Rest in peace, primary care [PODCAST]

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“The corporatization of medicine has destroyed primary care as a specialty. The primary care physician is supposed to be your go-to doctor, your advocate, the coordinator of your health care. Now that corporations buy out hospitals and private practices in an almost predatory fashion, the priority is turning a profit for the corporation at the expense of not only patient health but also the health and well-being of the primary care physician. Who do you think bears the brunt of patient frustration and public misconception? The PCP.”

Alexis Gopal is an internal medicine physician and can be reached at Vitality Medicine of New York.

She shares her story and discusses her KevinMD article, “Rest in peace, primary care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Alexis Gopal. She is an internal medicine physician, and she wrote the KevinMD article “Rest in peace, primary care.” Alexis, welcome to the show.

Alexis Gopal: Thank you so much. Thanks for having me.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Alexis Gopal: Sure. I am the medical director of Vitality Medicine of New York City, which is an integrative and functional medicine practice. Although I am a board-certified internist with specialization in functional medicine and obesity, I didn’t start out that way. I’ve been a physician for about 30 years, and I started out as a traditional internist with a traditional primary care practice. Although back then, you know, we’re talking in the early ’90s, it was quite different. You know, we still had paper charts. We still did the hospital as well as outpatient, as well as our own urgent care. It was a little different back then.

It was the beginnings of managed care, so there was some interference from bureaucracy, from administration. But the different thing about back then is that the administration were mostly physicians, and so it was a little more palatable when they set down algorithms and clinical pathways, because, you know, they knew what we were going through. They had the knowledge in the background, and they realized that medicine was not only a science but also an art, and still allowed us to practice that way in the constraints of managed care.

Over the years, you know, I continued to practice traditional practice, and then, you know, hospital medicine became a specialty, and I stuck to outpatient. I was a hospitalist for a year, but I mostly did outpatient. But things changed dramatically for me when a large corporation started buying up hospitals and practices, and it was no longer physicians that were in the administration, but attorneys and MBAs and non-clinicians. And things changed dramatically, not only for me but for a lot of my colleagues. You know, we had people who had no clinical experience dictating to us how to practice medicine. And I think that was the beginning of the downfall of, I say primary care, but I think for many specialties, this interference from corporate administration.

So what led me to leave internal medicine, because I actually don’t practice internal medicine anymore, was actually twofold. It was my experience not only as a physician but as a patient. You know, I had several medical issues, migraines, hormonal issues, some autoimmune issues, and I had gone, you know, to many, many physicians and was unable to get better. And I sought out some of the top people, and I was still unable to get better. And my frustration as a patient is what led me to functional medicine: just a different paradigm, a different way of thinking about medicine, about practicing medicine, getting to the root cause. I did so well with it as a patient, I thought, “Well, you know, this is something I need to bring to my patients.”

And initially, you know, I practiced a combination of both, the best of both worlds, you know, of traditional internal medicine and functional root-cause medicine. And again, there were a lot of roadblocks put up by, you know, insurance companies and administration: “You can’t do this. You can’t use supplements. You have to, you know, you have to.” So it’s very difficult to include functional medicine as part of a traditional internal medicine practice, and ultimately it was just impossible, and I decided to make a decision to leave traditional internal medicine and focus solely on functional medicine.

Kevin Pho: So tell me some of the challenges when making that transition from internal medicine to your functional medicine practice.

Alexis Gopal: Now, there are many, many challenges. You know, leaving insurance-based medicine, because, you know, insurance doesn’t cover functional medicine. Basically, it’s cash-based. It’s challenging to start that model of a practice, you know, a cash-based practice. You know, it’s very challenging. You know, patients expect you to provide services and accept their insurance, but their insurance doesn’t cover your services. So, you know, generating a new client base was very challenging for me.

And also, you know, it’s not that I lost my identity as an internist, because I still consider myself an internist and use a lot of my internal medicine skills and intellect in what I do now, but it’s a different ball game. And it’s actually a nicer ball game, because I have a lot more autonomy, and it works. You know, I found that at the end of my career as an internist, I was a fireman. You know, I was putting out fires. You know, my schedule was so packed, there was such little time with each patient, that I was basically just putting out fires. It was almost like assembly-line medicine. And I find it’s just so refreshing to be able to have the luxury of spending time with the patient and really getting to know them and getting to the bottom of their medical issue. So, you know, although it’s been challenging, it’s been wonderful. It’s been a real eye-opening experience, but for the positive.

Kevin Pho: All right, let’s transition now into the KevinMD article that you wrote. This was back in January. It’s titled “Rest in peace, primary care.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Alexis Gopal: I decided to write it partially because of my own experience with corporatized medicine and its constraints, but also because, you know, I do belong to a lot of physician forums and a lot of physician organizations, and I’m just flabbergasted at how little we advocate for ourselves as a group. It’s almost as if we have Stockholm syndrome. You know, I hear lots of different stories of, you know, administration just being unreasonable, and things that are being passed on to physicians, and physicians accepting that and not advocating for themselves. And, you know, no other profession would be like that. That would never happen to lawyers, or even nurses. Nurses have such a great lobby.

So seeing this recurrent theme, you know, it really just got me thinking. You know, I really want to put this out there, that, you know, there’s this perception in the public that, “Oh, you know, doctors are greedy. You know, doctors are a bunch of greedy millionaires, and they only spend five minutes with me because they just want to make more money.” And they don’t have an idea of the hierarchy behind the scenes. You know, there’s this public perception that it’s all the physician, when the reality is that all of these things are being dictated by non-clinical administrators.

And so, you know, the article was born of frustration: frustration of public perception, frustration with physicians who don’t advocate for themselves and have the Stockholm syndrome. And so I kind of wanted to put it out there. I shared it with my patients and my audience, many of whom are not clinicians, because the public is just not aware. And I think, you know, I also wanted to plant seeds in my colleagues that, look, you know, we need to advocate for ourselves, or we’re in big trouble as a profession. You know, we need to be more like nurses. Nurses are a great lobby. You know, they have great PR. You know, they have unions. They take care of themselves. Physicians don’t have that.

And I fear for the future of medicine as a profession, but also the future of health care. You know, one of the things I expressed concern about in the article was what’s going to happen when, you know, physician extenders are left to manage complicated patients. Because now what’s happening is that there’s this mass exodus of physicians who want to leave medicine because they’re so dissatisfied, and there’s going to be a shortage, and that’s not too far off. And, you know, hospitals and offices are going to rely more on nurse practitioners and physician assistants who clearly don’t, you know, I’m not saying that they’re not good, but clearly they don’t have the training and the expertise that a physician that’s gone through 12-plus years of training has. And I fear for the complicated patients. You know, I fear for, you know, the patients with the rare disease. You know, I fear for the future of health care. So my reasoning behind writing the article was multifactorial: frustration, fear for the future, and a little bit of frustration with my profession, in that we don’t advocate for ourselves.

Kevin Pho: So through all the stories that I’ve read on my site over the last 10 to 15 years that I’ve been doing this, and stories on my podcast, this has been a recurring problem and hasn’t really gotten any better. A lot of times, physicians are simply too busy seeing patients. They’re too busy doing procedures, and they proverbially don’t have the time to advocate for themselves. So that’s partially because of our own doing, as you said, but now that we’re in this position, how can physicians best advocate for themselves?

Alexis Gopal: That’s a great question, because, you know, I get the impression that a lot of people are looking to the AMA to be their advocate, which is not the case. They have their own agenda. So, you know, I think, you know, I admire doctors who do DPC, you know, direct primary care, because it’s almost like a grassroots effort to get our autonomy back. And I think regaining our autonomy has to be a grassroots effort, because if we’re not going to organize ourselves collectively, we have to do it in a grassroots way. You know, all of us, in our own way, have to take our power back, and that’s one way.

And, you know, I really admire DPC doctors. You know, they’re doing their thing, and it’s really catching on. They’re practicing medicine the way they want to practice it, you know, with integrity and with good quality of life. So I think it has to be a grassroots effort, because certainly relying on large organizations that are supposed to be advocating for us is not working.

Kevin Pho: Now, direct primary care, as you said, is a growing field, but certainly still very small, and it certainly can’t be expected that the majority of primary care physicians simply drop traditional practice and go to direct primary care, because there are certain challenges in that as well. Is there anything an individual physician can do to help advocate for the profession, short of joining an organization? Is there anything that we can do on an individual basis?

Alexis Gopal: I think individually, you know, we all can be as active as we can in our local medical societies, and in our local politics, and in, you know, hospital committees, and just try to be as active as we can, time allowing, because you’re right, we all have really, really busy schedules. But I think if we all have some kind of role in decision-making at some level, on a larger scale, if we all do that, you know, things have to change. You know, we’re facing a really severe physician shortage, and it’s an issue for the entire country, because, you know, it’s just going to change the landscape of medicine. And so what can physicians do individually? I think to become as active as possible in local medical societies, and just try to put themselves in positions where they can be decision makers.

Kevin Pho: We’re talking to Alexis Gopal. She is an internal medicine physician, and she wrote the KevinMD article “Rest in peace, primary care.” Alexis, what is your prediction for the future of primary care in this country? As you said, fewer and fewer physicians are going to primary care for a variety of reasons, and more advanced practice practitioners are now going to be primary clinicians. So assuming that we’re going on the current trajectory, what is your vision of primary care in the next five to 10 years?

Alexis Gopal: Not good. You know, I do see big-box clinics opening up, you know, all over the place, with nurse practitioners or physician assistants trying to provide care to areas that experience shortages. And I see more and more of that as physicians leave primary care. I have nothing against physician extenders. You know, some of them are wonderful, and some of them are very smart, but they don’t have the training and the expertise that a well-trained primary care doctor has, who’s seen a wide range of pathology, who can pick up that rare case of an aortic dissection, you know, based on very subtle signs. And I fear that people are going to get sicker, and people are, you know, things are going to be missed, and our already increasing mortality rates are going to go up. How is it that, as a country, you know, our patients are getting sicker? Obesity is increasing. We’re going in the wrong direction, and I foresee that continuing and actually accelerating if we don’t do something.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Alexis Gopal: My take-home message is that we need to advocate for ourselves, not only as physicians but as patients. You know, my own personal experience as a patient, and I always advise my patients to advocate for themselves, because they can get lost in this assembly-line medical system, you know, that we have. But for my colleagues, my takeaway message is: Advocate for yourself, to take care of yourself. Don’t, don’t lose your health. Don’t lose your spiritual health, your mental health, your physical health, for the sake of your job, because it’s not worth it. You know, the profession of medicine has changed. You know, the way that physicians are looked at as a whole has changed. It was very altruistic to make those kinds of sacrifices years ago, in the Marcus Welby era, but now, you know, you really have to take care of yourself. So self-care and advocacy are my take-home messages.

Kevin Pho: Alexis, thank you so much for sharing your time and insight, and thanks again for being on the show.

Alexis Gopal: Thank you so much.

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