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.