Some doctors may resist the primary care team approach

What if some physicians actually like the way primary care is currently practiced?

It’s hard to believe, considering the majority of studies suggest marked dissatisfaction among primary care doctors, and an increasing prevalence of physician burnout.

The ACP’s Bob Doherty recently summarized an epic Health Affairs article devoted to fixing primary care. The bottom line was that better paying primary care doctors isn’t enough. The whole field needs to be re-invented.

That means a more team-like approach, with physicians taking a leadership role. Instead of seeing 30 patients daily, doctors can involve more mid-level practitioners, like physician assistants and nurse practitioners, for more direct patient care, while physicians can take a more supervisory role. Small pilot programs have found a decrease in burnout using this model.

But what if some doctors were resistant to this change? It’s a thought I hadn’t considered:

I wonder, though, whether primary care physicians “in the trenches” really want to have their practices re-invented. Most physicians, in my experience, are rugged individualists, and resist the idea of practicing as a member of a team. Moving away from what one article calls the “tyranny” of the 15 minute office visits sounds like a good idea – but figuring out how to get there, and sorting out the respective roles of every member of the team, is another thing.

Maybe I’ve been fortunate with my collegial interactions, but most doctors I know embraces the team concept. Especially coming out of a medicine residency — where patient care is almost entirely team-based — newly minted doctors shouldn’t have problems transitioning into this approach.

Perhaps solo practitioners may have some problems adapting, but it’s clear that this is where primary care is heading. How fast it’s implemented depends on how soon we can change the underlying payment system facilitating such a model.

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  • Bruce Hopper Jr MD

    Doctors would not have to see 30-40 patients/day if we utilize technology properly and wisely.
    The PATIENT needs to be at the CENTER of their care, and we need to be collaborative and participatory with them (and their specialist consultants) at the primary care level.
    Small is the new big (and better, and more agile to change, and more flexible).
    Big systems make it very challenging to preserve the patient-doctor relationship and are extremely slow in adapting to change.

  • family doc

    The team approach has it’s own problems. In some areas, talented support staff are hard to find or retain for long periods. Turnover of staff is a major hassle when the physician’s schedule is dependent upon effective staff work to maintain a fast pace.

    Ideal practice or IMP is also a reinvention of primary care but in a very different direction. Both IMP and PCMH offer advantages over traditional practice but patients and physicians should have the option of both, not just the new high staff, high overhead PCMH model.

  • CSmith

    I think team-based care makes the most sense for vulnerable patients who need a lot of resources like those with multiple chronic diseases which require management or the infirm geriatric patient. Even the beta sites for PCMHs are having a hard time continuing the model due to poor funding. Many different models will probably exist in the future. A physician with one extender and 1-2 medical assistants can accomplish a lot with a registry to help manage chronic conditions and digital patient engagement and outsourcing of dietary counseling etc. What primary care needs is adequate capitalization and a new payment model which aligns incentives appropriately and minimizes fee-for-service.

  • r watkins

    There was no supporting evidence for the majority of the claims made in the Health Affairs articles.

    The experts can talk until they’re blue in the face, but, yes, the only way to save primary care is to increase pay dramatically and thus allow the docs to reduce their patient and administrative load.

    Primary care docs want to take care of patients: forcing them into “supervisory” positions would be the kiss of death.

  • Doug Farrago

    While medical homes sound fantastic it is more realistic that we will have medical condos, medical apartments, medical shacks, and medical shanties and will be paid in a commensurate manner.

  • MB

    I had the awful experience of being involved in the Tranformed pilot project. After my doctor’s clinic became involved in this project, I no longer had any type of relationship with my doctor. Over the eighteen months, I saw 7 different providers, not counting the two times I decided to seek treatment elsewhere because of the feeling of being passed around. I didn’t feel the physician assistants I saw made any effort to understand the background of my illness or make recommendations based on my needs.

    I live in a state where nurse practionioners can practice without the supervision of a doctor. The thought of being passed around the Transformed clinic for a gynecological problem was more than I could deal with so I made an appointment with a women’s health nurse practioner. She spent a lot of time with me, and not only did I receive care for the gynecological problem, she felt I was depressed and I began receiving treatment. She was there for my follow-up.

  • Rod

    Increase the pay for just few years and see how dramatically it will change the primary care to specialist ratio. It will also change the way referrals are done because if you pay them better, they will also spend more time with their patients instead of being on a hamster wheel.
    I agree with above comment that you can talk about everything else till you are blue in the face but PAY will be most effective means to lure people and keep them happy in Primary care

  • rwatkins

    Excellent posts, MB and jsmith.

    This is one of the elephants in the Medical Home concept that no one wants to talk about. As currently defined, the medical home requires such enormous amounts of administrative work by the physician AND by the skilled nursing staff that face-to-face patient time is inevitably reduced.

    In the AAFP’s “Task Report #6,” the main document so far on the finances of the PCMH (read it if you’re in the mood for a laugh or two), it is stated that “The physician is recognized by patients as the leader of the team . . . this approach reduces the amount of time spent by the physician per patient”!!! Is that what patients and physicians want? Even shorter appointments?

    The other elephant in the room, of course, is that no one outside of a few demonstration projects has any commitment to paying for the medical home.

  • jsmith

    The team approach is another panacea that sounds good to people who don’t know anything about what patients want and what doctors want. As several above posters noted, when people are sick, they want to see their doctor, not some rotating group of semi-trained people who might be more focused on lunch breaks than pt care and who have all the medical knowledge that a couple of morning seminars can give.
    Sure, have someone else draw the blood and send the normal lab letters. But the people seeing the pts should be doctors. Hasn’t anyone noticed why concierge medicine is taking off? Because medicine is and should be a personal service, and pts want this, and doctors want this. I do not want to be a middle manager and will resist that job with all my strength. There are thousands of family docs who feel the same way.
    Here is the problem: This society is not willing to pay doctors enough to do sustainable, reasonable-volume primary care, so med students are avoiding the field, and instead of actually solving the problem, America has come up with another yet pseudo-solution that will just make things worse–more expensive, more fragmented, less satisfactory for pts and doctors. The team approach will fail. Oh, and by the way, electronic health records are another false solution.

  • Nirav

    Wow, MB. I wonder if others have a similar experience with Transformmed. HealthCare is difficult thing because efficiency demands a division of labor and division of labor depersonalizes the experience. Since patients don’t walk away with something (like a TV or iPad), they want their money’s worth by seeing somebody. Unfortunately, a $10 copay doesn’t buy much just as it always didn’t. There are many doctors that care about more than money but with clinic expenses running between $1-$4 per minute, it gets tough.

  • rezmed09

    OK, residents work in teams, but there really isn’t much similar with the Medical Home or Team approach.

    For the PCP’s in the trenches – who are in small practices, this just means more employees in the business. Instead simplifying the life of PCP’s, the Team approach will only magnify the size of the small business. Now you have to hire, manage and fire several mid-level providers (whose work you are liable for). Now you have to hire more business staff. Now you need a bigger office.

    The only appeal this team approach has is to medical corporations, who can justify mid-levels seeing and managing more and more complex patients (which may be fine) with no downside. After all, the patient is still ultimately under the care of the deep pocket – the doc.

    Hospitalist medicine with a salary is familiar to IM residents, not the management of an outpatient business. Nothing will help primary care, until the payment mess and paperwork is simplified.

    • jsmith

      Well said, rezmed. This team approach business is yet another scam to try to fool med students into signing their lives away. You have to fix the money and the lifestyle issues. The team approach will do nothing for the money and will make the lifestyle issue worse for a lot of docs in small practice. I suspect the team approach is a also a way to try to herd PCPs into large groups. Med students won’t fall for it.

  • Matt Katz, MD

    I’m not familiar enough with practice management in primary care, but as a radiation oncologist it’s impossible to practice without a team approach.

    I see new cancer patients, but to plan and administer treatment requires coordination with radiation therapists, medical dosimetrists, and medical physicists. Once treatment begins, nursing also plays an integral role. Administrative staff also is critical for organization and as the first contact patients have with my practice.

    The complexity of treatment is what dictates required team approach, but I would imagine that there are equally complex aspects of primary care that could benefit from a strategically designed therapeutic team.

    • rwatkins

      Of course, every doc practices as part of a team, be it two people or twenty. In the medical home model, “team approach” means that the patient’s access to and time with the doc is significantly reduced (see my posting above).