“Your numbers are horrible!”
I was a resident physician in internal medicine seeing patients in primary care clinic. These words, from an attending physician, were meant as off-the-cuff feedback, and their impact surprised me. I suddenly felt exhausted, sitting on a rolling chair surrounded by an audience of computers, unsure how to respond to this statement that simultaneously made me feel enraged and like a failure. How could one metric change my feelings of purpose to utter disillusionment? At that moment, I felt how little worth the system had assigned to the time I had spent gaining my patients’ trust, documenting and poring over electronic records at night, and playing phone tag with out-of-network specialist physicians.
That evening, I texted a colleague and friend, “My soul is dead … just feel like I’m not doing anything right.”
She immediately responded, “How are you defining right?”
How are we defining right? This is a question worth asking.
A back-office visit to any primary care practice is not complete without mention of the “metrics.” In the business world, metrics are measurable values that show the progress of a company’s business goals. Good metrics mean more money. They fulfill a similar role in medicine. Both private insurance companies and government insurance programs (Medicare and Medicaid) are moving towards “value-based” systems in which health systems and clinics are reimbursed based upon their performance on “core quality measures” that emphasize chronic disease measurement and cancer screening parameters.
Although well-intended, front-line primary care physicians raise valid concerns with how these measures over-simplify a complex field. “If I lower my patient’s blood pressure and they fall and break their hip, I still get paid,” shares Dr. Andy Lazris, an internist in Maryland, “But if their blood pressure is above the target, I fail the guideline.”
Ideally, core measures would represent the values of patients, support primary care providers, and promote care that is valuable to patients, communities, and physicians. Unfortunately, pairing metrics with payment can create an environment where physicians and clinics are led to approach primary care as a checklist of measures rather than focusing on relationship-building and responding to the concerns of patients and the local community. The administrative and financial burden of these measures has been found to weigh heaviest on primary care.
My experience as a medical trainee is not isolated. Most people who pursue medicine are independent, purpose-driven, and want to feel like they are caring for others effectively. Despite considerable evidence that primary care has broadly beneficial health outcomes for our communities, we have failed to make primary care a desirable professional option. The job of managing health and advocating for appropriate health care within a gargantuan and often callous system is inherently difficult. Human connection and relationship-building are essential to be effective yet systemically under-valued monetarily. The workload and administrative burden are high, and the pay and prestige are low. It is no surprise that few American medical trainees want to pursue careers in primary care.
One example of how we can shift our focus to measuring what matters in health care comes from the Lown Institute, a think-tank advocating in pursuit of a “just and caring healthcare system.” The Institute recently released the Lown Institute Hospitals Index, which grades hospitals not only on patient outcomes, but also by untraditional parameters, such as pay equity, community benefit, and avoidance of overuse. Underlying this effort is the acknowledgment that hospital systems increasingly wield immense power within their communities. Sixteen U.S. states count hospital systems as their largest employers. Like anything else, these rankings are imperfect, but they do encourage a new paradigm of accountability for health systems. They are shifting how we define right.
We should measure hospitals’ commitment to primary care that is valuable to their patients and local communities. Primary care helps counteract income-based disparities in health, but primary care visits generate far less revenue for a hospital system than elective surgeries or specialist procedures. Consequently, a hospital systems’ support of their primary care physicians and clinics speaks to their dedication to serving their patients and communities over making profit.
How do we identify the systems that are doing well? Primary care physicians are notoriously underpaid relative to their specialist colleagues. Let’s reward systems that have a more equitable pay balance between generalists and specialists. Documentation is also a known driver of physician burnout, which is leading many primary care physicians to consider leaving the field. We should reward hospital systems which are minimizing documentation burden for their primary care physicians.
How are we defining right in primary care? The collection and reporting of “core quality measures” have shown incredible power to mold our healthcare system. The overall intent is good, but in reality, primary care as a “checklist of measures” is unsatisfying for patients and physicians both. It also underestimates and undervalues the complexity of practicing primary care, worsening the forces that drive trainees away from the field.
We need measures that prioritize patient care, take complexity into account, and lead to better recruitment and retention of motivated primary care physicians. This is best achieved by encouraging the most valuable aspects of primary care: relationship-building and time caring for patients.
As teachers, we discourage our trainees from acting solely on numbers—aberrant lab values only find meaning in the context of our patients’ contexts and values. We define “right” as caring for patients intelligently, holistically, and kindly, yet we have shackled patient care to incentive and payment systems that are uncoupled from this definition of “right.” In the pursuit of easily defined metrics, our systems ignore context. This makes kind, careful primary care exhausting and unappealing to practice. Our patients, colleagues, and field are suffering.
I am not the first, and will not be last, to call for a new era of American medicine that rejects greed, encourages trust, and is patient-centered.
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