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.