Don’t make me leave primary care

You need a doctor, and I love what I do. But this work just isn’t sustainable.

In 2009, I finished medical training and joined a clinical academic practice. For those not in the know, doctors can — very generally speaking — work in one of two domains: in private practice, or on faculty at a medical school where they see patients, teach, and/or do research. Some docs manage to keep a foot in both academics and private practice, but for most, it’s one or the other.

I stayed in academic medicine for many of the reasons that my colleagues did: to be immersed in the front lines of new knowledge, do a bit of teaching, and care for complex and diverse patients. I chose a salaried position, unencumbered by concerns of paying overhead or running a business. And even though academic physicians tend to earn less than those in private practice, I have no question that I am in the right place. I love my work. And more importantly, I love caring for my patients.

But primary care is broken across the board. The work is unsustainable. I’ll tell you why.

For a start, the pace is manic. In our clinic, we see established patients roughly every 15 minutes. This flows well when the patient is a young healthy woman on no medications coming in for the common cold. But what about the 70-year-old man with diabetes, high cholesterol, high blood pressure, and prostate trouble? He sees four specialists and takes 17 medications, is retired and enjoys chatting. Even though he keeps in his wallet a list of his pills, he forgets to update it. We spend six minutes fixing his medication list, eight minutes reviewing the recommendations of his sub-specialists, and he hasn’t yet mentioned the reason for the visit. You don’t need to be a mathematician to calculate why your doctor is always in a rush.

If the primary care doctor’s only task each day were to see patients within a very limited time frame, it might be doable, but unbeknownst to many outside of medicine, the doc does so much more. How much? A recent study in the Archives of Internal Medicine looked at clinics just like mine — academic general internal medicine practices — and for the first time ever attempted to quantify “the work no one sees.” The researchers found that in a typical clinic day, the general internist completes electronic orders for 70 laboratory tests, images, and consultations; writes and signs 31 prescriptions; responds to seven patient care-oriented messages; and reviews, edits, and signs 19 electronic medical documents. Most of this occurs outside of face time with patients, and — they postulate — this estimate is conservative.

But it’s not just that time is short and busy work abundant; primary care doctors also increasingly struggle with job satisfaction. Why? Two reasons. First, we primary care doctors take pride in being the “people people” among doctors, but time constraints force us to emphasize strategic decision-making over relationship. As much as I’d like to engage my talkative retiree, an extra five minutes per patient puts me over an hour behind at the end of the morning clinic session and imposes on the afternoon schedule. And yet, I need to talk with my patients, and they need to talk to me. These conversations build trust, clarify patient wishes as well as misunderstandings, and result in improved care all around.

We primary care doctors take pride in the jack-of-all-trades-ness of our specialty, but in practice, we do less and less medicine. Rather than master diagnostician, the internist often feels more like a glorified vending machine. Push enough buttons and you just might get what you want, regardless of whether it’s good for you.

I anticipate the response to my observations to be along these lines: Stop whining; other professions have it harder than you do. You chose this. You make a decent salary. You have job security.

Yes, all of those things are true. But when the unrelenting pace, scope, and quality of work leave me so mentally taxed that I am unable to engage my children or spouse night after night, then something must change. At the end of the day, the healers themselves must be healthy in order to continue the work of healing others.

The insufferable pace of primary care combined with the erosion of the doctor-patient relationship deters young physicians from entering the field. In my graduating class of 30 or so internal medicine trainees, only two of us chose to go into primary care. The vast majority picked sub-specialties with a narrower scope of work and a higher salary.

What can be done? I offer two simple suggestions as starting points. First, medical students need greater incentives to choose primary care. Currently, programs exist to help reduce student loans for physicians practicing in certain low-income settings, but individual states need to offer grants to reduce student loans for all primary care doctors accepting state insurance. For my part, as a working mother of two, more than 60 percent of my monthly salary goes to my student loan payments and to child care. There is almost no financial incentive for me to work.

Second, primary care doctors need more resources. More assistance with paperwork and telephone calls translates into greater opportunity to spend time with patients and practice the art and science of medicine. It is for my patients, after all, that I became a physician.

Primary care is in crisis, and I am here to work. Please help me to stay.

Lydia Dugdale is an internal medicine physician who blogs at Primary Care Progress.  This article originally appeared in The Huffington Post

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  • buzzkillerjsmith

    Nope, other professions don’t have it worse than we do. Life satisfaction among folks at about our level of education is lower among docs, and primary care docs in particular, than it is among others. ER docs have it the worst.

    Second, it’s da money. If we were paid more per unit time much of the horror would go away. Don’t hold your breath. In the meantime, young med students, consider derm or some suchlike field. You can’t solve society’s mess on your own, but you can destroy your family trying.

    In truth, we are heading to where teachers have been for a long time, although with more more money, true, but with infinitely more responsibility. No power, lots of blame bitter blame from society. My martyrdom needs are not that well developed. Are yours?

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      ER docs have it worst? Really. I don’t know an unhappy ER doc. Some may not love their days at work but considering their vastly higher income and significantly less hours of work I would say most I know are pretty happy. The average ER doc makes twice what an FP does and works about 10 hours less a week. Further their work is usually longer days so most work only 3 days a week.

  • http://twitter.com/RDBowman Rachel Bowman

    Couldn’t have said it better. I took a job in a rural health clinic because I’m from the same area and want to help my community, and also to help pay off my loans. The loans are still not paid off, and I’m already planning to leave after 3 years because I’m burned out.
    The majority of my patients have complex medical problems, but have no insurance and NO SPECIALISTS to help me manage diseases I wasn’t trained to manage as a family doc. It is a completely unsustainable system. I cannot take care of my patients, supervise multiple nurse practitioners (because of the physician shortage in rural areas, we have NPs staffing our community health centers), and do the paperwork alone. If I had another doc to split the work with, it might be better. We’ve been looking for another family doc for over a year, but we have had no takers despite the loan repayment offered. It’s a mess.

    • Elegia More

      Simple. MEDICARE CARE IS NOT A RIGHT. EVERYBODY SHOULD either pay for it or be qualified for disability. If you can work, you should not get free care. Because that keeps Dr. Bowman from treating those that have worked hard all their lives to pay their outrageous bills, even with insurance. Not the free loaders. People have a choice to live in rural areas. They can educate themselves and move to where there are good doctors. And PAY THEIR WAY.

      That is your problem, Dr. Bowman. The Nanny USA government doesn’t encourage Americans to take care of themselves.

      Please move to my town – I would pay five times the Medicare reimbursement just to get more than 30 minutes visit during a crisis.

      And note that my concierge doctor STILL doesn’t give me enough time.

  • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

    I’m a PCP and I made a change — I decided that I wanted to be a great doctor, and to be a great doctor, I cap my patients at 15 per day. I can give my full undivided attention, spend basically all the time that patients need with me, and my job satisfaction has skyrocketed.

    Now of course to do that I had to take a large paycut — I make 50k per year instead of 150k. But it was worth it.

    • azmd

      I’m guessing that you are fortunate enough to have one or more of the following circumstances, which most physicians do not:
      1. A very well-paid spouse who does not mind being the primary breadwinner for the family
      2. No medical school loans
      3. No children to put through college or professional school.

      • Elegia More

        Well, you should have thought about that when you entered medical school – the handwriting has been on the wall for 30 years that we would end up in this place where a physician cannot set his own price and will be screwed by the ever liberal government. The world is a different place, Dr. Simpson. Wake up.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      If you are seeing 15 patients a day and only making 50k, you need to seriously cut overhead. I could see 15 a day and make well over twice your pay easily and happily.

    • Elegia More

      GOD BLESS YOU! Do you take out of town patients? How can you get publicity so that other doctors could see a way out?
      Oh Wait. Most of them are Boomers with second homes at the beach AND The mountains, two Mercedes to keep running, etc.

    • Eric Meyer

      Help me understand. There is a PCP in my community that charges $30 per patient per month and $15 per visit. This PCP does not file nor take insurance and all patients are welcome. Let’s go with 15 patients per day, 4.5 days per week and 48 weeks per year. That equates to a patient appointment capacity of 3,264 annually. Assuming 4 visits per patient per year on average means a patient load of 816 patients. 816 times $30 per month is $293,760 in annual revenue. Another $48,960 in per visit fees (3264*$15). Total annual revenue – $342,720. This PCP has one receptionist and invested in an infrastructure that minimizes his administrative overhead in time and money. Even if net revenue is 40% that still is a nice income with 4 weeks vacation and Wednesday afternoons for golf.

  • IntMed2.0

    Time for all of you to see what it’s like at Kaiser Permanente. If I couldn’t practice primary care here, I’d leave this area of medicine. It’s not easy, but it’s sustainable, rewarding, supported, and the income is highly reliable.

  • http://www.facebook.com/homer.lew Homer Lew
  • http://www.facebook.com/luke.nath Luke Nath

    As a student currently weighing the options that a career in medicine may offer, it’s sometimes discouraging to see the hurdles young people are staring down when it comes to practicing in a primary care capacity. I, myself, am planning on attending medical school and have a propensity (as a public health undergraduate) to associate with primary care, specifically family practice, but I agree with this article that more needs to be done to support the work these doctors do. I recently read a great book addressing some of these concerns called Out of Practice by Dr. Frederick Barken. I suggest to anyone considering a career in primary care medicine to check it out. It was a great read that re-affirmed my desire to go into medicine, while simultaneously awakening me to some of the deeper issues that I had not yet learned.

  • Elegia More

    Dr. Dugale:

    Thank you for your article.

    TAKE LESS PATIENTS! Give each Patient 30 minutes! Sandwich in an extra 30 minutes each day. DOCTORS DID THIS FOR DECADES! Why did you physicians let this get out of control?

    If you are concerned about being SUED, bring it on if you only spend 10 minutes with a critically ill patient. In fact, you SHOULD be sued for that alone.

    LOBBY your congressman, physicians, to explain that patients are DYING EVERY DAY due to PCPs without enough time to even give them MINIMAL care. If you can’t make ends meet this way – LOBBY THE INSURANCE COMPANIES! Force Medicare to pay real world reimbursements.

    But doctors are abandoning the Hippocratic oath. Your post alone states that you did not give adequate care to the elderly patient. You have failed the oath.

    Now that y’all call yourselves “Providers” instead of “Physicians” we get the point. It’s about the money, not the patient.

    The day will come when the chronically ill will rise up with their spouses and parents and demand to be treated with respect. And that means more than 15 minutes for a dying patient. Why should I pay for care that doesn’t even begin to treat my condition?

    • azmd

      Please explain why patients do not have just as much responsibility to lobby for a fix to our broken healthcare system? After all, the patients are the customers of the insurance company, not the doctors.

      • N N

        What’s funny is the poster has the nerve to say, “Well, you should have thought about that when you entered medical school – the handwriting has been on the wall for 30 years that we would end up in this place where a physician cannot set his own price and will be screwed by the ever liberal government.” — I like how she doesn’t mind denigrating doctors in her post but wants doctors to lobby that same government and lobby health insurance companies (HA!) for them.

    • Crusty Ol’ Doc

      “But doctors are abandoning the Hippocratic oath.”
      FYI, doctors have NOT taken the Hippocratic oath since the late 70s.

  • Diana A.

    So what are people like me supposed to do if we lose our primary care physicians? I have been going to my doc for years, I trust her totally & she keeps a tight rein on my medications(since 1 is a fentanyl pain patch, I appreciate that tight rein). I have a liver issue that’s killing me, and I CAN’T undergo a liver transplant & my liver is too far gone for interferon/ribavirin, etc, I just can’t, so she basically keeps me comfortable. Why do I need a specialist when I refuse to let one DO anything, like a liver biopsy, Etc?? I have Medicare and I’m just TERRIFIED at what the future holds as more doctors go into other fields than primary care & more of you abandon us & just plain QUIT!!!! I’m sorry at how poorly the gov’t & insurance companies pay you people(I’m disabled & on Medicare), but seeing all of you in here who think primary care isn’t worth your effort rips me up. You’re NEEDED more in this field than in dermatology, plastic surgery, etc, even tho those fields may pay better. You doctors drop primary care and a lot of us have no other options than to just lay down and die……will you “doctors” come to our funerals after you’ve dumped us to go to better paying medical fields?

    • Crusty Ol’ Doc

      “…a lot of us have no other options than to just lay down and die…” Yep, you just answered the $10,000 question. SEE: Oregon health plan re: Barbara Wagner and others. The “Affordable Care Act” hinges on getting rid of everybody who has a disease more complicated than a cold. Beware of an organization called “Compassion and Choices”, a front group for a crowd trying to bring involuntary euthanasia to America.

    • N N

      Don’t blame doctors, blame the system. Primary Care is no longer worth it, and just like everyone else, doctors need to make a living pay the bills to keep the lights on. Doctors are not indentured servants to go into fields that you or the govt. believe we should go in.

      Don’t worry, you will be able to have your primary care provider, indeed, most likely a Nurse Practioner. You can thank Obamacare for that.

  • ObeOneKanobe

    Why do they need an incentive to be a physician??? If you need an incentive to choose primary care, then maybe not only primary care is not right for you, but also becoming a physician as well. This honorable job that you do day in and day out is not about how much money you can make, but the service you can provide