Why Did all the Doctors Go???

The Uncertain Future of Primary Medical Care
David Mechanic, PhD
Annals Of Internal Medicine
7 July 2009 | Volume 151 Issue 1 | Pages 66-67

The United States needs a strong primary medical care capacity as we engage the challenges of health care reform, expand insurance coverage, and constrain medical costs without sacrificing quality. Research over decades has repeatedly demonstrated that primary care services that provide continuing access to care are associated with superior population health outcomes . Nonetheless, the future of U.S. primary care is uncertain, many clinicians report high levels of frustration and dissatisfaction, and careers in primary care are increasingly unattractive to new medical graduates.
Linzer and colleagues studied 422 family practitioners and general internists in 119 ambulatory clinics. They report high levels of unhappiness about time pressure and practice pace, little sense of control over work conditions, and deficient organizational culture. Other data indicate substantial deficiencies on measures of quality outcomes and neglect of care processes.

Three themes persist across time, place, and practice arrangements . First, primary care physicians persistently report time pressures and insufficient time for patients, but practice disorganization substantially limits their ability to cope . Second, primary care physicians dislike intrusions on their clinical autonomy by managers and are particularly dissatisfied when their remuneration depends on successfully constraining the clinical choices they can offer their patients . Finally, physicians want remuneration to meet their expectations and reflect the intensity of their efforts . Each of these themes will be important as we consider different ways of restructuring medical care and improving standards of care and cost-effectiveness.

Average encounter time has increased substantially over the decades (8). The data do not support the claim that primary care visits are shorter , with an average time of around 15 minutes . However, the perception of time pressure is realistic because more competing treatments have become available; more preventive interventions are demanded; patients have become better informed, more assertive, and more insistent on explanations; and demands for documentation and other bureaucratic requirements have increased. Direct-to-consumer advertising has also increased physician stress because patients ask for advertised drugs, which requires physicians to either spend more time on explanation to divert demands or to prescribe drugs unnecessarily .

Studies consistently find that primary care physicians are more satisfied when they have fewer patients and can maintain a less hurried practice pace, but physicians who adopt this practice style usually don't achieve their target income. Some find lower income an acceptable trade-off for a more enjoyable practice style, whereas others seek to have their cake and eat it too by organizing concierge practices that achieve higher incomes through enrollment fees. Such personal solutions exacerbate health care disparities and increase the challenge of achieving universal access.

Maintaining the fast pace needed to achieve target incomes contributes to physician dissatisfaction and difficulties in providing comprehensive, integrated care. Cost constraints make increased remuneration for primary care unlikely unless income is redistributed from specialists to generalists, which the advantaged class understandably resists. Nevertheless, many clinicians, managers, and policy makers are becoming more interested in moving away from payment for each billable unit and toward coverage of episodes of illness or partial capitation that combines a base payment for managing care for each enrolled patient with fee-for-service and other performance and productivity incentives. Whether these changes will reduce income disparities between segments of the profession is ultimately a political issue.

Linzer and colleagues' findings indicate that, whatever the conditions of remuneration, reduction of chaos in the practice environment and development of more supportive organizational cultures are required to make primary care careers more manageable and satisfactory. Physicians need to be provided with the technical and professional team support that facilitates high-quality care and provides a greater sense of control over one's work.

When quality initiatives, such as evidence-based decision making, implementation of clinical effectiveness research, pay for performance, and electronic health records, are taken in isolation, some perceive them as exacerbating workload and reducing discretionary judgment. But taken together and integrated into effective practice arrangements, they facilitate higher-quality care and greater physician control. Evidence-based standards are essential guides, but health systems must protect physician discretion in decision making when patient circumstances justify it, as in Kaiser Permanente group practices . The key is not rigid adherence, but accountability to colleagues for the reasonableness of one's decisions.

Because physicians have different preferences for how they practice, different models will coexist. Kaiser Permanente and the U.S. Department of Veterans Affairs provide successful models for reorganization of patient care functions. In these systems, primary care physicians have a more defined role, working in teams with hospitalists, nurse practitioners, and other relevant personnel. Care coordination within the team takes time, but sharing workload and responsibilities facilitates high-quality care and often leads to increased physician satisfaction. The patient-centered medical home is popular in part because the conceptual model includes a management fee for the coordination and integration of care, an incentive that is so often lacking. Although many advocate the patient-centered medical home model, its implementation, effectiveness, and capacity to control costs remain uncertain .

Most primary care practices are small and will probably remain so for the foreseeable future . Some primary care physicians, using electronic health records and new forms of communication with patients (including e-mail and group visits), practice to their satisfaction in small or even solitary practices . Many more primary care physicians are likely to join with nurse practitioners and physician assistants to seek ways to manage workload more comfortably.

Electronic health records and an interoperable information technology framework are critical for implementing the coordination, integration, and continuity central to primary care. Although the start-up effort and learning curve may initially slow practice pace and increase workload, electronic health records help physicians manage care and workload effectively and contribute to professional satisfaction. They make possible virtual integration, even in small practices, and address many of the strains of contemporary care, including monitoring and coordinating (19), avoiding duplication and error, and facilitating transparency and accountability. Effective information technology is a core feature that helps build a constructive practice culture and a renewal of medical professionalism .

The future of primary care remains uncertain, and much depends on payment policies and incentives for developing workable frameworks for team efforts and professional responsibility. Primary care as an indispensable set of functions will persist in some form, because most patients want a primary care physician. The challenge is to organize 1-on-1 care as part of an integrated system that serves the needs of both patients and physicians, enhances quality, and keeps costs within reason.


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David Mechanic, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 30 College Avenue, New Brunswick, NJ 08901; e-mail, mechanic@rci.rutgers.edu.

Primary Care (Physician)???????

The ACP Advocate Blog by Bob Doherty

Are doctors and non-physicians speaking the same language when they define primary care?
I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.

The White House's primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to "What's my line?" style questioning, I think it would be become evident that their lines (roles) were very different from each other.

The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.

As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.

The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

Many of the professions represented at the White House's primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address "a large majority of personal health care needs" or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM's definition, but their skills and training are complimentary--not equivalent--to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.

I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.

But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.

Today's question: Do you think primary care means the same thing to the different health professions?