The doctor is out?

You may have come across this report that says half of U.S. primary care physicians want to leave the profession. Actually, I would pay approximately zero attention to this survey -- the response rate was less than 10%, and it's likely that the docs who were motivated to answer are the ones who are the most angry and unhappy. I don't think half of all primary care docs are about to quit.

Nevertheless, primary care in the U.S. is in crisis. We have a shortage of primary care physicians, with long waits for appointments, visits that are too short, and docs feeling hassled, overworked, underpaid compared to their specialist colleagues, and unable to give sufficient attention to their patients. In some parts of the country, it's difficult for people to find doctors at all, especially if they depend on Medicaid, which pays less than private insurance. The situation looks poised to get worse before it gets better, as too few graduating medical students go into primary care residencies, while a lot of primary care docs are nearing retirement.

NEJM recently hosted a round table discussion of this issue and they once again did the right thing by making it open access. Here Barbara Starfield, a physician who is also a highly regarded investigator into effective medical practice, lays out some of the issues. The entire suite of essays is on the NEJM front page right now, although unfortunately they haven't given us a permalink. (This Intertube thing is fairly new to them, evidently.) In my view, there are five major areas where we can look for solutions. The last three are not high on the panelists' agenda, so consider this a contribution to the discussion.

1. Pay more for primary care services: Right now, doctors are paid a lot for doing tests and procedures, but not paid enough for office visit time and not really paid at all for all the paperwork they have to do and informal consultations with colleagues and patients (as by phone and e-mail). By undervaluing time spent with patients, we make it very difficult for primary care physicians to sustain effective healing relationships and truly understand and meet their patients' needs. We also discourage young physicians from going into the field. Yes, as Starfield says, if we pay more many doctors will choose to see fewer patients rather than increase their incomes. That's good, as far as I'm concerned.


2. Develop new models of primary care in which M.D.s don't do everything: The idea is to have R.N.s, physician assistants, and counselors of various kinds spend time with patients on health education, support for medication and diet adherence, routine physical exams, etc., and have the expensive and scarce M.D. time reserved for services where it's really needed. I'm only partly into this. I think the physician-patient relationship benefits from having physicians involved with all aspects of patient care, but maybe there's a decent compromise position.


3. Use information technology to streamline paperwork: This mostly means electronic medical records, linked to Electronic Order Entry and billing systems. If we can really get this to work, it will make Marcus Welby's life considerably easier, but there are obstacles, including cost-effectiveness for small practices (not there, subsidy needed); the need for standardization so all the systems can talk to each other; and cutting down the hassles a lot of physicians experience with pop-up warnings, elaborate paths to get to what they need, etc.


4. An equivalent of the U.K.'s NICE, with real power: Evidence based guidelines that are respected by insurers, patients and the courts can cut down on unnecessary tests and procedures and make decision making easier. That's a long discussion which I'm not going to get into here.


5. Improve doctors' communication and time-management skills for patient encounters: I've listened to hundreds of hours of tapes and read thousands of pages of transcripts of physician-patient encounters. Sadly, few physicians are skilled at communicating effectively and efficiently with their patients. While I don't think 12 minutes is enough for most visits, doctors could get a lot more out of the time they do have -- and hopefully, some day, it will be enough. Medical training is barely beginning to address this, and the evidence base is inadequate. (Dear NIH: Give me lots of money. Thank you.)


6. Universal, comprehensive, single payer national health care: Right now, primary care physicians spend a whole lot of time figuring out what is and is not paid for by their various patients' various insurance schemes, managing complicated businesses that require infrastructure to bill multiple payers, and negotiating with their patients over what expenses they can and cannot pay out of pocket. If everybody has the same insurance, and everything is covered, all of that goes away. And oh yeah, we all save money.

So, whatever reforms we get in the coming year, these need to be in there. Let's make it happen.