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Editorials |

The Uncertain Future of Primary Medical Care

David Mechanic, PhD
[+] Article and Author Information

From Rutgers, The State University of New Jersey, New Brunswick, NJ 08901.


Grant Support: By the Robert Wood Johnson Foundation.

Potential Financial Conflicts of Interest:Stock ownership or options (other than mutual funds): McKesson.

Requests for Single Reprints: David Mechanic, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 30 College Avenue, New Brunswick, NJ 08901; e-mail, mechanic@rci.rutgers.edu.


Ann Intern Med. 2009;151(1):66-67. doi:10.7326/0003-4819-151-1-200907070-00012
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The United States needs a strong primary medical care capacity as we engage the challenges of health care reform, expand insurance coverage, and constrain medical costs without sacrificing quality. Research over decades has repeatedly demonstrated that primary care services that provide continuing access to care are associated with superior population health outcomes (12). Nonetheless, the future of U.S. primary care is uncertain, many clinicians report high levels of frustration and dissatisfaction, and careers in primary care are increasingly unattractive to new medical graduates. In this issue, Linzer and colleagues (3) studied 422 family practitioners and general internists in 119 ambulatory clinics. They report high levels of unhappiness about time pressure and practice pace, little sense of control over work conditions, and deficient organizational culture. Other data indicate substantial deficiencies on measures of quality outcomes and neglect of care processes.

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Primary Care: A Heretic's Viewpoint
Posted on July 10, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

The author correctly points out that a serious malaise has settled over the primary care work force. For sure, time pressures, disorganized and chaotic office environments, and poor pay are rampant and force many primary care doctors--borrowing a phrase from Thoreau-- to live lives of quiet desperation.

But simply paying these physicians more by putting them into a medical home is not the answer. Any increased income will be used to pay for added personnel to handle the scut work (the work that no one else on the health care team wants to do) that policy makers beguilingly call "coordinating functions".

Euphemistically grouped as "coordinating functions" scut work is intensely time-consuming. Most of it is a mind-numbing and distracting burden that leaves doctors soul-weary. The current literature mentions coordinating functions as important and worthy of more compensation; and some of it is, but I have yet to read a report that accurately portrays the drudgery and tedium that its endless interruptions represents and the psychological toll that it takes on doctors.

There are days when my coordinating functions consume most of my energy and attention. Besides lab reports, imaging studies, questions from visiting nurses, home health care agencies, getting approvals from HMOs for drug substitutions, imaging studies, and referrals; talking with pharmacists, telephone conversations with patients and their families, conversations with consultants and hospitalists, explaining procedures and results to patients (many of which should have been done by the consultants who saw them) and speaking with emergency room doctors, primary care doctors are often the "final court of appeal" for getting things done that require time and filling out of forms that no one else wants to do, e.g., forms for podiatric work, Medicare equipment,and forms for mail order pharmacies; not to mention the occasional house call to pronounce some one dead. It should also be noted that very often the primary care doctor is the only one that actually spends meaningful time listening and talking with patients, not just about their medical problems but explaining and reassuring and being there as friend and confidant.

Being paid more for these functions will not make primary care doctors' lives more enjoyable. Once they are formally recognized as medical home functions, other health care providers will be only too happy to unload any administrative or communication problems they might have on primary care doctors, their consciences assuaged knowing that these doctors are being compensated "more" for their added responsibilities.

The solution to primary care's malaise is to increase the work force so that the load is shared by more. This could be accomplished by rapidly expanding the number of primary care doctors being trained by shortening their training period form 11 to about eight years, cutting down on the basic science curriculum. Also, some specialists could act as primary care doctors giving them valuable knowledge of what front line medicine is all about. In fact why not have specialists practice a year or two of primary care before taking on a specialty full time. Lastly,advanced practice nurse could practice independently in some areas of primary care.

Innovation is needed in primary care and all the changes mentioned including electronic medical records, e-mailing patients, and increased remuneration as valuable as they may prove to be, will do little to relieve the administrative burden and drudgery that has overtaken primary care and resulted in the soul sickness that every day worsens.

Conflict of Interest:

None declared

How to drive Primary Care Physicians Out of Practice
Posted on July 16, 2009
Charles A Moser
Private Practice
Conflict of Interest: None Declared

Your recent editorial (1) on the future of primary care was just exasperating. I am a primary care physician (PCP) in solo private practice, board certified in internal medicine, and a Fellow of the American College of Physicians. ACP is my professional organization and the Annuals of Internal Medicine is my professional journal. I am anachronism, a PCP who sees patients in the hospital and in the office. I say all of this to put my following comments in perspective.

Dr. Mechanic, who is not a PCP or even a physician, wrote an editorial (the opinion of the editors of my journal?) that basically said to be successful, PCPs need to adopt an EHR, evidence-based standards, the Patient-Centered Medical Home model, use a variety of techniques (e.g., group appointments) to see even more patients, etc. He quotes a variety of papers, some of them his own and some quite dated to support his perspective, but he missed an important point; PCPs are rejecting that practice style. They are voting with the feet, retiring or moving into other fields. Just possibly, Dr. Mechanic's perspective is part of the problem.

Most of us went into primary care to take care of patients, group e- mail appointments may be cost efficient --just have to learn to type faster-- but it will drive more PCPs out of the business. No where in Dr. Mechanic's editorial does he show any understanding of why anyone would want to be a PCP under his scenario, I certainly do not.

In recent months there have been numerous articles in major medical journals, all with suggestions on how to solve the primary care shortage. What is most remarkable is how few are written by practicing PCP's. I see this as a failure of our professional organizations that are tacitly allowing others to dictate the solution to the "problem." Remember when increasing the number of physicians would bring down medical costs by supply and demand. Remember when Managed Care was going to solve all these problems. Remember when hospitalists were going to make office practices more efficient so the physician would not have to run between the hospital and office all day. Remember when IPA's were going to be able to bargain for higher fees. I could go on.

Now we are being told that the EHR, Patient Centered Medical Home Model, group appointments, e-mail appointments, group e-mail appointments, etc. are the solution to the primary care shortage. Since there is no extra money to pay PCPs, specialists are unlikely to agree to any redistribution of the available dollars, the only solution is to increase the number of patients that a PCP sees with these "new" structures. In the end, these "ideas" are doomed to fail, will result in fewer PCPs, and will definitely destroy private practice. At least we should make this decision knowingly.

So, where is the advocacy of my professional organization and my journal? Why not solicit internists in private practice to write these editorials? Primary care physicians need to be part of the solution, not told their perspectives are not supported by dated literature. What is ACP doing to advocate for me?

References

1. Mechanic, D. The uncertain future of primary medical care. Ann Intern Med. 2009;151;66-67.

Conflict of Interest:

None declared

Primary care: Med-Peds is also an option
Posted on July 23, 2009
Alexander M. Djuricich
Indiana University School of Medicine
Conflict of Interest: None Declared

I read with great interest the editorial by Dr. Mechanic on the future of careers in primary care (1). Despite the unattractiveness of primary care to new graduates in relation to other specialties, there is an opportunity to improve the percentage of students going into primary care fields. One such field is combined internal medicine-pediatrics (known as "Med-Peds"), an alternative choice for prospective medical students. This training option allows graduates to become board eligible in both internal medicine and in pediatrics in four years. The majority of Med-Peds physicians pursue primary care careers (2). However, a significant number of medical schools still do not have Med-Peds as a residency option, which likely decreases opportunities for students at those schools ultimately choosing med-peds as a career. Successful Med- Peds residency programs such as those at the University of Minnesota, the University of Rochester, or Indiana University, to name just a few, have had a track record of producing a high number of primary care physicians, and are examples of an alternative pipeline for recruiting more students to primary care specialties. I encourage those institutions which do not have Med-Peds as a residency option to consider what Med-Peds can offer in the changing landscape of health care complexity (3), and to the future of U.S. primary care.

References

1. Mechanic D. The uncertain future of primary care. Ann Intern Med 2009;151:66-67.

2. Chamberlain JK, Cull WL, Melgar, et al. The effect of dual training in internal medicine and pediatrics on the career path and job search experience of pediatric graduates. J Pediatr 2007;151:419-24.

3. Frohna JG. The role of the med-peds physician in a changing world. J Pediatr 2007;151:338-339.

Conflict of Interest:

None declared

Med-Peds: Increasing the interest in primary care or increasing the burden?
Posted on July 25, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

Dr. Alexander M. Djuricich's idea about increasing physicians' interest in primary care by offering med-peds programs is noble. But wouldn't this just increase the burden and work load of primary care doctors, most of whom are already at burn out or pre-burn out levels?

Conflict of Interest:

None declared

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