Rx for primary care

When primary care doctors openly admit they wouldn’t advise medical students to follow in their footsteps, it does not bode well for the future of patient care.

A couple of weeks ago I attended a local meeting on the future of primary care. It was one of several that were hosted around Minnesota this past month to gather ideas and perspectives on the issues surrounding primary care.

On many levels, the discussion was truly depressing. Among the concerns I heard: There’s too much paperwork. Aging and chronic disease have made patient care much more complicated. Doctors are overburdened and dissatisfied. The primary care workforce is shrinking.

There was some talk of potential solutions, such as bringing in scribes to reduce the burden of medical charting or finding ways for physicians’ work time to be more flexible.

But what I didn’t hear was where patients might fit into all of this.

For better or worse, there’s a lot of frustration in health care these days. Consumer Reports recently published the results of an online survey of 660 doctors and the findings are revealing:

– 70 percent of the respondents said they were getting less respect and appreciation from their patients.

– The top complaint was failure by patients to follow advice or treatment recommendations.

– The volume of insurance paperwork was the No. 1 barrier to providing optimal care, followed by financial pressures that force doctors to see more patients for shorter visits.

If health care providers are frustrated, so are patients. Consumer Reports also surveyed 49,000 of its subscribers and found that although the majority were very satisfied with their doctor, they were less so if they felt their doctor rushed them through a visit, dismissed their symptoms or were too quick to whip out the prescription pad.

By now you’ve probably connected some of the dots. No one’s happy with short visits, unappreciative patients, harried doctors or tons of paperwork. Whether we realize it or not, patients are deeply enmeshed in what ails primary care, and if the ship is going down, patients are going down with it.

It’s all the more unfortunate, then, that many of the so-called solutions to primary care often are formulated and implemented with little, if any, input from patients. Take medical scribes. On the surface, it sounds like a great idea: someone who can take over the burden of charting and documentation so the doctor can concentrate his or her attention on the patient. But how do patients feel about this? Will it change the dynamics of the encounter? It’s one thing, after all, to have someone transcribe the doctor’s notes after the visit; it’s quite another thing to have a third person in the room, during real time, taking notes on the visit.

Evaluations of demonstration projects to implement the medical home concept found that patient satisfaction actually eroded. Assumptions that patients don’t mind having their care turned over to mid-level professionals also can be mistaken.

For what it’s worth, I think patients and doctors still value the relationship-building that lies at the heart of primary care. In fact, when the Consumer Reports survey asked doctors what patients could do to obtain better medical care, establishing an ongoing relationship with a primary care doctor was at the top of the list.

Unfortunately the ability to form and sustain those relationships is being seriously fractured by multiple pressures from the outside. There’s a very real danger that in the rush to come up with solutions, we overlook or devalue what makes primary care unique, what draws physicians to primary care in the first place. Who benefits from that? Not physicians, and certainly not patients.

This is a discussion in which patients need to participate. I hope someone out there is listening.

Photo: Wikimedia Commons

2 thoughts on “Rx for primary care

  1. What they admit is something that has come out of their years of experience. They might have found it difficult to keep up with the modern medicine and their status in the society.


  2. Electronic medical records are indeed turning physicians into data entry personnel, which is a terrible waste of time, skills and education, and decreases time available a physician can see patients. Each new health care reform adds to the nonproductive work physicians have to complete, resulting in a smaller and smaller percentage of time available for patient care. Certainly, the intangible rewards of medicine (satisfying personal relationships with patients, professional respect, a legally non-threatening environment in which to practice medicine, and the reward of helping other human beings in an unencumbered fashion) are diminishingly small.

    With reimbursements for medical care declining in real terms, and the need for more expensive infrastructure to maintain a practice (computer systems, personnel to submit and resubmit insurance claims, increasing malpractice costs), and the massive bureaucracy of the federal government actively searching for ways to cut reimbursements in tens of percents for years to come, it is hard to be optimistic in the survival of the doctor-patient relationship as it currently exists.

    Certainly, the days of the best medical care in the world on demand and in whatever quantities desired and in the most timely fashion possible are at risk. Given the cost structure of medicine, earth-shaking changes are inevitable. Anyone who promises the current level of care for either significantly less money or for significantly more people without additional funding should be viewed with skepticism.

    Everyone needs to be involved in the deciding the direction of health care, but the final decisions will inevitably be made based on what is the best for greatest number of people, a philosophy that may put an individual at risk at not getting the intensity of care desired in any one particular situation. The British National Health System offers an example of this. Unfortunately, if the government eventually controls the majority of scarce health care dollars, system wide medical decisions will be at risk of political or societal influence, instead of directed by best medical practices.

    Technology (i.e. not the electronic medical record as it currently exists) offers the best hope for reducing the cost of medical care while maintaining quality. However, if the cost incentive is removed from health care, medical device manufacturers and pharmaceutical companies will be unmotivated to research new possibilities in technology. Currently, the United States is in the best position to benefit economically from the export of medical technology, which can result in well-paying jobs. Hamstringing companies that make a profit from researching, developing and eventually marketing medical technologies and drugs in order to control the cost of medicine, while pragmatic in the short term, may be penny-wise and pound foolish.

    Something new will come out of the current financial dilemma of medicine. As in all things American, there is enough ingenuity, energy, sincerity, and humanity in medicine that the new medicine can be successful, provided that those willing to guide these new changes are willing to be honest about the trade-offs faced, the costs involved, the consequences of political and strategic decisions, and limits on the all-you-can-eat health care buffet.

    We probably can’t have our cake and eat it too.

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