Thursday, February 12, 2015

"A monkey could practice primary care"

In case you missed this a few weeks ago, here's a well done story by Karen Brown, who followed several primary care residents and got a good sense of why many people choose not to go into this field.  The story was funded by a fellowship from the Association of Healthcare Journalists and the Commonwealth Foundation.  (To be clear, the quote in the title above is not mine, and certainly not my view!)  Excerpts:

These young doctors are in the middle of their residency at Baystate Medical Center, a hospital affiliated with Tufts University Medical School. They’ve completed four years of medical school – so they’re already MD’s – and are now in the hands-on part of their training.

Michael Rosenblum is a residency director.
“If you get people before medical school and even at the beginning of medical school, there’s a huge interest in primary care,” says Rosenblum. “The vast majority of medical students want to develop relationships and see patients over time. And then we see that kind of peter off.”
Brown notes:

Most doctors I’ve met going into primary care talk about their sense of social justice. They want to work for underserved communities. Or to fill a critical need. It’s rare to hear people list the superficial trappings of the job as a driving factor. And that’s not surprising, Tischer says, given what they hear about the field.

But then money and prestige raise their heads:

But perhaps even more discouraging is what the money disparity says about the status and prestige of primary care.

“Here are these type A competitive people that have been at the top of their class like since kindergarten,” says Gina Luciano, who co-directs Baystate’s primary care residency. “They tried to get into the most prestigious colleges. It’s always very competitive, very competitive, very competitive.”

So when they get into residency, she says, they want to stay on the up escalator. “And you have all of these mentors that are telling you, ‘you could do cardiology, you could do critical care.’ It feels really good that here are these really prestigious things to go into in medicine. It’s hard, I think, to be swayed from that.”

Dr. Andrew Morris-Singer, who runs the advocacy group Primary Care Progress, calls this the “hidden curriculum” of medical education. And not always hidden very well.
“There’s also explicit statements like, ‘You’re too smart to be a primary care doctor.’ ‘This is a dead field.’  Or my favorite, ‘A monkey could practice primary care. Why would you do that?’” says Morris-Singer. “So it’s a whole range of things, but the basic admonition is: ‘Hey, it’s a waste of a medical education.’”
Some stay true to their passion of wanting to be create deeper relationships with patients, but with a twist:

Levitt is planning to become a hospitalist – the person who oversees basic care in a hospital. His salary will be similar to a primary care doctor, but he will have set hours, and at the end of each shift, he’ll hand over patient responsibility to the next person.

Levitt says he would consider going back to primary care if he found the kind of private practice that would make him happy, but that’s not what he saw in residency. Across the country, residents often work in urban, hospital-affiliated community clinics where health and social needs are complex, and offices often under-staffed. Since revenue often depends on the number of patients seen, there’s pressure to push them through in 15-minute increments.


Barry Carol said...

If it were up to me, I would fix this by paying primary care doctors considerably more than they make now. Then they wouldn’t have to see as many patients to make a comfortable living and could spend enough time with patients to probably reduce the need to refer them to specialists as often as they do now. Of course, to make that work for the broader healthcare organization whether it’s a hospital system or a large multi-specialty physician practice, reimbursement would have to move away from fee for service in favor of some combination of capitation and bundled payments or shared risk / shared savings.

Chris said...

My spouse is a primary care Pediatrician here in Texas. Its not uncommon in her practice to see 45-65 patients a day. She sees everything from complex, multi-issue patients, to kids who have a mosquito bite. Anything remotely complex gets referred to specialists by necessity.

Dino William Ramzi said...

Somebody need to tell these folks about Direct Primary Care as a great model for a satisfying model with a social justice angle. Boy, do I have stories to tell, as I try to expand this part of my practice.

Paul Levy said...

Excellent point, Dino.

akhan13 said...

I agree with Barry. I have heard survey-based and other research that indicates that money is not the main reason that medical students avoid primary care, but the potential for higher reimbursement rates to reduce throughput thus allowing more time with each patient and providing the ability to address more complex issues is huge. The ability for cardiologists to do more and avoid/delay referral with new techniques as well as to earn more has flipped the prestige level compared with cardiac surgery. A specialty surgeon I work with (cautioning us about other specialties taking away some of his specialty's patients) stated (not my words, and I don't agree, but am trying to convey the viewpoint that some have) 'when I was training 30 years ago cardiac surgeons were gods walking the earth, and now they're cardiologists' bi***es!'.

Keith said...

It is discouraging that this conversation has been occurring for over 20 years and what has really changed? Each iteration of health reform that I have witnessed during my career has been touted as fixing the payment issues with primary care, whether it be RBRVS, HMOs, or the ACA, but none have done anything to change things for PCPs. In fact, the ACA has only added to the burden of paperwork (or computer work) with meaningful use criteria, quality criteria, MOC, and a quantum leap in the number of authorization requests for referrals, diagnostic studies, or drugs. Each change claims to put primary care in the drivers seat, but this is horse s##t since PCP has very little control. Lets stop kidding ourselves and turn over priamry care to the nurse practitioners. Medicine seems to have very little purpose for us other than as its dumping ground for onerous paperwork.

David said...

Interesting piece. I don’t think it is confined just to primary care physicians. When I was in Med school, no matter what rotation I was on, some of those specialists often demeaned other specialties. The worst were the surgeons saying “don’t go into Internal Medicine, all they do is think and talk, and nothing gets done”. Of course, when I was on Medicine, the internists demeaned surgeons as too aggressive, somewhat ignorant, too much like cowboys (shoot first, ask questions later) and so on. When I decided to go into Anesthesiology, many crapped on my decision saying “why would you want to sit on your ass and pass gas all day”. It wasn’t much different during my rotating internship, but I didn’t pay much attention to it, and I went on to a very satisfying career in Anesthesiology and Critical Care Medicine.

One other similar experience was that no matter which academic center I was at, (all were excellent institutions, and still are), each had physicians who thought they alone knew the only correct way to manage a medical problem, while other places were backward, or didn’t always do the “right” thing. I quickly learned there was more than one way to manage or solve a problem and no one had a monopoly on the right answers. What was hard to understand was the pernicious need to boost one’s own stature by demeaning the “other”. It is probably a curse in many work situations, but I can only write about my own experience with professional intolerance

Anonymous said...

Well let's face it. Primary care has been dragged into the dumpster steadily but surely by insurance companies and society in general which has steadily become more specialty oriented. I don't think that it's just the money issue that prevents students from entering the field but it's certainly one of the main factors. We've taken away all the prestige and left primary docs with the image of pencil-pushers. With over 200K in debt why would anyone opt for less than optimal pay. The problem is much deeper than the superficial solutions anyone has to offer. It really entails changing the societal views on primary care and also channeling some of that CMS specialist money towards primary care docs.

A lot of loss in Primary care has been due to the advent of Hospitalists which has stolen manpower in the outpt internal medicine field. the advent of telemedicine physicians can care for some of the patients in rural communities and hospital and hopefully help push care along. I think the entire system is going to have a makeover.