Thursday, November 27, 2008

Can Innovation Save Primary Care in its Present Form ?

November 27, Thanksgiving Day, 2008

I felt like I was becoming a guideline-following automaton and a documentation drone. It was draining to me, and I didn’t feel it was what the patient wanted either.

Christine Sinsky, M.D. General Internist, Medical Associates Clinic and Health Plans, Dubuque, Iowa, “Innovation in Primary Care- Staying One Step Ahead of Burnout,” New England Journal of Medicine, November 27, 2008

Effective innovation depends on assumptions. If you assume primary care’s troubles are due to poor or uneven physician performance or to woeful lack of use of information technologies, that’s one thing. If you assume the troubles stem from overwhelming and unrealistic demands on time and talents of primary care physicians, that quite another.

It also depends on what you mean by “innovation”?

If by innovation you mean current federal efforts to impose pay-for-performance and electronic medical records on primary care, the answer in my mind-field is “No, these things will not save primary care. Indeed, they tend to cause less time with patients, irritate the practitioner, and aggravate the shortage.

• Other industries learned long ago that annual performance reviews by managers of workers destroys morale, kills teamwork, and hurts the bottom line (Samuel Culbert, “Get Rid of Performance Review!”, Wall Street Journal, October 30, 2008). In health care, pay for performance makes the physician a surrogate to the “boss” i.e., payers, and evokes hostility, and is unlikely to improve performance.

• Why have only 15% or so of physicians installed EMRs? The reasons are legend, but the main one is EMRs take physician and staff time away from seeing patients. The assumption here is that good documentation makes for good doctoring, which is not only silly but fallacious. Physicians and patients alike treasure time spent with each other, not time spent entering or evaluating data.

Promises of November 2008

In a recent article I wrote for Physician Practice Options, which will appear in its December issue, I argued the U.S, may be on the cusp of a primary care renaissance. My argument went like this.

“When the history about American health care is written, November 2008 will be remembered as the month of emerging fundamental truths about the importance of primary care in the U.S. health system.

Five notable November events precipitated, crystallized, and revealed these truths.

1. On November 4, newly elected a president, Barack Obama, promised expanded coverage as a high priority. Shortly thereafter, on November 11, Senator Max Baucus (D., Montana), in a 35,000 word health reform white paper, “A Call for Action,” called for coverage of 95% of Americans. He cited primary care shortages as a barrier to achieving the coverage goal.

2. On November 10, as the U.S. financial meltdown sought its bottom, the American Medical News reported in “Doctors Tally the Economic Value Practices Bring to Communities” that private practitioners in general and primary doctors in particular positively impacted the overall U.S. economy. Health care is a growth industry in the U.S., generating more than 10 million jobs. Each private physician’s office creates 12 to 13 jobs and has an annual economic impact of roughly $1.5 million.

3. On November 12, at the interim AMA meeting, the House of Delegates adopted intact, joint principles of the medical home developed by the four major primary care societies – American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Society ( Among the principles was enhanced pay for primary care through a hybrid system of fee-for-service, pay for performance bonuses, and a capitated management fee for coordinating care.

4. On November 13, the New England Journal of Medicine. America’s most prestigious and widely read medical journal published two articles on the primary care doctor shortage and its implications (T,H. Lee, K. Treadway, T. Bodenheim, A.H. Goroll, B. Starfield =, and M. Roland, “The Future of Primary Care,” and T.H. Lee and Others, “Perspective Roundtable: Redesigning Primary Care.”

5. On November 18, The Physicians’ Foundation, a charitable foundation collectively representing members of state and local medical societies, the majority of America’s 900,000 physicians, released results of an unprecedented survey of 270,000 primary care physicians and 50,000 specialists indicating widespread loss of morale and desires to quit or cut back on practice (see two sidebars, the Physician Foundation and Highlights of Survey). Survey results were reported on CNN and other major media outlets”

November Promises Deflated

I felt self-satisfied with the piece until I sent it to Robert Gifford, MD, formerly head of general medicine and now on the admissions committee at the medical school. Here was his response.

I am not optimistic that the current crop of medical students are about to opt for a primary care career. The lure of high tech specialty training, the high educational debt, and most of all, the desire for a less frenetic life style, time to spend with the family, that will send their children to the best of colleges are all against an effort to fix the primary care shortage, even if salaries should rise (though that would surely help). I see the future of primary care in the hands of ‘managers’ who supervise an army of nurse practitioners, physician assistants and the like. Let’s face it, most of the common issues that take so much time in primary care are the management of diabetes, hypertension, stable coronary disease, congestive heart failure, chronic obstructive lung disease, osteoarthritis, depression, respiratory and pharyngeal infections, gastro-esophageal- reflux, and the like. Much of this can be managed by nurse practitioners as long as three is adequate supervision by a competent and well-trained primary care physician. Of course, I would rather by seen by a doctor, but I am not sure we can turn this awful situation around.

Hopes Engendered by Obama

Well, Gifford’s comments deflated my Renaissance argument about primary care’s future. But surely, I thought, the new Obama administration can step into the breach. Its emphasis on covering the uninsured, fostering primary care and promoting medical homes will have a positive impact on primary care. That what some medical leaders think. AMA Board of Chair Joseph Heyman says, “We think there’s that window of opportunity next year to really accomplish something...” And Ted Epperly. The American Academy of Family Physicians president, says he’s never been so excited about a new president. These comments do not give me confidence. It takes ten years to produce a competent primary care doctor, and medical students will still have the option to practice what and where they please.

Bailout from Burnout

Still, full of hope about the future, I turned to a November 27 perspective piece in the November 27 New England Journal of Medicine, “Innovation in Primary Care – Staying One Step ahead of Burnout.” If the government can’t bail primary care doctors out of burnout, maybe primary care leaders can. The article is based on innovative efforts of Christine Sinsky, MD, and her partner husband, Thomas Sinsky, MD, in the 114 person medical group in Dubuque, Iowa. Among other strategies, the Sinskys have adopted these practical strategies.

• A “minihuddle” with a nurse who has reviewed and summarized the patient’s lab work from a previous visit.
• Extensive advance work by two nurses to organize each visit by summarizing what has gone before on 1 to 2 sheets of paper.
• A brief comprehensive dictated note by the primary care physician summarizing the visit.
• Scheduling routine lab tests for next visit and ending each visit by planning the next one
• Organizing small doctor-nurse teamlets.
• Having the nurse take all calls, deciding which tests merit attention, and perfuming route monitoring tasks such as examining the feet of diabetics.

The author of the NEJM articles also cites the work of Kaiser Permanente Colorado. This group has 300 primary care physicians who have experimented with,
• Monthly sessions with a small group of elderly patients with common chronic disease problems following by individual sessions.
• Walk-in group sessions with a nurse practitioner and a pharmacists
• E-mail and scheduled telephone visits
• Responding to e-mail messages with 24 hours
• Making EMRs easier to use

In the case of Kaiser, the results are a mixed bag. Turnover among primary care doctors is much higher than among specialists, and recruiting primary care doctors for those who leave or retire is still difficult. It takes 10 months to recruit a doctor, only 2 months to hire a physician assistant, and in the past 6 months, Kaiser has converted six physician positions into slots for 9 physician assistants.

The Future

The future of primary care? Who knows? It’s bleak in the short run, perhaps brighter ahead. Innovations from above and below may better the situation and ease physician shortages. Solutions undoubtedly will mix public and private efforts. Only two things are certain, one, concerns will grow on how to meet demands for more primary care practitioners, and two, primary care will not be saved in its present form, with primary care doctors struggling alone to keep from drowning in the swamp or crawling out to reach higher ground


kevinh76 said...

When it comes to the role of midlevels as the future of primary care, one question always arises in my mind which I have never seen adressed or answered: Why is it assumed that mid-levels will want to do this work that physicians are fleeing, for a presumably lower salary?

Additionally, physicians don't go through their training to become managers of midlevels. If you want to completly stop all application for primary care residencies, just tell the current crop of med students that a career in primary care will involve managing an army of midlevels. I will never assume the malpractice risk of supervising an army of midlevels so that I can be sued and held responsible for their mistakes. I have other skills and there is always hospital medicine or concierge practice if the system forces an untenible change that would prevent me from making a living doing what I do now as a primary care internist.

RN forever said...

Ok Kevin- First stop that belittling language. I am an adcanced practice nurse (family nurse practitoner for 15+ years, RN for 35) and I am not 'midlevel' to anyone. I am a registered nurse with 6 years of PROFESSIONAL education (including premed organic chem, micro, physiology, patho phys, 4 semesters of pharmacology, anatomy, dissection, etc.) as compared to 4 years that MDs have. I understand things about patient care efficacy that nurses know and physicians rarely consider (family, community, and financial issues among them).

I do not need a physician manager and am very fortunate to work in a state where I do not have mandates for that expensive nonsense.And as far as malpractice? Get your facts-NPs are sued far less than MDS for many reasons-among them is that patients TRUST us, we care about them, AND our quality of care is excellent! In states where I practice independently, no physician will be sued for "managing" me (The data on PAs who ARE mandated "midlevels" with physician supervision in all states is quite different!).

I love doing the work physicians are "fleeing" and I don't mind make $70,000+/year-that is plenty to give me a very nice life, although I do not drive a BMW, Mercedes, Lexus, or Audi like most primary care MDs in my area.

Furthermore, my patients and I need physician specialists, just like you and your patients do, for referals for care that is beyond our capabilities-no question about that. But I do NOT need a physician to supervise me for standard daily routine primary care tasks-nor do you and I bet you refer to specialists all the time (or you should-if you don't you are practicing shoddy medicine).

Now, for a history lesson. Physicians have not filled the primary care needs in this country EVER. There has always been a primary care MD shortage. The NP movement in the 1960s was designed just for this reason as were public health nursing initiatives as early as 1900. Nurses have often been the professionals filling the gap and done so quite well. Organized medicine (such as the AMA, AANA, ACOG, etc. and others) and certain self serving individual MDs have always opposed nurses doing what nurses know and physicians want to control, and when the 'nay sayers' win, the people of this nation, particularly the poor and vulnerable populations, lose.

I'm sorry you chose a path that has you in a position where the world isn't turning out the way you wanted when you were in medical school. But maybe you and other MDs who are threatened should get a grip and see the big picture. Get the facts and get them straight. Stop focusing on your own self interest and think outside your narrow box. Start to care about people in this country and see nurses as allies and colleagues. Cooperation and mutual respect, and physicians who acknowledge nurses' experitse and importance, will make all the difference.

kevinh76 said...

RN Forever,

You start by saying stop the belittling language then spend 6 paragraphs scolding me and belittling MY education and training. You know nothing about me but I now know more than I want to know about you. You have not answered my question and have added nothing to the topic. Your call for cooperation and respect rings hollow after 6 paragraphs of insults.

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