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Is Primary Care Practice Sustainable? From the Secretary's DeskIs Primary Care Practice Sustainable?

Marisa A. Montecalvo, MD
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From New York Medical College, Valhalla, New York.

Requests for Single Reprints: Marisa A. Montecalvo, MD, Division of Infectious Diseases, Department of Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY 10595; e-mail, marisa_montecalvo@nymc.edu.

Ann Intern Med. 2015;163(5):394-395. doi:10.7326/M15-0339
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In an odd turn of events, I recently had some free time, and my husband, an internist, suddenly lost his secretary. Thus, I became the secretary for his solo practice of internal medicine staffed by two.





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Spoiling the fee for service patient
Posted on August 31, 2015
Owen Linder MD FACP
solo practice
Conflict of Interest: None Declared
It is not solo practice which is unsustainable it is fee for service solo practice.
Alternative modes of remuneration are described in many places.
If I was servant to EHR and to the unreasonable demands of patients as they are trained by your husband, then I too would have quit instead of persisted for 33 years.
My practice is alive because of capitation. It thrives due to risk based control. It is enjoyable because responsibility for communication, compliance, & follow through is a two way street.
Internal Medicine physicians are doctors for adults.
Lacking a responsible party --engage one.

If an ostensibly normal person returns without compliance to a previous plan there is only discussion of the stated barrier to compliance . Then they need to fix the problem and come back again later Or not.

I save most results except dire results until the next patient visit. I might send a letter with results. The nurse provides a letter of normal stools for blood, mammograms but not much else.
Phone calls for changes in treatment or urgent needs are important.
Applying sauce to the steak is not.
My wife is one rough rider when it comes to requests for duplicative requests. No one displays more righteous indignation against fools than she. Thankyou dear.
It is ok to express dismay or anger when confronted by foolishness.
Posted on September 23, 2015
Edward Volpintesta MD
Bethel, CT
Conflict of Interest: None Declared
In her essay “Is Primary Care Practice Sustainable? From the Secretary’s Desk” (1) in the September 1 issue Marisa A. Montecalvo MD described the very real challenges and difficulties facing primary care doctors today.
Her rendering of the non-medical chores (I prefer to call them the drudgery chores) of primary care truthfully describes why most primary care doctors are dissatisfied and demoralized and either burned out or close to it.
Her solution to the primary care problem is simple-- pay primary care doctors for the distracting and time-consuming tasks that are demanded of them so that they can reduce their patient load and make their patient load more manageable.
The result will be that the numerous distractions and interruptions to work flow will lessen and primary care doctors can have more time for their patients, and lead a more satisfactory professional life and personal life.
But her story needs to be taken the public arena. It is good to share ideas with colleagues in respected journals like the Annals but for change to occur we physicians need to get public opinion on our side.
So far we have failed to do this. Our leadership organizations including the AMA and our specialty societies have abjectly failed to protect our professional security.
Only if our leadership can muster the courage to push back against the many forces that have aligned themselves against primary care doctors will primary care survive.
But I doubt that our leadership will rise to the occasion. History clearly shows that they have not in the past and I doubt that they will in the future.
And to answer Dr. Montecalvo’s question “Is primary care practice sustainable” I say “no”.
Primary care doctors will no longer be the principal providers for their families. Even though being a primary care doctor is admirable, the financial and personal rewards will continue to decline and the hopelessness and desperation experienced by most primary care doctors will continue to worsen.
It is likely that in the future primary care will mostly be provided by advanced practice nurses (APNs). Already in many states they are independently licensed to practice.
(1) Montecalvo MA. Is primary care practice sustainable? From the secretary’s desk. Ann Intern Med. 2015; 163:394-395.
Edward Volpintesta MD
155 Greenwood Avenue
Bethel, CT 06801

Author's Response
Posted on November 20, 2015
Marisa A. Montecalvo, MD
New York Medical College
Conflict of Interest: None Declared
I thank Dr. Volpintesta for his comments and agree that we must move beyond voicing our concerns in the pages of our journals;  we  need physician leadership to champion primary care.    Dr. Volpintesta contends  that the primary care model, solo-practitioner/office manager1 , is not sustainable. 
I received letters from many physicians voicing similar concerns, ranging from a physician in training who chose a sub-specialty to lessen exposure to the “drudgery” chores,  to a 95 year old physician who expressed deep concern over the loss of continuity in medical care.   A  payment model with a “per- member per-month payment” to cover the costs of paperwork  might be helpful.   MD-VIP (Value in Prevention) has such a model,  and practices are capped at 600 patients;  but to allow this patients must be able to afford a $1650 annual premium,  in addition to insurance premiums and co-pays2.     Dr. Volpintesta concludes that in the future primary care will mostly be provided by advanced practice nurses.  Advanced practice nurses  bring many  assets to  primary care as they are excellent at  education and prevention, in addition to the provision of service.   However, we still need physicians to provide guidance and  leadership to patients navigating through the world of multiple subspecialists.   As physicians  we should work collaboratively with our advanced practice nursing colleagues, to join together and address the issues that are central to both of us.     
Beginning in 2019 Medicares’ new physician payment system will favor physicians who receive  payments from an accountable care organization, medical home or an alternative payment model 3.  This represents a broad step toward payment for adherence to “value” indicators and may provide some financial assistance for the primary care physician.  However, this substantive change heralds the need to study its effects and learn from providers with first-hand experience practicing medicine in the world of value based purchasing. 
How do physicians working in the field provide input to policy makers?  We do not have a good system for this.  How will our medical school graduates, who will begin work with a median educational debt per individual of 183,000 dollars4  ,find the time to work on policy issues?   Our professional societies must demand that the systems overseeing medical care require feedback from the direct care providers in the field of primary care, and they must create incentives that will allow providers the time to thoughtfully contribute their experience.        
1.  Montecalvo MA, Is primary care sustainable?  From the secretary’s desk.  Ann Intern Med 2015; 163:394-395.
2.  Musich S, Klemes A, Kubica MA, Wang S, Hawkins K.   Personalized preventative care reduces healthcare expenditures among Medicare advantage beneficiaries.  Am J Manag Care 2014; 20(8): 613-620
3. Oberlander J, Laugesen MJ.  Leap of faith- Medicare’s new physician payment system.   N Engl J Med 373; 13: 1185-1187.
4. AAMC Debt Fact Card for 2015.  https://www.aamc.org/download/447254/data/debtfactcard.pdf   
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