Headlines
As reported by the New York Times, November 12, 2009.
Primary Care's Image Problem
November 19 is the American Cancer Society’s Great American Smokeout
By Pauline W. Chen, M.D.
In my medical school class of 140, Kerry was one of the best and the brightest. Gregarious, unassuming and a dedicated fitness buff with a weakness for ice cream, she managed to sail through the weekly exams that most of us struggled with during the first two years. Later on, in the third year on the hospital wards, she quickly became what every one of us so wanted to be: the indispensable medical student.
When it came time to choose specialties in our last year of medical school, most of us thought Kerry would do what every high achiever and even the not-so-high achievers were already doing: line herself up for a coveted spot in one of the prestigious subspecialties, a field like dermatology, orthopedics, plastic surgery or radiology.
But Kerry wanted to become a primary care physician.
Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. "Kerry is too smart for primary care," a friend said to me one evening. "She’ll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something."
Unfortunately those comments would not be the last ones I would hear disparaging primary care. Even today, similar beliefs persist among medical students and trainees, though they have long since been condensed, reduced to an oft repeated acronym among those choosing specialties: I’m heading for the ROAD (radiology, ophthalmology, anesthesia and dermatology).
That ROAD has had devastating effects on the physician work force in the United States. While 50 years ago half of all physicians were in primary care, almost three-quarters are now specialists. The future implications are even more dismal. According to one study published last year in The Journal of the American Medical Association, as few as 2 percent of medical students are choosing to step away from the ROAD or from other similar "high prestige" and competitive specialties in order to pursue general internal medicine. The statistic has the power to bring even the best efforts at reform and universal coverage to a grinding halt. Even with other health care practitioners like nurses and physician assistants helping to care for as many patients as they can, universal health care will be doomed if there are not enough primary care doctors.
Experts in medical education have pointed to three reasons for this lack of enthusiasm: debt, income and lifestyle. The vast majority of medical students finish their schooling saddled with enormous educational debt — the average amount is in excess of $140,000 — and primary care remains one of the lowest-paid specialties.
In addition, with fewer doctors and more patients, as well as little reimbursement for the specialty’s growing administrative aspects — filling out insurance company and health maintenance organization forms, making telephone calls and writing e-mail messages to coordinate care with other caregivers — primary care physicians end up working longer hours than doctors in other fields just to make ends meet and fulfill patient care responsibilities. Moreover, while pressing and acute care needs arise routinely in patients with high blood pressure, diabetes and heart disease, there are rarely calls of the same urgency among patients with, for example, a skin lesion.
But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough. Despite the fact that primary care physicians remain this nation’s frontline doctors — diagnosing new illnesses, managing chronic ones, advocating preventive care and protecting wellness — medical students may continue to turn away from the practice of primary care.
Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.
That image, however, may be changing. This week in Boston at the annual meeting of the Association of American Medical Colleges, more than 100 members of the Association of Deans and Directors for Primary Care convened to discuss that how their specialty might prepare to care for potentially millions of newly insured patients.
High on the group’s agenda was the need for overhauling the practice of primary care. But unlike the image held by naysayers of primary care, the changes proposed and discussed make an innovative vision of primary care practice central to some of the most exciting solutions for the country’s critical health care problems.
"We’ve got this chance now to do something and create a model of practice that will actually work for patients and attract talented students," said Dr. Bruce E. Gould, head of the Association of Deans and Directors for Primary Care and an associate dean for primary care at the University of Connecticut School of Medicine in Farmington, Conn. "When I finished training, practice was less complex. But the systems haven’t evolved to keep pace with what we can now do for our patients."
"A lot of primary care doctors feel like they are chasing a bus that they are never going to catch. With lives hanging in the balance, that is not a good place to be."
Steven A. Wartman, president of the Association of Academic Health Centers and a general internist who participated in the discussion, added: "Changes in the practice environment could become the single most important force on medical education. If you look at history, some of the biggest changes in medicine have been a result of changes in practice."
One of the practice innovations is the patient-centered medical home. "For a long time, we have had this old-fashioned model of an individual doctor working with an individual patient," said Dr. Nancy A. Rigotti, a professor of medicine at Harvard Medical School and president of the Society of General Internal Medicine. "But the model that works best for patients and doctors is a collaborative one."
This teamwork approach could transform the very role of the patient-doctor relationship. Currently, primary care doctors often serve as a patient’s principal guide through the health care system maze. In a patient-centered medical home, the doctor would be one guide among many. A patient could turn to an entire team of physicians, nurses, physician assistants, social workers, pharmacists and other health care professionals; and each of those clinicians would in turn work collaboratively with other team members to address that specific patient’s care, concerns and health issues.
"In a patient-centered medical home, I would not be the sole proprietor," Dr. Gould said. "Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader."
Other members of the team would also take up responsibilities that have traditionally fallen to primary care physicians but that are more appropriate to their area of expertise. For example, scheduling and follow-up of routine preventive measures like Pap smears, colonoscopy and mammography would be the responsibility of not the doctor but a health care professional with training in electronic medical records and clinical practice support.
"With a team approach," Dr. Gould added, "each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction."
Dr. Rigotti said there were demonstration primary care practice projects across the country. "It’s sort of like the thousand-flowers-blooming kind of thing," she said. "Money alone won’t make primary care fun and rewarding. We have to enjoy the practice of medicine."
"And," she added, "I can’t help but believe that students and trainees will be excited by seeing primary care physicians who are being creative and solving the national problem of high quality and efficient care for patients."
I called my medical school classmate Kerry and asked her about her career decision 20 years ago. "I do remember that the expectation was that you should go on and become a specialist," she said. She never wavered from her choice of primary care and went into practice after completing a residency in internal medicine.
"But," Kerry said, "I kept seeing a lot of working people who wanted to take care of themselves and their health problems but who couldn’t afford it and didn’t have the insurance." So in May 2000, she left her practice and joined two nurse practitioner colleagues to open up the Good Samaritan Free Clinic in Moline, Ill., a clinic that offers free health care to 1,000 working but uninsured adults and that counts more than 70 health care providers as active volunteers.
As I listened to Kerry talk about the clinic, I remembered what Dr. Rigotti had said earlier: "There are a lot of students who want to change the world. Primary care is advocacy one patient at a time."