The Front Lines of Primary Care, Part 2

In my previous post, I discussed how the realities of primary care—the “hamster wheel” of 15-minute visits with sometimes-difficult patients suffering from complex, chronic conditions—can burn out idealistic primary care physicians (PCPs). Increasingly, disillusioned PCPs are leaving the field. A recent survey from the Physicians’ Foundation reports that one-half of PCPs would leave medicine if they thought they could do so. 

Well-intentioned doctors choose primary care because they love the idea of working closely with patients and building lasting relationships over time. But the low reimbursement rates force them to see as many patients as possible in a given day, and the frantic pace of their work often de-humanizes their practice. They are pushed to practice “assembly line” medicine.  Understandably unhappy with this state of affairs, many think to themselves, “this is not why I wanted to become a doctor.”

Ideally, as Thomas Lee, an associate editor of the New England Journal of Medicine, recently put it, PCPs should go home every night thinking “this is what I was meant to do.” This seems like a high bar to reach, but we’d be a lot closer to it if our system recognized one simple fact: no physician is an island.

The Importance of Teamwork

Primary care can’t be a one-man (or a one-woman) show. There’s simply too much to do. In a recent commentary for the New England Journal of Medicine¸ Dr. Thomas Bodenheimer of the University of California-San Francisco notes that “it would  take a primary care physician 18 hours per day to provide all recommended preventive and chronic care services to a typical” cohort of patients.

Making the time-crunch even worse is the fact that PCPs often take on duties that have little to do with the actual practice of medicine. In a recent comment over at Theresa Chan’s Rural Doctoring blog, a PCP named “Doctor Jen” describes the diversity of responsibilities that she faces over the course of a day. “Today,” she begins, “I saw a young woman who brought a list with 17 issues to be addressed…I also saw a newly diagnosed cirrhotic gentleman who is really struggling emotionally with his diagnosis, an 88 yr old lovely woman who needed medical clearance to take a driver's test, and a poorly controlled bipolar client who can't get a psych appt for 3 [months] because he's not suicidal.”

Further, she says, “I filled out multiple notes [for patients to] get back into school, to get out of school, to [authorize] meds, tests or referrals, and received a note from one lady who hasn't seen me in a year wanting me to fill out medical leave paperwork for the 20 something days she's missed due to her migraines! I also saw 3 inpatients this morning.” 

That’s quite a day—and a lot of it has to do with paperwork, correspondence, and administrative tasks. Little wonder that Jen’s exhausted. She continues: “I tell my senior partner sometimes that I just don't think I can do this for 30 years…and he says he's been saying that for the last 26 years.”

One way to help Doctor Jen is to transform primary care from a solo sport into a team-based practice. Bodenheimer notes that, currently, PCPs “perform many tasks that do not require a medical degree and could thus be delegated to other team members.” This eats up precious time and resources that doctors could spend being doctors. Thus, Bodenheimer suggests, primary care should be more “team-based,” with “many functions from the 15-minute visit” offloaded to medical “extenders” such as nurse practitioners and physician assistants, all working within the same practice as the PCP. (This is the core idea of the much-vaunted medical home model of primary care). 

Medical homes not only coordinate care for patients’ sake, but also allow PCPs to spend more time with patients and better prioritize their work. For example, Bodenheimer notes that “patients with one or two chronic conditions” could be cared for by nonclinician members working under physician supervision. These patients could be directed to health coaches, i.e. “registered nurses supervising trained medical assistants or community health workers.” These coaches would advise them on relatively straight-forward matters, such as lifestyle changes and medication mixing. Redistributing medical duties in this way frees up the PCP to spend his 15-minute visit on “patient-generated agenda items.” By getting some of the basics out of way, PCPs would have more time to listen and respond to patient concerns—exactly the sort of interpersonal exchange that many feel is missing from primary care today.

Collaborative primary care also allows PCPs to spend more time with the truly sick. Recall in my last post that Theresa Chan, an ex-PCP, left primary care in part because she found herself rushing through visits with patients that she wanted to help. With more hands on deck, PCPs would be able to better prioritize their time. Patients with more complex health care needs—such as multiple diagnoses or medications, or those who need expensive treatments—would get more of a doctors’ time, and physicians would once again feel that they were providing care for people who really needed it. Someday, perhaps, Doctor Jen won’t spend half of her day writing notes.

A Cultural Shift

Note-writing aside, however, we have to ask: will a more collaborative primary care delivery system really make doctors happy? There is evidence that a collaborative practice is a better, happier, and, ultimately, more distinguished place to work.

Last year the American College of Physician Executives (ACPE) published profiles of “some of the top group practices in the country”—the sorts of places where any physician would be eager to work—and looked at “how they achieved success.” More often than not, the answer was teamwork and a culture of cooperation across different medical providers."

We have a very strong commitment to an interdisciplinary approach,” Glenn Forbes, CEO of the legendary Mayo Clinic in Minnesota, told the ACPE. "It's not about me as an individual, it's about the team.” Indeed, Mayo has a famously egalitarian culture: after the first five years, all physicians within a single department are paid the same salary, and physicians in the same department share the same administrative staff, helping to coordinate appointments and treatments.

Other top-notch group practices are similarly integrated. “…I chose the [multispecialty] group practice model and I've found it to be the most fulfilling,” said Andrew Jacobs, the chief of cancer services as Virginia Mason, a world-renowned non-profit group practice in Seattle.  “We have something here called 'The Physician Compact,' a sort of rulebook that formalizes the 'gives' and 'gets' of working here,” says Jacobs.  According to this compact, physicians have a duty to “collaborate on care delivery” by “includ[ing] staff, physicians, and management on team…treat[ing] all members with respect…[and] participat[ing] in or support[ing] teaching.”

Physicians also commit to “listen[ing] and communicat[ing]” and “tak[ing] ownership” for patients and problems by “particiat[ing] and support[ing] group decisions.” As with Mayo, Virginia Mason has placed a strong institutional emphasis on integration.

In Louisiana, Ochsner Health Systems, a non-profit group practice whose doctors comprise almost one-half of the state’s “best doctors” list, is similarly oriented toward cooperation. "The core of our very being is that we're a large multispecialty physician group,” says Richard Guthrie, the groups’ medical director. “[We have] a special type of esprit de corps,” says Guthrie. “We know we're all in it together…Compared to private practice, where physicians often value independence—[in everything ]from how much they pay the receptionist to how they pay their bills—here the emphasis is on teamwork.” Ochsner physicians, like their Mayo counterparts, are salaried.

All of this bodes well for team-based primary care. We’ve already seen that collaboration and a focus on working together have produced some of the most renowned group practices in the country. Indeed, University of Minnesota professor John Kralewski, an expert on organizational structures and health care, told the ACPE that “the [group practices] that are really good” have “a pretty free exchange of information. A shift from a 'me' to an 'us' perspective. A shared sense that, 'We're an important organization and we're proud of it.'”

Could we see this sort of sentiment develop in primary care? Probably. After all, if you organize care in a way that requires collaboration, then you need to hire people who are good at cooperating. And that’s the first step in developing a shared culture—and ultimately, a sense of mission.

"Our emphasis in recruiting," says Virginia Mason's Jacobs, "is on ability to work within a team…we look for communication skill and the ability to go with a group consensus. It's not all about what you want to do…You can't be a cowboy, a solo player.” Bruce Hamory, chief medical officer of Geisinger Health, a well-regarded physician group in Pennsylvania, agrees. "When we recruit …we…try to make sure they're the right fit for the group…People get along. We do not tolerate bad behavior, whether toward patients or toward colleagues."

These standards would be just as important in a medical home model. You can’t have an effective primary care team if there’s no sense of teamwork. As you develop a team, and recruit people who can work together, you begin to develop patterns and standards of interaction and values; practices begin to work toward collaboration, w
hether through egalitarian payments or codes of conduct.

Eventually, a practice finds itself with a shared purpose that can help imbue its work with greater meaning. Indeed, Kralewski says that the best group practices are “able…to develop a well-defined culture and gain widespread buy-in to that culture.” You don’t want physicians to feel like they’re in a hamster wheel; you want them to feel like they’re part of something special. A more team-oriented approach to primary care could help to make this happen. 

The Patient Factor

Even if a collaborative practice is attractive to physicians, however, we must ask how patients would respond to team-based primary care. Some might be offended by the idea of being shuttled around amongst various providers—you can imagine a sour-puss grumbling about how he “only wants to see my doctor, not some nurse.” This would be bad: the last thing we want is a system that churns out more difficult patients. After all, our whole point is to improve the working conditions of primary care.

But Bodeneheimer argues that if “the team approach is clearly explained to patients; if patients are offered continuity with the team, and if team members provide patient-centered, high-quality care, it is likely…that patients will transfer their trust in the physician to a trust in the team.” Perhaps more importantly, team-based primary care would better allow PCPs to give patients what they want: time, attention, and answers. A 2005 Wall Street Journal/Harris Interactive poll reported that patients’ first priority is to have a doctor with strong interpersonal skills: eighty-five percent of Americans said that it was “extremely important” for their doctor to act respectfully toward them, and 84 percent said the same for listening carefully and being “easy to talk to.” A 2004 Harris poll of 2,267 U.S. adults found that respondents cared more that doctors listened to their concerns and questions than they did about doctors being up-to-date on the latest medical research and treatment.

In other words, primary care systems that allows doctors to engage with patients is exactly what patients want. And if patients still stamp their feet and complain, then they need to realize something very important: primary care doctors are only human. They won’t always be at your beck and call, and they won’t have easy answers to every problem. And sometimes, they need some help.

10 thoughts on “The Front Lines of Primary Care, Part 2

  1. The notion of hiring people with good communication skills and the ability to work in teams in order to insure a good fit in both a culture and personal chemistry sense is an important point. Perhaps the same approach should be extended to patients. So, the patient who just wants to see “my doctor and not some nurse” should be politely told that maybe he should take his business and his medical needs elsewhere. Especially given the shortage of primary care, I don’t see anything wrong with telling a patient that we have a collegial and collaborative team oriented approach here. If you’re not comfortable or happy with our approach, we’ll try to help you find another doctor elsewhere who might better meet your expectations, at least with respect to his or her general approach to medical practice.

  2. The evidence clearly affirms that team based models improve care and lower costs. This model is/can be effective in large urban settings where physicians can organize into large multi-specialty groups, but what about small rural communities where there may only be one or a handful of physicians? Is this model the death of the solo and/or small group practice?

  3. I totally agree with the team approach – but this will involve some sort of grand bargain, including (at least for PCPs) new and fair forms of reimbursement, medical education loan subsidies or full assumption of primary care medical education costs, and special malpractice consideration. Also, it will involve working with the AAMC, the AMA, and other critical physician groups to change the character and orientation of much medical education.
    Given the high percentage of PCPs who practice solo or in very small offices (at least in some parts of the country), there will need to be some sort of coordinated and funded organizational development initiative to create and deploy teams as well as more large multi-physician practices. I think this website has suggested that some sort of cooperative effort with and piggybacking on the VA system might be a fruitful approach.
    Finally, the deployment of electronic medical information systems will need coordination, with regional approaches and government funding, and again with a commitment to the organizational development needed to deploy these systems. The VA piggybacking idea is also relevant here.
    There are serious issues about individualistic American culture which are especially pertinent to medical education and practice which we ignore at our peril if we are serious about making a change. Not to mention the issue of expanding and making acceptable the use of physician extenders and especially of nurse practitioners as part of team-oriented, multi-provider practices.

  4. Barry-You’re right, there is some flexibility here. I also tend to think that even the most stubborn patient can come around if he ends up getting good care from an NP, even if he does so kicking and screaming at first. Further, it’s hard to see how someone who trusts their doctor WOULDN’T trust someone that that doctor has chosen as a right-hand (wo)man. And the real curmudgeons can be dealt with on a case-by-case basis.
    Larry–You’re exactly right. As we’ve said before on Health Beat, reimbursement rates for primary care–including the coordination of care–must be higher, and there need to be financial reforms to make primary care more financially appealing. It’s all part of the same tapestry.
    Your point about individualistic culture is well taken, and an interesting one. It would be very interesting to reflect on the “superstar” culture of medicine, the sort of hotshot ideal that makes a team-based approach–and the sharing of duties amongst non-MDs–such a thorny proposition. Is there something about the historical development of doctors in the US that gives us today’s environment (read Paul Starr’s The Social Transformation of American Medicine for some insight on this possibility)? Or is it that, so long as the option to make a half-million a year as a neurosurgeon exists, hotshots will be there, and the allure of their lifestyles will constantly warp the decision-making of other doctors?
    There definitely seems to be an interesting qualitative story of history, perception, and opinion here to help us understand why, up until this point, something like the medical home model has been so outside our health care equation…

  5. I wonder how these reports fit with another movement–toward Micropractices–that also seems to yield greater patient and physician satisfaction?

  6. Niko,
    I could not disagree with the premise of your posting or with the concept. First, the plight of the family physician in this country isn’t any dire than the rest of the profession, we’re all on the wheel. Why do FP, GP, & Primary IM slots not fill with US grads, probably because they don’t graduate enough AMGs. Even so FP residencies filled over 90% of their slots last year, leaving them about 250 short. Over the last 10 years that would leave about a 3-4000 FP short fall. Barely enough to fill the alotted slots for the Community Health Centers and IHS LET ALONE THE REST OF THE US POPULATION. Where have all the FPs gone. Over the last 5 years the Meccas have hired the equivalent of 1 out of every 5 physicians graduated. Why? From the Deans I have put that question to the response was the same,Its Big Business.
    Second, physician dissatisfaction is a world wide phenomenon. The FPs in Europe are no happier than their American counterparts. The big performance bonus the GPs in UK got was pretty nice. So what did the UK GPs do? They change the contract in 2004 and told the NHS they would no longer be responsible for their patients after office hours and the RCGP called for a National Urgent Care System. Not quit the patient centered model. This is going on all over Europe and their ERs are as crowded or more so than ours. The team model is hardley new but was being taught when I was in residency over 20 years ago. The model also doesn’t take into account what scientific advancements in medicine and IT are going to occur. These advancements are going to happen 5 times faster in the next 30 years then they did in the last 30. Given the mind set of the generation X,Y,Zers they will probably be receiving disease management and physician consults over their Blackberrys. So forget about the patient centered model as an industry wide model. It will have its niche, but only that, just a niche. Would love to continue but an ambulance just pulled up and the wheel keeps turning.

  7. My own experience varies, although some of that is partially my being an atypical impatient (no, that’s not a typo). By and large, my experience with advanced practice nurses in specialties (cardiology, emergency, anesthesia, trauma, etc.) has been very good, but much less so with primary care NPs. With a small sample of PCP NPs, I’ve found I very quickly get into power struggles that I don’t get into with physicians, or specialized advanced nurses. The participatory model seems to go only so far, as long as it’s general health maintenance — when it gets into a specific discussion of prescribing, laboratory testing, etc., sparks tend to fly.
    Unfortunately, I have not spent the same amount of time studying NP peer communications as I have MD/DO communications. With someone from a physician training background, we establish a very quick shared context, or decide to terminate the visit to avoid violence. 🙂
    In one specialized inpatient setting, the MDs dealt with the specialty area and an NP dealt with everything else. Very quickly, we came into conflict about my diabetic care, including when glucose measurements were most meaningful, my individual responses to food and insulin types, etc. She was literally shouting that she would manage my care while I was there, while I, admittedly, was going more deeply into the physiological, pharmacological, and experiential reasons I wanted things done my way. Eventually, the attending cardiologist had to intervene. My guess, and it’s only a guess, is that the NP training model is more interpersonal and less clinical science, and I’m more comfortable with the latter.
    I’ve been a patient, in several solo or small group practices, where an RN and I would turn to the MD and say “go away. You don’t need to know about this discussion. We’ll call you when orders are needed.” More often than not, this was unscrambling some totally confused prescriptions. In my current practice, the RN and I have agreed on worksheets that the MD can approve, but save us all from his handwriting and calculations. Everyone, however, is laughing loudly.
    Don’t automatically assume that nurses communicate better than physicians. I still giggle about an non-NP situation at an HMO, when I was trying to get a prescription refilled. I gave a list of maintenance drugs that were going to my regular PCP. The nurse demanded to write down what each did. This puzzled me, since Ellen, the MD, had prescribed them and obviously knew this. Rather imperiously, she pointed at one line, and yelled “tell me what this does so I can tell the doctor!”
    Rather automatically, I responded that it was an HMG coenzyme A reductase inhibitor. At that point, my ex-wife turned to the nurse and said, “it’s for bad cholesterol”, and dragged me away as I whimpered that cholesterol is amoral, but there are evil lipoproteins…

  8. The notion of hiring people with good communication skills and the ability to work in teams in order to insure a good fit in both a culture and personal chemistry sense is an important point. Perhaps the same approach should be extended to patients. So, the patient who just wants to see “my doctor and not some nurse” should be politely told that maybe he should take his business and his medical needs elsewhere. Especially given the