care models should receive graduate medical education accreditation.
These innovations, while disruptive, are essential to address the dysfunction that plagues traditional primary care. Nostalgia for tradition is thwarting progress, driving burnout, compromising patient satisfaction, and adding stress to a fractured health care system.
Instead of waiting for payment models and policies to dictate how primary care evolves, primary care should focus — now — on making itself invaluable for both patients and physicians alike.
Richard Joseph, M.D., and Sohan Japa, M.D., are senior residents in primary care-internal medicine at Brigham and Women’s Hospital in Boston. Following the completion of their residencies, Joseph will be working in weight management and obesity medicine and Japa will be working as a hospitalist.