Frustrations of the primary care physician should be a wakeup call

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Primary care physicians (PCPs) have multiple frustrations today. The greatest frustration is “time, time, time.” From in-depth interviews with over 20 PCPs, everyone said that time or more correctly lack of time was the greatest frustration of their practice (or was previously if they now were in a practice that limited the patient number to a manageable level). Each knew that they could not give the time needed to give the level of care that they were capable of giving and that their patients deserved.

Stated somewhat differently, they said that it was very frustrating to always be focused on meeting overheads and trying to earn what they thought was a reasonable income because to do so meant less time with patients and a sense of frustration and perhaps even guilt. New practice patterns have meant not being readily available to patients, not visiting them at the hospital or ER, and no longer being the “captain of the ship.”

A geriatrician told me about a time when he needed to check his patient’s blood for possible anemia. The results came back that evening but he was engrossed in various activities and never got to it. The next morning he noticed it on his desk, saw that it was normal and continued with his rather hectic schedule. Later in the day he found an email from the patient.

“I like you and think you are a competent doctor and I know that you are very busy. But you failed [my italics] me just now by not getting back promptly to me with the results of my blood test.”

The doctor, who prided himself on his caring manner and responsiveness, was deeply troubled and touched by the message. It was an important personal wakeup call. Although it happened some years ago it is still uppermost in his mind today as he thinks about what patients really need from their doctors. They need to be able to trust.

The complexity of the health care delivery system was a common frustration refrain. In such a fragmented system, “I need to go an extra mile to communicate with my patients but there is not enough time to do it.”

Other frustrations were dealing with insurers for preauthorization of a test, procedure or referral; trying to figure out what drugs were or were not on an individual insurer’s formulary (and each has a different formulary) and in dealing with their reimbursement methodology. Some insurers are very slow to pay reimbursements which mean carrying high working capital — difficult for a small practice.  One noted the amount of time required to arrange for something like home care which, if the insurer was logical, would actually prevent more expensive time in the ER, doctor’s office or nursing home. PCPs find it exceedingly frustrating to deal with non-medical people at the insurance company who deny tests or medications that the doctor feels are very much in the patient’s best interest.

A few noted that many specialists were lax in getting back to them after seeing a referred patient. Since these PCPs try to send patients only to specialists that they feel are excellent and appropriate for their patients, they become very frustrated when the specialist does not get back to them in a timely and meaningful manner. Alternatively, some specialists sent notes promptly but after the first one for a patient being seen repeatedly, the notes were obviously computer generated without any real individualization. “One neurologist sent me the same note five times over the course of six months.”

Another complained that many specialists see the PCP as the “clerk,” sending the patient to the PCP to fill out disability claim forms, etc. Of course, many specialists will retort that the PCP does not make clear the reason for the referral and is not available when they try to call back.

What is very clear in this extremely dysfunctional health care delivery system is that the primary care physicians (and most other providers as well) are very frustrated that they cannot give the level of care that they believe they were trained to do  and would like to do.

Frustrations of the primary care physician should be a wakeup callStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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  • Patient Kit

    As a patient, I was well aware of the issues of time and insurance co hassles. But I must say, until I started reading regularly here at KMD a couple of months ago, I was clueless about the Grand Canyon sized rift and enormous hostility between specialists and primary care docs. It’s been a real eye opener.

    • buzzkillerjsmith

      Oh yeah. Part of it is jealousy. You look at the guys who got the same grades as you in med school and see them earning double for the same amount of work or earning the same for half the work. It will drive you nuts if you think about it too much.

      Then of course you want to smack yourself upside the head for making a bonehead choice you can never undo.

      Then of course you are disgusted by a system that puts money ahead of people’s medical care.

      It goes on and on… Don’t get me started.

      OTOH, we earn much more on a per hour basis than most people and are treated with much more deference.

      We also, most of us anyway, earn enough to accumulate enough wealth such that it is a high multiple of the wealth an average person can accumulate. (If we don’t blow the money, which many of us do.) If you can’t make it on a doc’s income, even a family doc’s income, you should pack it in.

      We get to help people out, and there’s not much more satisfying than saving someone’s life.

      Gee, I’m starting to feel better….

      • Patient Kit

        Thank you. I appreciate your candor and I do empathize with doctors’ frustrations, to a point. But, having just gone through a year during which I had to lose everything financially in order to qualify for access into our healthcare system to see doctors and get the medical treatment I needed, I will admit that sometimes the financial woes of doctors gets old, compared to the financial woes I and many other Americans are going through right now. (My short story, for those who missed it elsewhere on KMD: layoff>loss of insurance>ovarian cancer dx>sudden serious pre-existing condition that no new insurance would cover>Medicaid until I find a new job).

        While I can empathize with the basic unfairness that primary care docs experience, compared to specialists, I would happily trade your bank account for mine (This would be the best time for someone to steal my identity, if that’s going to happen too!). And I would gladly swap my reality of constantly living in fear, one tiny step away from becoming homeless, for your house.

        Fairness is important enough to fight for, but perspective is also a wonderful thing that can help keep you from being unhappy when you’re actually pretty lucky, all things considered. (“You”, not meaning you specifically, but primary care docs, in general.)

      • rbthe4th2

        I feel better that you were honest. I don’t care for docs who hide it all in. At least I’d know where they were coming from and if there’s anything we can do to meet them half way. You have some docs that aren’t worth it, but someone honest about the above is worth it to me to help out.

  • Deceased MD

    I would say it is far worse than that. Little focus on how there is increased morbidity and mortality with a dysfunctional system. After all, if they cannot effectively communicate, then the patient suffers. Or like the last post about a specialist refusing to see a pt becuase the PCP was in private practice vs. corp med like the specialist. I think we are the only ones that reaiize just how bad it is. It’s more than just expensive. It’s more than there is too much regulation and not enough time. If PCP’s can’t be running the ship, then who is?

  • LeoHolmMD

    Last paragraph sums it up almost entirely. We are not being allowed to do our best for our patients.

  • Suzi Q 38

    If you want to know who is the “captain of the ship,” it is not the PCP or the specialist.

    It has to be me, by default and distrust in the “system.’

    • Dr. Drake Ramoray

      The insurance company is in the drivers seat. I await the stack of prior authorizations in my inbox when I return from my conference.

      • Suzi Q 38

        “The insurance company is in the drivers seat…..”

        Sometimes I have to call the insurance company myself.

        Don’t get me wrong. I have had to call the insurance department as far back as ’94. Back then they would not approve an MRI of my left knee. I had to threaten to go to an imaging center with my doctors’ RX, and pay cash for it.

        I then told them I would sue them in small claims court if I was injured and needed surgery. I might also ask the judge to tack on the 6 months of pain and suffering that I had endured while waiting for their approval. I was fairly confident that I was injured since I could not walk properly, and I was in severe pain everyday.

        They approved it on the phone within 2 hours, as I told them that I was going to such and such imaging center next door to my hospital the next day.
        They asked me to postpone that appointment. I told them “No,” as I was tired of waiting for them, and my pain was escalating.

        They finally called me that same day with the approval, and told me where to go to get my MRI.
        The insurance price was about $400.00 less than the cheapest price I could find.

        • rbthe4th2

          Oh my, I’ve told a doctor once or twice, let me talk to the insurance. I think one was for a refused MRI. Dang sure got on the phone with the insurance. I almost told the doc to butt out and I’ll make some points.
          :) PS MRI got approved. ;)

          • Suzi Q 38

            Good for you!
            I think more patients should get involved if it is really important.

          • rbthe4th2

            Exactly. I would prefer doing it rather than the some in the office. I know of one office that has had complaints for years about the insurance end of things.


    Thank for pointing that out. I too was wondering what the “failure” was.

  • guest

    The doctor beat himself up over it because we are all socialized to think that the needs of the patient should come before our own. In the residency training program in which I teach, this is an explicitly stated tenet of the “professionalism” which we are supposed to train the residents to have.
    Of course, there are a lot of situations in which it is absolutely true that the patient’s needs should come before your own. An emergency with a patient should of course supercede your need to have lunch, go to the bathroom or leave work at a certain time for a personal deadline.
    The tricky part comes in where we lose clarity on whether something is a bona fide medical NEED or just something that the patient WANTS. This distinction gets muddled, not only by our own professional tendencies to be perfectionistic and to assume a position of martyrdom, but by the corporatization of medicine, with the patient assuming the role of the customer who is always right.

    Additionally, a generation ago, people were under a lot less pressure, with a relatively stable job market,not as much income inequality as we have today, and less abusive workplace environments. As our social fabric has frayed, people are more stressed and have fewer inner resources which they can deploy in order to tolerate minor frustrations.

    • buzzkillerjsmith

      Very well said.

    • futuredoc

      Likewise. Very well stated

  • buzzkillerjsmith

    Really. If not getting back to patient the same day with a normal lab results is a sin, we’ll all be burning in HE-double-toothpicks.

    Put it on the MAs pile and have her call when she can. It is right to get the result to the pt at some point, however.

    • NPPCP

      I wouldn’t; even if I could. Relax and we will get your results to you – usually in ONE day. If you are more than 24 hours worth of uptight – go away.

      • rbthe4th2

        Nowadays, all the lab results come back in your EHR. I had a doctor call me up a couple of days after I had seen and already checked the lab results out. I think they were bothered because I never asked questions. When they made a few comments, I simply responded, oh yes, thanks I already saw & know. I see all the dx’es and lab results and head to UpToDate or the like. I save them the time & trouble for something that a patient could take upon themselves to really look up valid medical info and research themselves.

        Cancer results, HIV results, that’s another story but the regular bloodwork or labs, just give me. I think I’ve had a question less than a handful of times in the past year. Even then it was here are my results and here are my concerns based on X.


    Yes – need to know more details. If a patient said that to me, I would tell them to go find another NP or physician who will call them back on the same day with normal lab or even see them within a week or two (we see in 24 hours). Then, when they can’t find someone – I will be glad to take them back; even though I don’t have to. Zero tolerance for crap like that.

  • T H

    Specialists need to fill out their own damned paperwork. If the DMV requires an eye exam, the ophtho shouldn’t send it to the FP with a note saying ‘everything’s fine,’ and expect the FP to send it. Same for DMV/seizure stuff and neurologists. Or schools, severe asthmatics, and allergists. It is the height of laziness and hubris.

    And patient expectations: didn’t call back 1 day after the blood test? That is not failing to do your duty to the patient. If the Hgb had been 5 or the platelets 22, sure, but normal labs should get a routine reply either via email or snail-mail “Just wanted to let you know your labs all looked fine. See you in 6 months for ….” would be entirely appropriate.

    • Suzi Q 38

      I didn’t really understand all that.
      Here you say you don’t want to fill it out, and the Specialist doesn’t want to fill it all out.

      I think if I had that situation again, I would give up and ask for the nurse navigator at my hospital.

      • T H

        I’m just complaining to other primary and urgent care docs about specialists who can’t do their own work.

        No, I do not wish to fill out paperwork that the specialist is perfectly capable of filling out. Her time is not more valuable than mine. Just like a specialists not prescribing medications: “Just have your Family doc write the script for this…” and its some specialty-specific drug with which I have no experience or knowledge (around here Rheum and Derm are notorious for this). Or Orthopedic Surgeons, Dentists, and Dental Surgeons not writing for their own pain medications following procedures. “I don’t prescribe norco. See your primary care doctor for this.” Some of the Tooth guys have even gone so far as to have the patients see the FM prior to the procedure: “You’re probably going to need this as soon as you get home.”

        And a nurse navigator (some hospitals call them ‘Ombudsman’) is an outstanding idea.

        • Suzi Q 38

          “……And a nurse navigator (some hospitals call them ‘Ombudsman’) is an outstanding idea.”

          Thank you for your reply. No, your time is just as valuable.
          My specialists prescribed me Norco after both surgeries.
          The hospitals that want referrals always send us back to our GP’s. My GP said, “Why do I have to write the referral?” I guess it is because he is the one that has seen me he most over the last decade.
          My neurologist noticed I was still limping slightly after my knee surgery last August. She told me to go back to the surgeon, and have him order some physical therapy for me. I thought her direction made sense.
          If I thought the specialist was dumping work on my GP, I would ask him/her directly for the script or the order for blood work or whatever.

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