Is it any wonder why young doctors shun primary care?

With the announcement out of Washington about the 2015 budget, much has been made about the apparent presence of significant support for the development of more primary care practitioners in the years ahead.

This support includes programs aimed to encourage medical students and residents to choose primary care as a profession, including loan forgiveness packages.

Response in the press has already raised issues with this, suggesting that this move would do little to encourage more trainees to opt for primary care careers, and that limitations in the number of residency training positions provides a “ceiling” that would prevent us from being able to provide enough PCPs to satisfy the needs of an aging nation and new models of patient-centered care.

For a patient-centered medical home to work, we need a highly trained, intelligent, motivated, dedicated workforce of primary care practitioners standing at the center alongside the patients, coordinating care, refining systems, trying out new ideas, and developing a system that provides the highest quality care.

But it seems that almost nothing is going to tip the balance back towards primary care in the minds of trainees, until the quality of life for primary care practitioners is also brought up to par with those of other practitioners, and the economic playing field is leveled.

Let’s take a look at my mail from this morning.

When I arrived at work early this morning, there were 42 letters in my in-basket, and 17 faxes. (Faxes? Who faxes anymore, anyway?)

The majority of these were paperwork that required my review of some information, and my signature, and really did not provide added value or care for my patients.

The bulk of these were from insurance companies and visiting nurse services, who needed to do their due diligence and make sure they had the appropriate paperwork on hand in case an auditor came looking at their files.

“Patient to be aware of signs and symptoms of their disease, patient and caregiver to be aware of risk of falls, patient to be aware of signs and symptoms of broken skin integrity, patient to be compliant with medications within 30 days, patient will be compliant with their care plan within 30 days.”

Endless, not very useful trivia, bureaucratic mumbo jumbo that my signature does not really add to, doing little to further the health of my patients.

There were a few letters from other healthcare providers, informing me of their consultations on my patients, including one from a subspecialist who actually shares my electronic health record, at my own institution.

So think about it: After he finishes his electronic note, he has a staff member who prints all of his notes, folds them, hand addresses an envelope, puts that note in the envelope, affixes postage, and mails me the consultation letter.

This seems to defeat the purpose of an electronic health record, and prevents the actual coordination of care, or at least makes it much more difficult — something that our 21st-century systems should aim to facilitate.

FYI, routing the note to me in the EHR takes one click of the mouse.

We all knew when we entered this profession that there was a lot of administrative burden that went along with it, but this has reached a point where we are all inundated — buried under an avalanche of paper and forms — and the minutia of our nonmedical lives prevents us from really providing the care and time we need to give to our patients.

We as a profession must ask ourselves, why would bright, motivated, talented, young medical students or residents choose to enter a field where they are swamped, overwhelmed, and not really practicing medicine any more?

As we move forward developing a patient-centered medical home, and as the bureaucratic and administrative landscape changes, we need to help recreate a system wherein we as practitioners are not dictated to about what we can do to take care of our patients. We have clearly let ourselves be pushed down by a system that keeps us from practicing medicine in the way we believe is best.

I would argue that the amount of money spent over the course of a year by insurance companies and visiting nurse services on paper, envelopes, personnel to print letters and stuff envelopes, and postage, could easily double the salary of quite a few primary care practitioners.

The number of employees at our own institution who are printing and mailing out consult letters could be re-tasked to roles that actually improve the care of patients, working with practitioners to provide care coordination, serve as community liaisons, and provide after-visit care.

As we all know, bureaucracy is necessary up to a point; we need to make sure fraud doesn’t occur, and there needs to be some paper trail. However, I would think that in this modern world we would be able to figure out how to make this stuff happen without taking such a lot of time from practitioners who were trained to practice medicine. I did not take a course in medical school or residency on filling out forms.

Now if you’ll excuse me, I’ve got to get to my mail.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • guest

    Your doctor had been turned into middle management by the corporatization of American healthcare.

    His job is no longer to take care of you.His job is to “work at the top of his license” and manage the people who are taking care of you while keeping an eye on your “dashboard.” Oh, and to “manage the health of the population” that you happen to fall into, which means making sure all of your “metrics” meet quality criteria.

    Personal contact with you is not required for any of those functions. It’s kind of funny, considering the fact that it’s called “patient-centered” care…

    • Kristy Sokoloski

      This already happens in the Medical School setting now. The care is provided by the students and residents, and then they check in with their professors who are the M.D./D.O. to make sure that it is acceptable care for the patient. Then the treatments are carried out and the patient goes back in for regular follow-up visits and such as indicated by “their” doctor.

      This kind of care has been going on since I was a kid. Yes, when I was a kid I had some of my care given to me at the Medical School in the area. And also the same thing when I consulted the ENT at the campus of the Medical School in my area when I needed their input 6 years ago.

  • guest

    Personally, I think there are a lot more reasons that our trainees are avoiding primary care than that communications are not entirely digital.

    • NPPCP

      You are right there. In my private NP practice it is a long daily slog, taking whatever comes in. Your brain is worn to a frazzle considering all the simple and complicated diseases that may or may not come before you. There is no one there to help and a medical home doesn’t help at all. Primary care is a big calling with little thanks and lots of needy folks – and I like it. It’s just that not many do. Ironically, the independence and freedom of owning my own clinic is one of the biggest benefits that motivates me to continue serving. And those are a couple of things that many want to take away from me.

      • Dr. Drake Ramoray

        This. A million times this. Diabetes day in day out. I actually liked it before all the prior auths and God help me should we go pay for performance. I have insurance companies now denying meds to patients that they have been on for years, and was the only thing keeping them off insulin. I just need a couple more years to break free for a thyroid only practice, but it’s getting miserable even independent (still light years better than my multispecialty or hospital jobs)

  • guest

    “Routing the note to me in the EHR takes one click of the mouse.”

    Ah, herein lies the crux of the fallacy that EHR would make us more efficient: that “click of the mouse” can only be done by the doctor, like many, many other “clicks of the mouse” that are required to complete clerical tasks that used to be completed by….clerical workers.

    It probably sounds a little petty, but if you are a full-time practicing clinician, those “clicks of the mouse” do add up kind of fast. In addition to the clicking, there’s also the phenomenon that whomever is responsible for the clicking is also responsible for unraveling any electronic glitches that might arise from an (ahem) imperfect EHR system.

    So, when our facility rolled out a new feature of our discharge summaries in which we could “share” them with other clinicians, and that “share” function resulted in our not being able to put a final signature on our discharge summaries, guess whose job it was to spend 45 minutes on the phone with the Help Desk while they tried to figure out why notes which we had completed were showing up in HIMS as “incomplete.” Astonishingly (or not), it was the DOCTOR’s job! Although, I did notice that when I refused to do it, someone in HIMS was able to figure it out for themselves…

    With the advent of electronic charting, I probably spend about 2 hours a week engaged in such clerical activity. Because the transfer of information management to an electronic format means that clerical workers have been let go, and there is no one else, other than doctors, to unravel problems when they occur.

    • Keith Williamson, MD

      EMR’s have potential, but none are ready for use from a physician-patient standpoint. Meaningful use is an Orwellian term; meaningful use is neither meaningful or useful.

    • Margalit Gur-Arie

      That part of the equation was never part of the equation. The savings, if any, from reducing clerical staff was put towards paying for maintenance & support of the EMR, which most likely exceeds those savings, hence you need to become more productive now that you can do everything with “one click of the mouse”….

  • goonerdoc

    Crap, SD1, you beat me to it.

  • Mengles

    “My experience with the PCMH…my doctor was part of the demonstration project…was that real face to face care was provided by midlevels while my doctor…”

    Bingo. That’s the whole point in PCMH. Your doctor will have more of an “administrator” role meanwhile having to manage midlevels. Medical students see this clearly.

    • Kristy Sokoloski

      Those that need to get their care through the Medical Schools already go through this now as it is.

  • Patient Kit

    The more I read about PCMHs, the more unappealing they sound. As a patient, I have little interest in going to a “physician led” so-called “patient-centered” medical home in which the doctor oversees the staff but never sees me. If that’s the future, Dr Google sounds better and better.

  • LeoHolmMD

    “As we move forward developing a patient-centered medical home, and as the bureaucratic and administrative landscape changes, we need to help recreate a system wherein we as practitioners are not dictated to about what we can do to take care of our patients. We have clearly let ourselves be pushed down by a system that keeps us from practicing medicine in the way we believe is best.”

    Uh, wasn’t the PCMH supposed to recreate a “patient centered” system. Now you’re telling me we have to recreate another one. How do I get certified? Isn’t the PCMH yet another system, in a cha cha line of systems, keeping us from doing what is best for patients?

  • Brailleyard

    As a E.D. Scribe -turned Medical student, it always breaks my heart when I see healthcare inefficiencies that could easily be solved by a well-trained undergrad with an interest in medicine and the ability to type. What I would love to see discussed however – is an easily quotable financial breakdown of the value of scribes/student computer techs in healthcare. It seems that both doctors and administrators are moved by numbers ( the latter requires an “$” in front of them ) and I imagine the change would be swift if it could be shown that the addition of a scribe to an all-digital (read: Meaningful use) practice actually saves money in the medium-to-long term.

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