Moral injury from a primary care perspective


The backbone of a great health care system is its primary care task force. From Singapore to France, elite health care systems rely on these cerebral doctors to provide preventive, urgent, and acute care along with chronic disease management. Primary care doctors have a broad-ranging impact from health care access, cost control, and impact on mortality and morbidity rates.

I was a graduate of a class of 50, of which only a couple went into primary care. Like my peers, as a second-year resident, I also wanted to be an interventional cardiologist. The idea of putting stents for ST-elevation myocardial infarction seemed heroic. Fortunately, I did not match in cardiology. I ended up going to an underserved area in northern Maine to deliver primary care. This started a love affair that is one-sided as primary care does not love me back— and here is why:

In the past 15 years, I have seen the corporatization of health care and a war on physician autonomy in general and primary care in particular.

Primary care physicians have been relegated to triage workers for big health systems and insurance companies. The devaluation is so extreme that in many areas of the country, they are losing out on competitive jobs to physician assistants and nurse practitioners. These physician extenders are valuable assets to the health care system but also more likely to sing the tune of the administrators and regulatory bodies.

The infliction of moral injury for primary care started with the widespread adoption of electronic health records.

These extremely clunky and physician-unfriendly systems were designed to give out cookie-cutter medicine with tools like checkboxes and templates. They dish out electronic documents that have mostly garbage information with a few lines of useful information.

Electronic health records impacted primary care in particular who earn their living with cerebral work and do not perform procedures. They are underpaid and lack political clout and resources to take short cuts like using transcription and medical scribes. Primary care physicians are impacted more by these changes as we are responsible for the majority of work in the health care system. It is no secret that all medical supplies from wheelchairs to alcohol swabs to incontinence pads, personal care attendants, and visiting nurses need signatures by primary care physicians. Also, any test ordered on our patients, even if it is on Mars, becomes the responsibility of the primary physician.

We are also supposed to track preventive services, consultant notes, and recommendations and held accountable for patient outcomes and keeping their complete records. The fragmented electronic health care system has challenged us like never before.

Moral injury happens when a person does not get professional or personal satisfaction from their work. Being held responsible for everything but having zero authority creates a sense of sadness, decreases self-esteem and morale. This is what is going on for most primary care physicians in the country — orphaned by the system, burdened by insurmountable tasks, and being replaced by providers with less training, with a threat of a lawsuit hanging on your head by mistakes made by the very providers who are replacing us. This sort of institutionalized abuse would drive anyone to feel injured, depressed, and irrelevant.

In a typical day, I see a lot of patients, renew prescriptions for patients, follow up on tests and emergency room records, go through records of patients hospitalized, review care plans of visiting nurses, sign paperwork for a patient to get their diabetic supplies, wound care equipment, appropriate housing, disability equipment, home modifications to prevent falls and physical and occupational therapy. The list is endless. In between, I also triage calls and make critical decisions that cut down on emergency room visits.

It would seem like that a person who does all this is a hero. It would be great if I could pretend to be Superman as I work like him. The injury occurs as I am expected to be superman but made to feel like Lex Luther.

The government and insurance companies are setting up roadblocks for patients to get care. It is a work of god and pages of documentation to get some patients the medicine, medical supplies, or necessary diagnostic tests. We are juggling a million tasks. And at the end, the patients are not happy as we did not complete that one form that was needed for them to get their preferred medication, or the test that their consultant suggested, or the number of home care hours that their home agency required.

Replacing the injured primary care doctor is in process.

Family medicine, pediatrics, and internal medicine doctors are retiring at a fast rate, and medical students are not going to these specialties.

Corporate health care has already found their replacement. As the injured physicians hang up their stethoscope, I hope that the system will appreciate the next generation of physician extenders and not inflict deep wounds on the gatekeepers of health care. Injury to the front-line soldiers of health care can only result in defeat and eventual pain and sorrow for the whole system.

Talal Khan is a family physician and can be reached at Personal Primary Care.

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