From MD to HD: The Slow and Painful Decline of Primary Care Doctors

Primary care is dying. Not dead yet, but getting close. It’s been decades since anyone has caught a glimpse of the idyllic, Norman Rockwell-esque doctor (you know, the one with the leather bag and all the time in the world). And recently, the downward trajectory appears to be steepening.

For those of you who may be unfamiliar with the term, primary care is the field of medicine that serves as the initial patient contact for most concerns. I’m talking about the pediatrician that tracks your child’s growth and development, answering all your questions about illnesses and behavior along the way; the family doctor that has known your granddad since high school, delivered your baby, and takes care of most of the town; the internist that delicately broke the news of your father’s cancer and whose name is printed on all 26 of your mom’s pill bottles. They are the front line in recognizing, diagnosing, and treating the vast majority of illnesses; they’re also the ones that know you well enough to gently reassure you when your fears are unfounded.

Today’s primary care doctors are seeing upwards of 30-40 patients a day. That math works out to between 10 and 15 minutes per patient. They’re not plowing through patients because they’re greedy, or because the fuel for their yachts has gotten expensive; they do it to cover their overhead, repay student loans, and send their kids to college. But now the scene is changing even more. I’ll get to that in a minute, but first, you need to understand some of the forces causing this shift.

For many physicians, going to medical school was a lifelong dream. It wasn’t easy getting there; the competition is steep. And once they were accepted, it was not an inexpensive venture. The average medical student graduates with $170,000 in student loans for an education that costs about $250,000.

Upon graduating from medical school, a new doctor must complete a residency program, which involves 3 or more years of training specific to his or her field (for me, pediatrics). An average medical resident makes about $52,000 per year, which is essentially unadjusted for cost of living, no matter where they live. Not an unrespectable salary (assuming they don’t live in LA or Manhattan)—but arguably, not one worthy of 80-hour workweeks after 4 years of absurdly expensive post-graduate education.

After residency, a young doctor stands at a crossroads. He could choose a career in primary care, managing the majority of the healthcare for 2000-3000 patients and seeing 30 or more of them every day; alternatively, he could elect to specialize in a more procedurally-based field and [typically] make significantly more money. This discrepancy in reimbursement is woven into the fabric of our healthcare system, and—coupled with the rising burden of student debt—it pushes new physicians away from primary care.

To confound the issue even more, physician reimbursement tends to remain unchanged or even decrease every year, at the same time that administrative costs and malpractice premiums are soaring. Unlike most segments of the free-market economy, doctors can’t simply charge more for their services to offset these costs. Physician reimbursement is essentially fixed by Medicare/Medicaid regulations and contracts with insurance companies. The only way to make up the difference is to see more patients. (Most doctors have an altruistic side, but few of them are willing to do their jobs for free—or at a loss. Our kids like to eat, too.) When doctors have to see too many patients, the quality of the care they provide drops off, along with patient satisfaction. They also spend more of your money, by over-ordering tests or by unnecessarily referring to specialists—all because they don’t have time to stop and think, take a more thorough history, or look something up.

In addition to the enormous patient volume, there are ever-increasing requirements for administrative documentation. It doesn’t matter how much your doctor improves your life—if she doesn’t click on all the right boxes, print out the correct handouts, and document that she asked all the questions that someone else thought would be relevant, she won’t get paid. Most of these administrative requirements are great ideas, and might even improve our quality of care—they can just be impractical during a 12-minute visit, and they result in even more time being taken away from face-to-face interaction. [I recently read an advertisement from an electronic health record company, claiming that they offered a superior interface allowing patients to “meaningfully interact with their electronic health records,” which is evidently every patient’s dream. Things must be different on the patient side, because I seldom feel a meaningful connection to my electronic health record.]

The way things are going, we are going to end up with have primary care doctors who are burned-out and broke, specialists who are seeing cases that should have been handled by primary physicians (who didn’t have the time to address a complex issue during a 12-minute appointment), and patients who have health coverage but can’t find a doctor with an open appointment. The more difficulty people have accessing primary care, the more people go to the ER, where they are over-tested and over-treated at an average cost of over $1200 per visit.

There is a principle in project management known as the “Triple Constraint.” It emphasizes the interrelatedness of cost, scope, and schedule—essentially stating that you can choose any two of three options: “fast,” “good,” and “cheap.” That’s what we are struggling with in healthcare right now. We’ve figured out “fast” and “good,” and we’re trying to make them “cheap.”

Perhaps this explains why Wal-Mart is opening a chain of primary care clinics within their stores. We’ll see how that turns out—financially, they may be very profitable. But does anybody really believe that Wal-Mart is the place to find the best medical care? And are there doctors out there that really dropped $250,000 on tuition for the opportunity to work at Wal-Mart?

Another trend in medicine is towards the use of “telemedicine.” This is essentially an appointment held by videoconference, in which the physician and patient may be thousands of miles apart. It’s becoming more common, and has been embraced by some very respected names in medicine. Telemedicine may not be a bad approach for psychiatrists, who don’t tend to make decisions based on a physical exam—or even for urgent access to sparsely-distributed subspecialists. But in primary care, where personal relationships and physical examinations are key, it helps to be in the same room. This trend will doubtlessly lead to delayed or incorrect diagnoses and inappropriate management, including the overuse of antibiotics and steroids.

Here’s an example: let’s pretend I have a patient who is a digital image of an 18-month-old boy. His mother says he had a fever this morning and has been pulling at his ears. She is convinced that he needs antibiotics. As a pediatrician, I know that there’s a good chance he has a viral illness and is pulling at his ears because it helps to equalize the pressure across his Eustachian tubes; he’ll very likely recover fully in a couple of days without any intervention. I know that prescribing antibiotics when they aren’t necessary contributes to developing multi-drug resistant organisms. I’m also aware that the American Academy of Pediatrics issued a detailed 40-page review article (with 275 references) about the diagnosis and treatment of ear infections. Deciding what to do with my patient is not nearly as simple as you’d think—unless he’s in a different state. If I can’t look in his ears, and his mom paid $50 for me to prescribe antibiotics, it becomes a pretty easy decision—especially if I have 6 other digital patients flashing in my queue.

My fear is that, in an effort to accomplish “fast” and “cheap,” we’re sacrificing “good.” And “good” is what we all want, right? Quick, convenient care is great—when it’s appropriate. But it opens the door to misdiagnosis and inappropriate management. Decreased costs are wonderful as well, unless they preclude quality or drive our front-line doctors out of practice…and onto a screen near you. Now, if you’ll excuse me–my computer is beeping. It looks like I have patients to see.