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.

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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.

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  • Very insightful article. It hits on most of the feelings that primary physicians face. I have been a primary care physician for 23 years and it’s getting harder. Bureaucracy kills us. When it takes PAs to get generic drugs and a mountain of paper work to get a wheel chair, something is very wrong! When one insurance has a different system than another and they all differ from government plans, it makes delivery of care virtually impossible. We need simplification and streamlining.

  • I’m a Family Medicine Doctor (with an MPH before staring my MD training) who trained for and is practicing full scope family medicine (Hospital, clinic and OB) with a fellowship in Behavioral Health and Psych now 3 years out of my training.

    I agree there are large system problems. The problems come from high cost fractured care based on services and outcomes rather than prevention. I often say the American Health Care System is not healthy caring or a system. However I don’t think the solution comes from making a system more fractured by not having a physician coordinate care. A team approach is definitely needed, but someone needs to lead the team.

    The other problem is that there is simply not enough physicians for vast majority of the population. More and more centers are turning to mid-levels which simply do not have the same training. The US has a few physicians trying to do the job of many, and are highly in debt, under paid compared to that debt and dealing with moral abuse from both insurance companies and employers.

    That said- I still think physician lead primary care is the foundation to a functioning health care system. This has been shown world wide to be true.

    • I agree fully with this comment, having experienced health care in a country where there are enough doctors. (Two actually, as the US of my 50s childhood also had enough doctors.)

  • I would say amazing insight to a situation from two docs who have yet to complete residency. My approach is from 30 years primary care experience and parallels many of your description of the problem along with the conclusions.
    Good luck with your next positions in medicine.

  • I work in an urgent care facility as a technician. A vast majority of our patients come in to be seen for issues that should be seen by their primary care physician, but their reason for coming to see us is that they cannot get an appointment to be seen when they want.
    The need for immediate gratification is becoming a plague that has spread through our country.
    The reduced number of primary care physicians and providers has fed the rise in the number of urgent care facilities, thus contributing to the rising cost of healthcare. Patients aren’t educated on self-care for common ailments. Visits for issues that can be treated with everyday over-the-counter medications are now the norm. Nurse advise call lines almost always end in telling the patient to go to urgent care or the emergency room instead of giving out actual advise.
    Medicine in all aspects is a science, and science can be flawed. A diagnosis is often a best guess based on the evidence that is available at the time.
    Problems with the primary care system, and the medical system overall will continue to worsen unless a major issue is resolved; medical malpractice lawsuit reform. Providers today are more concerned with making their patient happy than doing what is right for the patient. Radiologic exams and laboratory testing are often ordered at patient request, even when not medically necessary. Patients want a non-stop shop where they can have everything under one roof and they want it now. The standard primary care office is unable to meet this need for the patients of today.

    • As a practicing physician 4 year out of training, I just want to say that is a refreshing and very accurate analysis of healthcare issues we face. I believe you as a person working in this small (I’m assuming) clinic have more insight than a lot of administrators, congressmen, or even many physicians!! Thank you.

  • Nice hook at the start of the article to seem sympathetic to our plight, but the total 180 degree turnaround to plug the various things that have destroyed Medicine, urging our compliance with it all, is despicable.

  • I greatly appreciate and agree with the assessment and summary of the complex demands placed on GIM. The expectations of an excellent patient experience, comprehensive evaluation of medical history and needs, assessment and plan with follow up and documentation that is inclusive to ordering labs, diagnostics, referrals, procedures etc. is daunting. GIM as well as other primary care specialties has historically been everything to their patients and it was an honor to provide that care. Primary care is an essential specialty but it will need to transform and redesign itself to fulfill the needs and demands of the next generation of patients.
    Thank you for your thoughtful insights.

    • I appreciate that internists are overworked, and I know from experience what burnout is: it’s hell. But I’d like to say two things: 1) my last two women internists love their jobs and it shows (one is still my internist, the previous physician moved with her husband to another town). And 2) I live part of each year in France. My internist there is relaxed, can often see me the same day I call, or if not then the next day after his hospital rounds. I don’t have any friends here with a burnt out GP. As far as I can tell, it’s largely because there are plenty of doctors. From whom I’ve always received good care, and whom I like and trust. The WHO ranks medical care in France among the best in the world, often in first place, always better than the US. Let’s find out why! Then the wonderful people who dreamed of this job and are now burnt out and disillusioned can work towards making their dream, for so long a reality in France, a reality in the US.

  • Bravo! You echo what I have said for 20 years! Patients ask why so many doctors are leaving medicine and this is why for us PCP’s. Add in the ludricous MOC requirements and daily frustration long hours and dictatorship of admin. I actually discourage students from going into medicine unless they go in with realistic expectations. No longer being altruistic enough

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