We have been primary care physicians for a combined total of 98 years. Every day we are reminded why we do it and why we love this type of medicine.
Here are three examples from a single day in one of our practices that show how a trusting relationship built over time has been vital to providing good care. One patient was a young woman whose recurring sinus infections and refractory asthma were treated with single-contact visits with specialists for years. None of them identified the underlying immunological disease that was causing her problems. But by observing her clinical course over time, her primary care physician realized she needed to be seen by a specialist in vasculitis. She also needed ongoing rapid access to a doctor who knows her complicated history when new issues arise and can coordinate specialists so nothing falls between the cracks.
Another patient was a middle-aged man with severe back pain due to lumbar disc disease who had been prescribed opioids for his pain when that was the standard of care. Over the next five years, his work took him out of the area, and he switched to heroin as prescription opioids became hard to find. Feeling consumed with guilt, he returned to his primary care provider, told her what was happening, and asked about buprenorphine treatment.
A third patient, a woman with severe depression and poorly controlled diabetes, arrived in the office with her log of blood sugars, finally engaging in self-managing her disease after consistent outreach by a dedicated and caring team, some of whom she has known for 30 years.
These are not one-off visits to a walk-in clinic. Primary care at its core often requires a deep understanding of the patient and the development of trust over time. We feel honored by this trust and inspired to give our best to help.
So we are alarmed and confused when the residents we train choose to leave primary care. We agree wholeheartedly with a number of the issues they cite: the electronic medical record with its primary service to the billing department rather than the patient, the unfair reimbursement for non-procedural specialties, the overwhelming debt burden from medical training, the long hours, and the complex social and emotional contexts that complicate our patients’ care. These are undeniable barriers that sap the joy and satisfaction that come with providing the longitudinal coordination of care, advocacy, clinical reasoning, and caring that are the core of primary care.
For us, and many others, the joy of primary care has not vanished. We recently surveyed students who graduated from Harvard Medical School between 1980 and 2016 and matched into residency programs that might lead to careers in primary care. Only 48% of the respondents continued on with primary care. Those who did that said they were highly satisfied with their choice. Despite the travails of the electronic medical record, the long hours, the complex patients, and the lower pay, they still found intense satisfaction in their generalist’s practices and their deep connections with patients. The intensely engaging core of the work is still there.
Still, too many young doctors have lost faith that their ideals for primary care can be realized in today’s health care environment. We suspect it’s not just the electronic medical record, or even lifestyle issues. Practicing medicine has always been hard, and we know that our trainees are strong. We suggest that the root of their dissatisfaction is the corporatization and bureaucratization of medical practice, which impinges on our professional autonomy, leaving us less flexibility to do what needs to be done for each patient.
A call to overhaul primary care and deconstruct it into newly “specialized” and more manageable pieces worries us as being potentially problematic for the health of the public, since ample evidence documents better health indicators and higher patient satisfaction in societies that have robust primary care systems.
“Specializing” primary care does not guarantee freedom from debt, inefficiency, or burnout. We see other solutions:
- Address and solve some of the systems that overburden primary care providers.
- Support them with multidisciplinary teams to deal with the multitude of contextual factors that create poor health and complicate care.
- Train them differently so they see complex patients as deeply in need of their care and thus more rewarding to work with, and see systems obstacles as opportunities to innovate.
Fixing primary care doesn’t lie in turning away from it, but rather in working together to create a system in which physicians can effectively lead interdisciplinary teams in providing high-value and equitable health care to the populations they serve.
The dominant values of the environment in which medical students and residents learn medicine shape their experiences, the lessons they absorb, and the solutions they envision. We must train a cohort of young physicians who see themselves as change agents, and who embrace and advance the mission of primary care: to improve the health of the public through a continuous relationship with a caring provider who provides first access to care, coordinates treatment and preventive efforts, and advocates for patients in an often complex system.
We must also clear away the obstacles, and ensure that residents learn and train in an environment that promotes, rather than undermines, a vibrant primary care system that is at the core of a rational and effective health system.
Barbara Ogur, M.D., is a faculty member of the Center for Primary Care and an associate professor of medicine at Harvard Medical School, and a primary care physician at the Cambridge Health Alliance. Katherine Miller, M.D., leads the Harvard Home for Family Medicine is an assistant professor of medicine at Harvard Medical School, and is a primary care physician at the Cambridge Health Alliance. Russell Phillips, M.D., is the director of the Center for Primary Care and a professor of medicine at Harvard Medical School, and a primary care physician at Beth Israel Deaconess Medical Center.
As someone going through IM residency training now I can tell you why most of my class has no intention of staying in primary care directly. This is the honest scoop rather than the politically correct spin these Harvard educators are trying to throw on you out of guilt of what “you owe to society.” 1. Primary care is not compensated anywhere near what it should be. When I rotate through subspecialty office fields like cardiology I actually find it easier because you are concentrating on one issue rather than 10 issues that have not been attended in years because they have not seen a doctor in as long as they remember. Why is it that my friend in orthopedics who has a similarly large amount of debt as me should get paid 2-3x the amount as me? We both did well in med school and went to a US med school. Along with these lengthy and underpaid visits comes extensive documentation which makes the field even that more unbearable. 2. Almost all of our primary care patients are spanish speaking and we are given little ancillary help with translation and support. Additionally, they can’t afford just about any meds so trying to go through what they can afford since they are charity care and where best to send the medication for them is a total disaster. There is almost no practicing and learning medicine at all. We are basically social workers in white coats. Even if when we are attendings we should a primary english speaking population if this is our experience whenever we have clinic is it really a surprise we think it will be like this long term. 3. Primary care is probably the least respected field in medicine. Mid-levels (np,pa) and even now EM docs think they can do your job just as well so why respect and pay general practice docs like they should? There are many more reasons if I ask my co-residents. Most importantly, ignore these authors liberal and unrealistic rant.
This article shows why more people are leaving primary care. Those in leading positions who should be versed in the issues that plague the field are confused by the young physician’s disillusion with PC.
Her identification of the problems ( number one is the medical record and payment incentives turn doctors into coders and data entry monkeys) and skips very lightly over the second biggest problem, the corporatization of medicine and stripping of primary care of income sources. Her solution is layering more costs more employees that continued cuts in reimbursement cannot sustain. Currently reimbursement for corporate hospital based (employed primary care )group reimbursement is multiples of what a practitioner may be paid. My practice receives $150 for a point of care echocardiogram that is reimbursed much higher at a hospital based out patient imaging center, and the hospital based clinic receives a $200 facility fee that triples the clinic income for the hospital corporate entity not the physician who treats the patient and interprets or incorporates that information to clinical use . The answer to train primary care nurse practitioners only basically for simple care belies the entire primary care complex recurrent sinusitis scenario you cited as where primary care is so important. In actual practice it fails entirely in the current system because physician extenders in fact have almost no support and absolutely no training in differential diagnosis, and thus in the average primary care setting would in fact never be diagnosed or even an attempt made to rule in or out more complex issues underlying such a problem. So replacement of physicians with inadequately trained nurses works for the data monkey function of primary care only and more data monkeys will not be a solution for clinics like mine who have had already tripled office support staff to manage data demands. It will be the absolute end to primary care. Unless you are just going to a doctor to get an antibiotic for your cold. It works fine for that.
Thank you for this. I have been working in primary care internal medicine for over 30 years and plan another 10. My reason for burn out is fairly simple: I’m not doing primary care. There are so many distractions that very little of my time is spent providing medical care. In a well-meaning attempt to provide “whole health” our system seems to add to the physician’s tasks so many things that I’m not trained for or interested in. Most of these things can be done by someone else. I am largely “rubber stamping” things that others want done (prerequisites tests for specialists, needless consultations, forms that a clerk could sign) or things others are more qualified to do. There has been a lot of rhetoric about having other members of “the team” do these tasks…but that is an unfulfilled promise. I think it is unwise to think that just because I’m a physician, I need to be involved in all the social, economic, religious, and cultural aspects of a patient’s life. Certainly those are vital: but am I the best person to be addressing them? I would be less burned out and more productive if I spent more time on the activity I’ve been trained to do: critical clinical thinking and shared medical decisions with patients. Currently there just isn’t time to do that. While whole health is a wonderful idea, I don’t think I can provide it unless the system can afford to have me seeing 2 patients per day.
Spot on with these comments! The psychosocial aspects of care are great but the other mind-numbing tasks including “meaningful use” charting and documentation that takes hours after every long day is killing primary care. I consider myself a “comprehensive internist” not a PCP or worse, a “provider”. This is what it has become and it’s no wonder young doctors are fleeing this field. The reimbursement disparity is also a huge factor. I guarantee if Internists were paid like derm or urology or anesthesia I predict the shortage would go away.
amazing how you all skip over the real problem – the AMA that is controlled by the pharmaceutical companies and is only driven by GREED. 50 years of ZERO Cures but hundreds of new drugs for the guinea pig patients. Because that’s how big money is made. And it’s not only more profitable to be a specialist, it allows the doctor to not take any responsibility for the patient’s total health. Modern medicine is a dismal failure.
I don’t think (or at least I hope not) that your critique is being passed over, per se. Rather, I think this absurdity is being taken as a given, the precondition for our current predicament; and people are looking for “practical” solutions because addressing the core issue — the role that profit motive should play in medicine (read: ABSOLUTELY NONE) — seems insurmountable. A self fulfilling prophesy, to my eye, but alas.
So sure — by and large, people are doing what they’ve always done in the face of endemic social problems — look for palliatives. Mistake symptoms for diseases. Maybe complain loud enough for elected officials to smile and stage a photo op of putting a band-aid atop the bones of fundamentally malignant social structures.
This (inadequacy of) framing is certainly problematic. However, it IS understandable. Perhaps even, in a roundabout way, almost reassuring as far as caregivers are concerned. That is — I, as a non-physician, have the LUXURY of abstraction. The ability to conceptualize, analyze, and strategize about long-term macro struggles is oft the privilege of those whose lives don’t center around having to empathize (and/or rationalize) at the fallout of this struggle on a micro scale.
Thus, the banal tragedy of modern institutions: the people who tend care the most about improving them — the people working within those institutions — are often the very people least equipped and/or incentivized to do so. Cognitive biases. Anxieties tied to self-interest/career preservation. Hell, even noble impulses like willingness to ignore or break any rule to save a life. All of these things and more, when the urgency of the Actual is deemed more important than the benefits of the Possible — ideals, calculations, strategy be damned.
Short reply: much as with education and prison systems, the profit motive has no place in health care. I say this not only for (hopefully self-evident) moral reasons, but really very practical ones. Corporations, as an entity, are LEGALLY BOUND to act only in the financial interest of their shareholders. Though are granted all the rights of an actual individual (and often then some), they are NOT granted the agency to make decisions based on things like empathy, altruism, public good, and other non-sociopathic human considerations. There is simply no place for the profit motive in matters of social well-being.
My primary care doctor is the best physician I have ever had. Kudos to her for great observational and listening skills. She makes it her business to give her patients a pedestal to connect with her . This guarantees her successful treatment of her patients.
I agree that primary care must change but those at the table hold a significant degree of “power”. I find that the change that is looking to be made is allowing midlevels to be autonomous and equal themselves to physicians…large systems look at these clinicians (well we are now termed providers) will feed the machine of high cost testing without critical thinking as to what is the cause of the problem. I find that many recent FP grads are turning to apps and referrals rather than think through the presenting symptoms and determining the cause with a goal to fix the cause but because we are a consumer driven system giving a pill to stop the symptoms is common place. Systems are more concerned about a clinicians survey scores than doing the right thing for the patient.
I am not sure if this is the right fix but emphasis on primary care, financial adjustment and elimination of the EMR, since let’s face it the idea has failed, may fix the problem but until large healthcare systems, insurance and politicians are removed from the table and those who actually work in the trenches are put I their place no change will occur.
So here are a few ideas….increase pay for family medicine residents (double the yearly salary)….change the program to four years to increase exposure as a resident, upon completion of the residency and five years of practice all loans are forgiven by the government; eliminate or better yet simplify the EMR and not use this as a means of determining payment; FQHCs are paid a flat fee for each office visit for Medicare and Medicaid patients…that could be negotiated for Primary Care with all insurances which would allow for the physician to concentrate on the patient and not the laptop or computer screen; continue to encourage office based procedures as well on the same fee for service level as the specialists. Eliminate prior authorization and create an app or two to assist in ordering the most appropriate testing when certain symptoms or findings are entered as this is what is done anyway with the prior authorization process. All primary care….OB, Peds, General IM, FP should be covered under the Federal Tort Reform Act from a malpractice perspective. By increasing pay for the visit to an adequate fee as above salaries would be able to be increased there by equaling the playing field or tipping the scales toward Primary Care.
Finally let’s teach primary care physicans the skills needed to run a practice or even better yet a hospital…no need to be paying MBAs millions of dollars that the physicians are the producers of and then be told by someone following the widget factory model that we are not doing enough, ordering enough, billing enough when they go home at night not loosing a night of sleep thinking about that sick 6 month old or if the 75 year old will be able to afford their medications..
I not long rant but until the Pharma, hospital management and insurance apple cart is turned over nothing will change.
Profoundly agree.
Profoundly agree
As a millennial physician who has left the practice of commercial medicine, it is partly due to the view that we physicians as a group have abdicated our role in how the overall system works. We have, for many reasons, given in to the corporatization and the system continues to devolve. Things incrementally are worsening and we can’t or don’t work together to fix the system. To practice medicine and make the numbers work, in order to survive, compromises my personal ethics. There is no one problem – there are a multitude of problems and no single solution. To repair the system will require a concerted effort and I just don’t see at this point how we are going to accomplish anything.
I would add that I agree with the benefits to patients and the system provided by primary care. Problem is, non-physicians and patients have relatively little limited u derstanding of what we can really do. Thus our value is not appropriately considered in the calculus of designing the healthcare system.
Agreed with Dr. Green. The delivery system is broken, and on top of that, the people that want to be primary care providers in rural areas are faced with a paucity of the specialty referral services that are necessary to make primary care an effective node in the healthcare network. Until we have a more equitable healthcare system on a policy level, one that gets away from profiteers and hospital complexes and meets patients where they are, primary care will continue to suffer.
The delivery system is broken and depends on too much bureaucracy for young doctors to wade through. A single payer system will relieve and give peace of mind to professionals and patients alike. Those seeking to become effective clinicians should realize the unnecessary burdens present day payment systems that dictates, excludes, complicates, and frustrates everyone involved. It doesn’t hurt that it will also be affordable.
As a millennial physician who has left the practice of commercial medicine, it is partly due to the view that we physicians as a group have abdicated our role in how the overall system works. We have, for many reasons, given in to the corporatization and the system continues to devolve. Things incrementally are worsening and we can’t or don’t work together to fix the system. To practice medicine and make the numbers work, in order to survive, compromises my personal ethics.