There is no question that the United States healthcare system is in trouble, but getting to the root of that problem is a complex issue. While insurance conundrums and pharmaceutical price gouging have gotten the most press, another possible cause lies in an area the has so far escaped media scrutiny: the use of primary care physicians (PCPs).The World Health Organization regards primary care as an integral component of healthcare strategy, and the Commonwealth Fund goes so far as to say that underinvestment in primary care is one of four fundamental reasons that the American health system ranks last among high-income countries. Yet, it seems that the US system is actually working to drive PCPs away.
Fifty years ago, at least half of the doctors in America practiced primary care. Today, fewer than one-third of them do. What is behind this mass exodus? I asked my friend Dr. H, who has been practicing primary care for 25 years now, and got an earful.
Dr. H got into primary care because he genuinely enjoys working with patients. He likes to understand where they are coming from and take the time to shape treatments that will work for each individual. When he first began his practice, most of his time was spent doing just that. He came to really know his patients because they stayed with him for years. In order to keep track of details, he made simple notes on charts. Today, the picture has changed. He spends fully half of his time on the computer.
It all started with the Health Information Technology for Economic and Clinical Health Act of 2009. The intent was to bring the medical records industry, still buried under paperwork, into the 21st century. On that level they somewhat succeeded. Today, the vast majority of US hospitals and doctors are equipped with electronic health record systems. But in the process, primary care physicians took a hit. Suddenly, there was an outpouring of regulations, new coding systems and ghosts in the machine that came to haunt the halls of medicine. It was a change that no one was ready for. To quote Dr. John Halamka, chief electronic medical records guru at Beth Israel in Boston, “We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools. In a sense, we gave clinicians suboptimal cars, didn’t build roads and then blamed them for not driving.”
Fortunately, Dr. H. learned to drive quickly – he’s fast learner and an even faster typist. But computerized data didn’t just take up time, it also took a big bite out of patient engagement. Electronic efficiency was paid for with a dehumanization in patient treatment. Physicians were expected to extend quality care and establish empathy with patients in a matter of 12 minutes, after which there was a pile of data to enter. A further constriction was the lack of communication between electronic providers. While a medical office had easy access to its own data banks, transferring information from one office to another is no simple matter. If consulting doctors or specialists are not part of the same system, patient information has to be extracted like so many teeth.
You would think that with all the extra work there would come an increase is salary for PCPs. There has not. Primary care is low on the totem poll when it comes to compensation. Specialists make, on an average, two to four times more than their PCP counterparts, even though primary care physicians spend far more time with patients. By capitalistic standards, the implication is clear – in terms of value, the AMA deems the PCP’s role as less important than that of a specialist. It is an especially bitter pill to swallow because the opposite is true. According to studies, an emphasis on primary healthcare results in better health outcomes and lower spending, along with fewer emergency room visits and hospital stays. It is one of the reasons that primary care doctors outnumber specialists in other industrialized countries. In the US, specialists are now the majority, and our clinics provide far fewer services in the primary care setting.
Is the primary care physician becoming a relic of the past? It is doubtful. While specialists may have the ability to deal with specific problems, they rely almost entirely on PCPs for initial diagnosis and referrals. Without the guidance and skills of the primary care physician, the patient would be wandering in a wilderness of symptoms without a clue. Patients depend on their PCPs as they would a trusted family member. When I feel crappy and I don’t know why, I don’t start leafing through the yellow pages – I go to my primary care doctor, a person who has been there for me through the years. There is a comfort in that history that has a healing power that goes beyond the insurance codes that define us.