Direct primary care: Solution or problem?


Longtime readers know of my fascination with the affect heuristic. Simply stated, we overvalue the benefits of a concept that we like, and underestimate the problems or vice versa.

This article about direct primary care induces conflicting analyses: “Here is the PCP crisis solution, and it’s simple.”

I like the idea based on this reasoning. Primary care in 2017 has several problems. Both physicians and patients have dissatisfaction with direct face time. Primary care physicians suffer high levels of burnout because the financial model requires them to see patients too quickly to do their job properly. These quick visits likely induce physicians to order more tests and consultations than they would if they could spend more time on history and physical examination.

Direct primary care allows physicians to spend more time with patients because they decrease their “panel size” from greater than 2000 to 800 or less. These physicians have more time to communicate with their patients — using telephone and email.

But the panel size decrease waves a red flag for opponents of this movement. They always ask — who will care for the patients?

When primary care physicians burnout, they often leave their practice becoming hospitalists, urgent care physicians or subspecialists or retirees. If direct primary care keeps them practicing, even with fewer patients, at least they are providing important primary care.

Currently, medical students and residents find primary care unappealing because of the work conditions. I often argue that direct primary care may induce students and residents to choose primary care and work with a reasonable number of patients.

This debate has no solution. My arguments are not based on data, but rather on anecdotal observation. I worry about primary care because the current model often leads to more expensive substandard care. You cannot rush visits and provide the highest quality primary care. You must take shortcuts to shrink your visit times.

This debate is philosophically interesting and, in my opinion, a great example of that affect heuristic. We cannot resolve this question with data because the factors are multiple. And too often, you do not understand the underlying motivations for doing primary care, leaving primary care or moving to direct primary care. So we will likely continue to debate this issue with no clear conclusion.

But of course, I am correct.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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