Monday, February 3, 2014

Why I'm (Probably) Not Going Into Primary Care

I have to say when I was applying to medical school originally I was interested in primary care.  One of my role models was my aunt, a PCP, whom I worked for as a scribe/medical assistant.  She walked me through her differential diagnosis for each patient and I was hooked at her level of knowledge and thought process.



Primary care now I feel is a field that, if not dying, is at least going through a great upheaval.  The part that was valuable and exciting- coordinating care for patients with multiple chronic diseases, figuring out what's wrong with a complicated patient, treating complicated conditions that were on the brink of needing specialist care- wasn't what she did the majority of the time, or even necessarily common on some days.  It was interspersed with countless physicals where everything was normal (a recent study found the annual physical to be largely useless); telling myriad patients to come back if their colds didn't get better in a week or two; referring everything interesting and complicated to a specialist; and other mind-numbing tasks that a high school grad could pick up in a week (really, skills which most moms do pick up fairly rapidly).  Forming a long-term emotional connection with patients was very rewarding- but many specialists also see patients long term, and the joys of an emotional connection could not outweigh the feeling that for most of our patients we were doing little that a friend or a nurse-practitioner couldn't do.  The paperwork was manageable- the sense that half of what PCPs do was of little value/could be easily done by someone with far less education was something I didn't want to deal with.

Primary care in the US does a lot less than many other countries.  In Canada, internal medicine takes five years of training, and if you show up to a hospital with chest pain, chances are your initial work-up and management will be done by an internist, who may refer to an interventional cardiologist if appropriate (at a lost of hospitals they'll just push thrombolytics).  In the US, you'll see an EM specialist, who will then call a cardiologist, who may then call an interventional cardiologist to do the cardiac catheterization.  So called primary care specialties in other countries learn more and can take care of more things.  Here, so much of the care is "referred" to specialists.  Part of that is malpractice driven- the US has a more litigious medical environment than any other country.  Few PCPs want to face a lawyer who asks them, "Why didn't you refer your patient with hypertension to a cardiologist?  Aren't they better trained in dealing with heart problems?"  Never mind that the patient would have died regardless of who was managing them.  Thus, PCPs in the US manage and treat less, and refer out more.

All this adds up to why I'm thinking of going into surgery or some other field where the training and skills can not be replicated by a computer or a far less trained clinician.  I wish that seeing only complicated patients that I have to think about/managing complicated conditions was an option as a practice model, but apart from hospitalist jobs, that's not possible in 'primary care'.  I don't mind the workload, but I want to work a job where I feel that I'm making a difference- not referring everything to specialists.  There's been a lot of complaining about Primary Care pay, but that's not the real problem.  It's what the field has become that is the problem.

So, what are some solutions?

One is to re-imagine the primary care physician as the leader of a team (The so-called Patient Centered Medical Home).  This is an approach touted by many: PCPs would stop seeing all but the most ill patients.  Instead, all the head-colds and the like would be seen by Nurse-Practitioners and Physician Assistants, clinicians frequently referred to as "mid-levels".  (Presumably this means they are at a middle level between nurses who carry out physician orders and physicians who practice independently.  That said, no one who wants to work in a hospital and stay alive has ever referred to nurses as "low-levels").  The physician would only see the serious patients, and would coordinate care between multiple specialists.  Instead of directing, the physician would work more collaboratively with his or her staff.  The team would also focus more on population health of all of their patients rather than on individually providing care to patients in isolated episodes.

This is an interesting idea, and I may be interested in working in primary care under such a model- but many bumps in the road exist on the path to get there.  For starters, there aren't nearly enough NPs/PAs in practice for this to be a common model.  Then, there's this question: how many patients are there really that aren't serious enough for specialists but also aren't simple enough for NPs/PAs?  Will physicians under this model become managers leading NPs and PAs and rarely if ever treating patients themselves?  How will the coordination of care occur?  Will the PCP ever see the patient, or will they silently input notes into the EMR for the cardiologist and nephrologist to read before they see the patient in question?

Here's my solution: increase the amount of training that Family Medicine/Internal Medicine goes through, to make them more comprehensive.  Programs that take years off the FM curriculum are exactly the wrong tactic.  We need to expand the training of PCP graduates to five or six years or create a 3 year fellowship in comprehensive primary care, so that they can learn to take care of as many problems and patients as possible.  Primary Care pay will naturally rise- once PCPs start doing things that previously had to be referred to other specialties.  Why can't PCPs order and interpret most EKGs and Echocardiograms instead of cardiologists?  Why can't they be trained to do most ultrasound scans or even ultrasound guided biopsies under sedation instead of radiologists/surgeons?  Why can't they manage the vast majority of complicated diabetes patients instead of endocrinologists?  Why can't they do most of the intubations and initial eval and stabilization instead of Emergency Medicine specialists?  With 5 to 7 years of training instead of 3 (which is equivalent to the current training time for a general surgeon and their practically required fellowship), Primary Care Physicians will cease being relegated to triage and instead become again the General Practitioner of old- with appropriate pay that will lure many into the field.  I would love to be a primary care physician under this system, even if it took me half a decade or more to finish my training.

There are obstacles: chief among them being the ridiculously large number of specialists in American practice today.  In Canada, 50% of all physicians become PCPs.  In the US, the number is more like 30% last time I checked.  The ACGME would need to force a lot of residencies and fellowships to close in order to get a better ratio of PCPs to specialists.  Not to mention, all those PCPs now in practice would have to do a lot of training to get up to speed on all the new skills that they'd need to become General Practitioners again, qualified to do all sorts of procedures and provide comprehensive care.  But there is at least one more benefit: the war between Nurse Practitioners/Physician Assistants and Primary Care Physicians would probably end overnight.

Will this come to pass?  Can it come to pass without malpractice reform?  Who knows.  Doctors certainly live in interesting times.