Embracing the Death of Primary Care Medicine
Posted on June 11, 2009
Filed Under Primary Care in America |
Here’s a Podcast of this post:
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If DrRich was correct in his previous post when he decreed primary care medicine to be officially dead, the death certificate having been duly executed by one of the main physician organizations charged with defending the practice of primary care medicine, then DrRich’s pronouncement seemingly has left many good American doctors high and dry.
For, if primary care medicine is dead, that is, if the designated functions of a primary care doctor have been devalued to the point of officially having been made equivalent to what a competent nurse practitioner can do, then what’s the point of becoming (or having become) a primary care physician? Why, save for a lack of viable alternatives, would anyone practicing primary care medicine continue to do so? And why would any medical student choose such a career path?
It seems clear to DrRich that they would not.
But this does not mean that primary care physicians (or current trainees in primary care programs) should despair. For, when one takes a careful and analytical look at what has just transpired here, it becomes evident that the actual clinical value provided by primary care practitioners has not been diminished one whit. They are every bit as valuable, every bit as critically important, as they have ever been - and even more so. And by summoning up their resolve, reinforced by an abiding confidence in their extensive training, these physicians can re-define a strong position for themselves within the healthcare system, and can finally demand the pay they deserve for the service they provide.
But to do so, they will have to abandon primary care.
This will not be a loss, because actually, primary care has abandoned them. Whatever “primary care” may have once stood for, it has now been reduced to strict adherence to standards, 7.5 minutes per patient “encounter,” placing chits on various “Pay for Performance” checklists, and striving to cause high-and-mighty healthcare bureaucrats (who wouldn’t know a sphygmomanometer from a sphincter) to smile benignly at their humble compliance with the dictates of “quality healthcare.” This is not really primary care medicine. It’s not medicine at all. It’s something else. But whatever it is, it’s what has now been officially designated as “primary care,” and the people who do it (doctors, nurses, high-school graduates with a checklist of questions, or whoever they may be in the future) are all Primary Care Practitioners.
While there has been much earnest back-and-forth in the medical blogosphere about nomenclature, specifically regarding the definition of “primary care,” that question is now settled. Primary care is the provision of routine, standards-based healthcare to the masses, following prescribed quality guidelines, with limited or no latitude allowed for clinical judgment or individualized care. Since this is now the true definition of primary care, DrRich can think of no rationale for forbidding nurse practitioners to provide it. Indeed, once physicians and their professional organizations (such as the American College of Physicians) gradually allowed this to become the de facto definition of primary care, it became inevitable and proper to admit nurses to the field, and rear-guard actions to the contrary merely amount to the mindless, guild-like behavior so often attributed to physicians by those intent on diminishing and demoralizing the profession.
What generalist physicians (heretofore known as primary care physicians) need to realize is that “primary care” has been dumbed down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.
The beauty is that to survive and flourish, you don’t really need to change your medical ideals or even your medical behavior (unless, of course, you have bought in to the strict adherence to guidelines, checklists, etc.) You simply need to practice medicine exactly as you were trained to practice it - taking all the time needed for careful, thoughtful attention to detail; seeking meaningful nuances; personalizing both diagnostic and therapeutic recommendations not only for the individual’s medical condition, but also for their psychosocial and economic circumstances; relishing the challenge of making the difficult diagnoses, and managing the complex medical disorders that so often break from the designated norm; and treating guidelines as just that, as often-helpful guideposts, rather than mandates; and most important of all, embracing the classic doctor-patient relationship in all its particulars, and having the latitude to become a true advocate within a hostile healthcare system for the benefit of your individual patients. In short, you can go back to being a real doctor, and not a cipher in some bureaucrat’s database.
There are only two things you need to do to move in this direction.
First, abandon the “primary care” label. Remember, primary care is now the standards-based, checklist-driven, one-size-fits all, “high-quality” system of practice imposed by insurance companies and government bureaucrats, which is open to both doctors and nurses (and, in the future, most likely to others). That’s not what you do anymore. Primary care medicine is dead. So find a new name for yourself.
The choice of nomenclature is yours, of course, but DrRich humbly suggests “Advanced Care Medicine.” What you do is not primary care; it’s far more advanced than that, and nobody could do it without the sort of extensive training you have. Advanced Care Medicine captures that notion. It also opens the possibility of referrals from the new-style PCPs, who occasionally will recognize that at least 20% of their patients (the ones DB writes about as the long tail) will present as clinical puzzles that do not fit very well with any of the standard medical diagnoses with which they are familiar, and another 20% will not respond to the recommended therapy as the guidelines say they must. These patients obviously will need advanced management. Why not refer them to an ACM practitioner?
Second, you need to establish practices whereby you are paid by your patients. A few years ago doctors who did this sort of thing were called “concierge physicians.” This elitist terminology was later changed to “retainer practitioners,” which at least rendered the economic model no more reprehensible than that favored by attorneys. But nowadays this kind of practice has been rechristened with the much sweeter title, “patient-centered practices,” and practitioners are paid by a variety of methods including the retainer model, or by the hour, or by the visit, or or by the service. Payment models can be established that will allow most patients to participate (and thus blunt the obligatory attacks of “elitist!” which will be aimed your way in an attempt to shame you into remaining safely within the primary care gulag). You can set up your practice and your payment model any way that suits you. There really ought to be nothing particularly revolutionary about this kind of practice, since it was the norm throughout most of the history of medicine until 40 years ago. It is likely that many patients who today would never consider paying any doctor out of pocket will eventually change their minds, once it becomes apparent to them what primary care medicine has devolved to in the United States.
In any case, when you are paid by your patients, you answer to your patients (not some hostile bureaucrat), and the quality of the care you deliver is measured by your patients (and not some hostile bureaucrat). There are no externally imposed time-limits to your office visits, no checklists you must complete, no bizarre documentation rules you must follow for reimbursement, no guidelines you must obey even if it makes no sense for the patient sitting in front of you. Those things are for the primary care practitioners to concern themselves with, poor souls, and you do not dwell among these unfortunates anymore.
And happy it is that primary care medicine is killed off now, because time is of the essence. DrRich has already pointed out that an essential feature of universal healthcare will be to make it illegal (in the name of fairness) for individuals to spend their own money on their own healthcare. For Advanced Care Medicine (or whatever you may choose to call it) to become a viable path, you’ve got to begin now making it a fait accompli - establishing it as something patients value, and which they fully expect as a personal healthcare option, and furthermore, as an indispensable referral resource for those sad souls - physicians, nurses and others - who retain the label “PCP.”
So at the end of the day, the fact that the American College of Physicians has now brought primary care medicine to a merciful end, whether that result was intentional or something bumbled into during a misguided attempt to remain politically relevant, can be seen as a positive thing. “Primary care” having been irretrievably defined down into something less than the actual practice of medicine, for the ACP or any other physician organization to engage in a rear-guard action to ward off the inevitable advance of nurses and others into this diminished realm would have been quite enervating.
Worse, fighting this unwinnable fight would have wasted much of what little time you have left to establish yourselves as practitioners of the exciting “new” specialty of Advanced Care Medicine, before it’s too late.
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16 Responses to “Embracing the Death of Primary Care Medicine”
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I believe you miss an important point in this rant of yours here. All licensed providers are accountable (or should be) to not harm patients and to actually help them on a proven basis. You seem to feel your new postion will only be accountable to the patient, but that is not true for a servant of the licensed system. You better provide your care outside the country and stay there it is your desire to do your thing any way you like. Furthermore with good studies, it may well be shown that proper guideline driven care provided by any provider can beat the record of “doing it my way” care, and then what??
I don’t disagree with the underlying premise that what internal medicine physicians provide is well beyond the scope of the extant definition of a primary care provider, but I’m so disappointed to read of your demonization of nurses and professional nursing. By continuing to silo by ad hominem attack mode and creating we vs.they issues based on competing interests and conflict, opportunities to enhance strength of position of collaborating where interests overlie and where goals are identical: patient safety, optimal patient outcomes, optimal use efficiencies, etc. come to mind, no one is going to win. Divide and conquer works against your own aims, DrRich.
Since my former profession, nursing, is on the brink of catastrophic failure - much of that failure of its own making, and since it cannibalizes nurses who speak up about this, consider me a picked clean carcass, whose primary interests now lie in my own inability to access any sort of healthcare in a state which mandates health insurance (I’m an exception) and which is lousy with physicians, hospitals and all manner of high tech, high complexity, cutting edge treatments.
I wish I had the talent/wit of humor, because if the Colbert Report or The Daily Show talents featured professional nursing issues, I think millions more would get at what I’m trying so woefully inadequately to convey.
But since I don’t, I’ll just provide a mini links fest to essential resources about what you absolutely positively need to know about the state of nursing in order to be able to hold it to account.
American Association of Colleges of Nursing links:
Nursing Shortage White Papers
http://www.aacn.nche.edu/index.htm
Nursing Education White Papers and US programs by degree granted
http://www.aacn.nche.edu/Publications/positions/index.htm
http://www.aacn.nche.edu/Education/nurse_ed/nep_index.htm
Commitment To Quality Health Reform Consensus Statement From the Nursing Community (undated - addresses advanced practice nurses, primary care, patient outcomes and federal and state reimbursement issues)
http://www.aacn.nche.edu/Government/pdf/ConsensusStmnt.pdf
On a side note: have you and Maggie Mahar every considered tandem blogging about an issue of mutual interest?
You have much of the story right, but you are imposing your definition of primary care. As I write frequently, ACP and other organizations are considering Advanced Medical Care to be primary care.
This confusion is the real problem. When someone uses the term primary care, then listeners hear a variety of definitions.
I urge my readers to have a look at NG’s comment, to see what we’re up against.
1) He/she invokes the Amish Bus Driver rule to insist that since the government licenses physicians, physicians must do what the government says or get out of the country. Accountability to the patient takes second priority.
2) Failure to follow the guidelines to the letter - treating guidelines not as absolute mandates but as guidelines - constitutes “doing it my way,” and is to be forbidden.
These are the people who are in charge, I think. Establishing Advanced Care Medicine had better hurry up, because there’s very little time.
Rich
NG
Are you a physician? Did you not read the post?
DRRICH is correct in that 20% of patients won’t fit into the guidlines and 20% won’t respond like the guidlines say they will. These folks will be disenfranchised by a checklist driven system.
The physician is wholly and singulary responsible to the patient, not the “system”. The fact that the “system” tries to game that relationship for it’s own benefit is beside the point. Any “system” that does not fundamentally recognize the physician’s responsibility to the patient is illegitimate from a medical perspective. I don’t know what you would call it, but it ain’t medicine.
Where DRRICH falters above is his belief that if physicians make ACM valuable, there will be a place for it in the new order.
He is deluded.
The new order is all about control and what folks may or may not value will be beside the point, sadly they are viewed as not knowing what is best for them.
The only strategy is to practice now while you can, pay down debt, put away some coin (preferably in gold) and if you still want to be a physician, emigrate while you have the chance. Like the prohibition on using your own money to pay for health care, to maintain a viable physician workforce current physicians will have to be restricted from emmigrating…..think of it as a professional Berlin Wall
The American Experiment is over.
Annie,
It is not my intention to insult or demonize nurses, a profession I respect and admire. Nor is it my wish to condemn them to a life of primary care practice as dictated by the soul-eaters. As I said in an earlier post, I actually think they’re too smart and too ethical to fall for that.
I’m merely trying to say that the clinical judgment of physicians has been formally downgraded to worthlessness, and that primary care is envisioned by the overseers as so easy that a caveman can do it. Right now, the overseers are equating “caveman” to “nurse,” and I have left it at that. But again, I think it’s also ultimately degrading to nurses to put them in this position - and I think they’re smart enough to stay away from the trap.
Rich
DB,
The point I have tried to make, which is controversial I realize, is that this is the definition of primary care that the ACP itself seems to have adopted. It’s certainly the definition our bureaucratic overseers have adopted. In my view, it’s too late to fight the battle of primary care.
From now on, when we say “primary care” people can think “functionally equivalent to NPs,” and the ACP’s stance in effect seems to support this notion.
So my viewpoint, admittedly an outsider’s viewpoint and one which should not carry as much weight as yours, is that the thing to do now is to define what internists do as “more than primary care.” “Advanced Care Medicine” is the name that occurs to me, but as I say, I’m an outsider.
Rich
Having spent a few years on active duty in the US Armed Forces, it appears to me that the bureaucracy is trying to mold the civilian medical system into a crude copy of the field military medical system.
i.e.
(for illustration, I’ve put the military term first, followed by the civilian “equivalent”)
- first level care - your buddy/first aid
- second level care - field medic (Nurse/EMT/Paramedic)
- third level care - Aid Station (NP)
- fourth level care - MASH/field hospital (Physician Assistants)
- fifth level care - evac hospital (GP MDs)
- sixth+ level care - theater hospital (specialists)
The goal is to keep as many patients as possible at the lowest level in the system. Theoretically, it should save $$$$$.
Primary care is not dead but it is in a severe crisis. Each of us needs a competent, caring and available primary care physician but that is less and less possible. Many can’t find one; others cannot afford one; and others have one but cannot get adequate time and attention from him or her. PCPs will tell you that they do not have enough time with each patient; are overwhelmed with paperwork and mandates; and are earning less and less per year. There are about 1000 graduating physicians entering primary care per year in the USA but about 3-4000 retiring. Average income after about ten years in practice of $150,000 has been stable or decreasing for some years while the costs of practice including staff wages, rent and utilities, malpractice insurance and supplies has been rising. Most medical school graduates have about $155,000 in debt to pay off. To make ends meet and retain the same income, PCPs are seeing more patients with longer days and shorter visits. This is not good for them and it definitely is not good for you. Basically they have a non-sustainable business model today as a result of the reimbursement system through our commercial and governmental insurance system.
To counter the problem, more and more PCPs are taking steps to increase their income while decreasing the number of patients seen per day. Some approaches are frankly disappointing such as the doctor with a sign in the waiting room that you may “only raise one problem per visit.” A colleague told me last week that her internist is no longer taking Medicare. She will have to pay for each visit. Perhaps not a problem if you only go for an annual exam and then once or twice for minor problems. But if you develop a complex chronic illness that requires multiple visits it could add up quickly, especially for someone on a fixed income in retirement. Other PCPs are opting for “retainer-based” practices, sometimes called concierge or boutique practices. Here you pay $1500-2000 [or more] per year and in return your PCP reduces his or her practice from 1800 patients to 500 and guarantees that you can be seen the same or the next day, that he or she will be available by cell phone and email 24/7, will visit you at home, will meet you at the ER as needed, and will care for you in the hospital and the nursing home. And each visit will be as long as needed for you and your issues. This is the way it used to be and is the way it really should be now but is not. Another advantage of this type of system is that it becomes a true relationship again between the doctor and the patient with the patient contracting directly for services from the physician – not through a third party. The downside, of course, — this is extra money out of your pocket since you will still need your insurance for specialists and hospitalization.
What is clear is that the current system does not work and either PCP reimbursements by insurers will go up or more and more PCPs will either retire early or switch to retainer-based practices.
More at http://medicalmegatrends.blogspot.com
NG,
I could do all those guidelines perfectly if my patients’ actions and bodies would cooperate! Actually, in the last couple years, some of our research hasn’t cooperated—found the guidelines were wrong(see DrRich’s previous posts on guidelines).
The NPs who take on this role of PCP will be betrayed the same way by the same medicrats in the end. The Vogons will control the medical galaxy.
I saw the writing on the wall many years ago.
I switched to a cash practice + traditional medicare in 2008. My cash practice has self pay options for those that need only a few visits a year, and an affordable retainer option for those that require more care.
My practice draws the upper, middle and lower incomes of my community. DrRich is wrong in one respect. Primary Care of the 21st century is dead. But primary care before the age of Medicare and Mangled Care is alive, but hibernating under some rock. SOmeone needs to lift the rock and hit some docs over the head with it, so they can wake up and lead the reform movement, instead of following the governments path!
Lots of interesting info above. Supposing I was from some other planet, I might conclude:
1] cost-efficient suppliers of a fungible good became cost-inefficient when they began to gatekeep access to other expensive products (translate: the family doc was cheap when what he had was compassion, knowledge of the patient, and penicillin; when that fountain pen started to order tests and drugs and implantable defibrillators, the economic model collapsed)
2] replacing said suppliers with alternate suppliers who a) themselves are less expensive, and b) have reduced authority to mandate the purchase of expensive diagnostic and therapeutic goods, is one way to save money - TRUE
The system will work if:
3] most citizens are adequately cared for, over the course of their lifetimes, by the alternate suppliers (NP, PA, what have you), using whatever system they use (checklists, guideline worship, formularies, care maps) - this could be publicly funded
I don’t believe that #3 has been shown to be broadly false. Yes there is the 20% of 20%, but note I said “most”.
Then 4] an MD can become, in essence, a purveyor of ‘luxury medicine’ - leisurely, comprehensive, and time-efficient because multiple diagnostic leaps can be made in a single bound, so to speak, relative to the Checklistos. This would be patient purchased
As long as the #4 physician (MD) prices himself sensitively for his market relative to the #2 provider, he can make a good living and have a job he really likes.
The insured need no longer feel guilty about the uninsured.
As I have said before I do not believe that #4 will be legislated into illegality as there are just too many taxpayers who will want the option. The objection would come from the non-taxpayers who want things to be “fair” but who gives a damn what they want, they aren’t paying for it.
I was surprised to see your name at the bottom of this insightful prose, Richard. I was a resident at AGH in the late 80’s under your tutelage. I am now a frustrated internist in Wexford who is ready to go with MDVIP if they’ll have me. Thanks for re-iterating what I already know about primary care - it’s dead. Stick a fork in it.
Randy,
It sounds like you are making a very smart move. I wish you all the best with it.
Rich
Dr. Rich. What a breath of fresh air (Or at least I know I’m not the only one dying of stale air)
I agree with absolutely everything you say. I am working in a Federally funded clinic (the enemy). My holistic cash, Bc/BS/ Medicare practice failed when malpractice rates skyrocketed. Plenty of patients low reimbursement. Anyway I grabbed a life ring the FQHC. The mandates are getting stiffer and stiffer, punishment threats growing and demands to see a pt every 7.5 minutes including documentation AND I quote verbatim from the state board at a recent conference “We expect you to be perfect any mistake or perceived mistake will result in repercussions!” By my estimates from reading blogs and answers to polls I think %70 of physicians out there will always choose to stay in the “Matrix” They are the cattle lowing on the way to slaughter. Remember, they asked no controversial questions in med school, they just sat there and took notes hoping to be a doc.
There are only about %30 of us who really get it. Thirty percent of us who say wait this isn’t right! I think that we are too small and too poor to have a political voice. We are easy to replace with new graduates and my last stint at lecturing confirmed that in general a lower IQ is required than 10 years ago to get in.
In essence we are a dying breed. BUT If you are one of us you hear from your patients…”Doc I am sending my _______(friend, family member, etc,) to you. You are different you really care and you help and I like your approach. I don’t feel nervous to see you and I thank you for helping me”
If you hear this weekly then you have something!!! We are Marketable!!! The boards forbid us to make claims that we are better so we have to let our patients say it for us. Not like a lawyer 1-800 referral service ad, but just put our name on a plaque DR. Rich MD or DO. We can no longer say Holistic, or any words not on our degree. I would even say we cant use advanced care provider in my state.
I say we tell the Gov medicare failed by opting out and going to a cash only practice. If the government outlaws us then that makes us the outlaws and we have a choice to leave, stay and conform, or go underground.
If they don’t outlaw us we likely will have trouble sticking together because the boards offer us up as sacrificial lambs to the legislature as proof of quality control if we do anything out of the “checklist”
As long as we are alive we have power because of our knowledge. There are many to help. If they outlaw us here then let me add this bit. Go to a failed country where poverty and disease rule. Join a community teach them, love them, show them God’s love through your blessing of knowledge. Narrow is the gate and straight is the way.
You might loose the house or a car, but you very well could save your very soul.
God bless.
Thank you for the discussion on primary care which has been the large part of my life since 1985. When I first went into Internal Medicine, it was a high charged mostly hospital based training and post training experience. When I graduated and went to work with the Army, I ran my own treadmills, Holters and did my own flex sigs. When I left the Army and went into HMO practice, at first I split my time in the office, in the urgent care and then in the hospital. It was a very fulfilling practice.
Over time, the took away the urgent care and then later relegated us to the office practice only. In so doing, much of the alure of my original practice vanished. The drugdery of pushing paper all day long made me question why I was doing what I was doing. Yet, still within the fatiguing and uninspiring menial labour that was not the predominant aspect of my job, I did still find some snippets of actual doctoring upon occassion.
Yes, the life of an internist has been turned upside down in just a few short years.
Lastly, I have had the opportunity to supervise many nurse practitioners and see them in action. With the exception of 2 that exceeded the usual training, I found the fund of knowledge in most quite lacking to be able to take over my position. There is a good reason why all of these type of providers are supervised. They simply do not have the type of training to be able to tweek out the common from the uncommon and the bothersome from the dangerous.
I did not acquire those skills until I was honed into a practicing physician during my grueling residency. If the RNPs wish to come to the plate and undergo the type of training that an MD does, then go to it. Being on call for 36 hours at a time led to the development of much needed skills. From what I have seen of the skill sets in the RNPs that I have supervised, they simply don’t get that type of training.
Thus, it is not an issue of MD vs RNP so much as the acquisition of very much needed skills.
On the other hand, RNPs are very well adapted to doing algorythmic type of medical chores that should let the MDs do what they are trained to do. Seek out the common from the uncommon and the bothersome from the dangerous. There is a very good reason why RNPs and PAs have an MD/DO supervisor.
Just my opinion.