My colleague, Skip, was the kind of primary care doctor I always wanted to be. He could riff on the evaluation of a patient with new joint or liver inflammation like an improvising jazz musician. He could discern a familiar rash in the most puzzling plumes of hot, angry bumps. When I had lab results that flummoxed me, I’d go see Skip. He’d tip back in his chair, swivel a bit in thought, and make sense of the findings.
Six months before the Covid-19 pandemic emerged, Skip died by suicide. At his memorial service, a friend described Skip’s dedication to his patients: he would overhear Skip tell his wife he’d be home to cook dinner, only to get into a series of telephone calls with patients and miss dinner altogether. Patients described how when they were ill, Skip would double book them into his schedule or go see them at home.
None of these stories diminished my admiration for Skip; in fact, they demonstrated the ideals of patient care that animate many primary care physicians. But they left me deeply conflicted, and I have grappled with Skip’s legacy, particularly now that I am the unit chief in the department where Skip worked.
Suicide is complex, and I know that other issues contributed to Skip’s death. Still, I wonder if things might have turned out differently if he hadn’t given so much of himself to his work. And it disturbed me that many of the attributes we lauded in Skip — dedication, accessibility, commitment — may have harmed him.
Covid-19 swept through Chelsea, Mass., the community our health center serves, like a fire in dry grass. Adrenaline got us through the first surge. But over time, the pandemic magnified the essential dysfunction of primary care.
As a unit chief, I see the added burden of the last few years weighing down my colleagues of all stripes. Though I focus here on primary care physicians, the themes of this essay apply to all types of health care workers.
Patients are messaging their clinicians through online portals in greater numbers than ever before and are coming in sicker after skipping years of appointments. I’m on a text chain with some medical school friends, all primary care physicians. We regularly poll one another: “How’s the burnout today? Pleasantly crispy, or smoking pile of ashes?” We joke, but the humor masks fear.
While burnout and depression are distinct entities, the two certainly overlap. And as clinicians’ in-baskets swell with post-Covid demands, it frightens me to see friends and colleagues giving ever more of themselves to fulfill an idealized vision of primary care that is increasingly unrealistic.
Primary care is crucial, even foundational, to health care. Yet it remains under-resourced. There is a yawning gap, widened further by the pandemic, between practicing primary care in the way it is resourced and in the way that patients deserve. Most primary care physicians bridge that gap by spending hours of their personal time on patient care, staying up at night answering messages and reviewing and sharing test results. I used to accept that because it is what patients need, so that is what should be done.
From the first day of medical school, physicians are taught that patients come first — always. Before Skip died, I never thought about each choice my colleagues and I make to put a patient first — one more phone call, one more hour on the computer, one more family dinner missed — and how much those choices cost when magnified over a career. Putting patients first should not mean self-abnegation, and often in those small moments it doesn’t seem to.
And yet, it does. The sum of those small choices erodes mental health. Physicians have among the highest rates of suicide of any profession, and almost half of them develop depression by the end of training. As physician and writer Elisabeth Poorman persuasively argues, depression and suicide are occupational hazards of practicing medicine.
Since Skip’s death, I haven’t given up on the promise of primary care. But I am keenly aware that the current asymmetry between the expectations of primary care and the support for it harms me and my colleagues and imperils the future of our profession.
I now see that a crucial part of my role is to encourage the doctors I work with to give less of themselves to their work. As a unit chief, I have few levers to achieve this. I don’t have any bandwidth in my budget to hire the many additional staff I believe we need, and I can’t reduce our workload by wishing it away.
But what I can change is how I talk with my colleagues about our work. We can name that the widely accepted expectations of primary care are almost wholly aspirational. We can change the stories we tell ourselves about what it means to be an excellent primary care provider. And we can establish a new archetype: a physician who cares intensely for their patients and is also empowered to practice medicine sustainably, in a way they can continue doing year after year after year.
I have tried to engage my colleagues in a discourse about sustainable primary care practice in a few ways. First and foremost is encouraging them to set limits with patients. Because medical training equates providing good care with putting patients’ needs first, many primary care providers hesitate to put up boundaries. But just like any other aspect of primary care, such as best practices in population health, we should talk about and share best practices for setting boundaries with patients.
That might include limiting the agenda for a visit to three topics for patients who bring numerous concerns to each visit. Or it might involve limiting the time spent on answering messages received via the patient portal. Many messages can be answered by other team members but, when a physician must respond, they should answer messages only when they have a moment during a workday — and never at night or on weekends. Lengthy conversations about test results should be scheduled as virtual visits, so the time is accounted for in clinical productivity, even if this delays the conversation.
Many hospitals and health care systems ask patients to review their providers. I would rather work with physicians who feel their work is sustainable and have some negative comments from patients that their visit was too short or their results took too long to get back to them because those problems reflect flaws in the health care system, not in the physician.
I have also tried to emphasize sustainability in primary care by encouraging my colleagues to embrace team-based care. Teams have been the watchword in primary care since I was in medical school, yet for many clinicians they remain an unfulfilled promise. Making this a reality is partly up to local leaders like me working more effectively to weave well-trained team members into every workflow. Working against this, though, is that low reimbursement for primary care is a barrier for many practices to hire strong managers and sufficiently staffed teams.
But I also think that some primary care providers still harbor a desire to fulfill the antiquated archetype of a physician who solely holds all aspects of a patient’s care. It’s time for physicians to have the humility to recognize and embrace the gifts and skills other team members bring to patient care that they lack.
To be sure, such efforts are only a drop in the bucket. Front-line clinicians and local leaders cannot solve the real problem: the architecture of the U.S. health care system. If payers and provider organizations want patients to have more time with primary care providers and same-day personal communications through portal messaging, they need to increase primary care reimbursements so providers can spend more time with their patients and hire staff to help manage those portals. And if teams are the future of primary care, a dramatic increase in funding is needed to support, train, and maintain those teams.
I often doubt whether policymakers and health care executives will ever make the difficult choices necessary to fix primary care. But I have no doubt of its value. I recently finished a visit with a patient I’ve taken care of for years. Each time I had offered her the Covid-19 vaccine, she demurred, concerned about stories she’d heard from friends and family despite my reassurances. But this time, she arched a perfectly penciled eyebrow at me and said, “If you still recommend it, I guess I’ll take that vaccine today.”
Those of us in primary care want to give our patients the time and effort and excellence and passion that Skip invested in his patients every day. But we can’t do it without investment in us.
Audrey Provenzano is a primary care physician and the unit chief in adult medicine at MGH Chelsea HealthCare Center and an instructor in medicine at Harvard Medical School.
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.
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