“I’ve been with my doctor for years and years,” an elderly man, voice hoarse but lilting with fondness for his caregiver, told a nurse in the primary care clinic where I was waiting to see a doctor. “He’s fantastic.”
I was coming to the clinic for a follow-up appointment about an injury for which I’d been seen a few months prior, but neither the initial appointment nor this follow-up were with my primary care doctor. In fact, I hadn’t been able to see my own doctor for any issue for months — and I’d recently learned that I might never again. I found myself feeling jealous of this man’s relationship with his doctor.
I mentioned my fantastic primary care physician in my last blog post, but it’s been a challenge to see her. While it’s common for patients to be unable to see their own provider in the next day or two for acute issues, for me it was especially difficult because my doctor was a resident. Although she was in a primary care internal medicine (IM) residency, she spent most of her time in inpatient training and only two days a week in the primary care clinic. Though I’d been to the clinic several times in 2011, I’d not seen her since January, and a letter from her saying that she was graduating the residency program told me I would not see her again. The new provider assigned to me was a first-year resident with whom I would face the same continuity challenges, and I couldn’t get an appointment with her, even for acute issues, for weeks.
This model of primary care residency seems counter-productive. Shouldn’t a patient get long-term, continuous care from a primary care doctor, resident or otherwise? And shouldn’t primary care residents spend most of their time training in, well, primary care?
The history of residency training partially explains these circumstances. Residents got their name because they actually lived at the hospital where the highest density of patients could be found. The hospital was believed to offer the most intensive patient-doctor interactions. However, today, the bulk of care is delivered in outpatient settings. For Medicare patients alone, in 2009 there were 10 million hospital admissions versus 147 million outpatient visits.
So why haven’t residencies adjusted accordingly? Because here, as everywhere else in health care, pay structure dictates how patients are cared for and how doctors practice. Resident salaries are covered by Medicare, and teaching hospitals are reimbursed at a higher rate for resident-provided inpatient versus outpatient care. Because of this, even residents who ultimately want to practice in outpatient settings, such as primary care, dermatology, gynecology, or endocrinology, spend most of their time in the inpatient setting.
The Patient Protection and Affordable Care Act will provide more compensation to teaching hospitals than those hospitals previously received for outpatient care delivered by residents. It will also create more primary care residency programs. While a change in pay structure is a crucial first step, it isn’t the only reason residents have such intensive inpatient shifts. Errors are more likely to occur during inpatient handoffs, and longer shifts reduce the number of handoffs. However, this residency structure results in numerous outpatient handoffs that can be just as detrimental to patient health.
I’ve been through a number of these handoffs: When I see my new primary care doctor over a month from now, she will be the third doctor I’ll have seen for this injury, and the sixth in the past year overall. Caring for me in this way does not give the residents the model of long-term continuous primary care that must have attracted them to the field in the first place. I hear this complaint repeatedly from students, residents and clinicians associated with Primary Care Progress, and I’m sure it’s also not the model that led this elderly man sitting next to me to say that his doctor is “fantastic.”
Primary care IM residency programs need to give residents more time in primary care to benefit both the doctor and the patient. The current model compromises trainees’ education and morale. Through the pain of my lingering injury, I can literally feel the negative effects of this structure.
Susan Putnins is a social worker who blogs at Primary Care Progress.