The crisis of primary care physicians

[Guest guest]

The crisis of primary care physicians

By Annie Brewster | May 29, 2008

MRS. J. LOOKED baffled and hurt. I had just explained that I would no

longer be her primary care doctor. I was leaving the field after just

three years. " I have had three different primary care doctors over the

past 10 years, " she said. " You can't leave now. I was just starting to

feel comfortable. I am getting older now. I can't keep changing doctors! "

Primary care is in crisis. Current primary care doctors are quitting,

and medical students are pursuing other specialties. Primary care has

lost its attractiveness as a profession because of poor compensation

and plummeting job satisfaction. Primary care physicians are in short

supply, and in Massachusetts, this problem has intensified in the wake

of healthcare reform, as more than 300,000 previously uninsured

individuals have joined in the search for available doctors.

As a former primary care physician, I am most troubled by the

antagonistic state of the patient-doctor relationship. The system sets

us against each other. Like many in the field, I chose primary care

because I love people. I wanted to take care of the whole person, body

and mind. I wanted the intimacy that comes with knowing your patients

well and following them over many years. These goals are difficult to

achieve in primary care today. After two years in my practice, I

walked into an exam room one day and introduced myself to a patient.

" We have met before, " she replied, clearly aggravated. I was horrified

and saddened.

Patients are angry, and rightly so. They feel frustrated by the

inability to get timely appointments with their physicians, rushed by

the 15-minute visits and the seemingly harried doctors, ignored when

they do not receive letters with lab results or follow-up phone calls.

They feel disrespected when they come to their medical appointments on

time and then sit in the waiting room for 45 minutes. All of these

feelings are justified. We are not offering high-quality care.

Doctors feel angry, too. We have too many patients. It is not uncommon

for a full-time primary care doctor to have upwards of 3,000 patients.

It is impossible to know all of these individuals well, to give

adequate focus to each person's unique situation, to sift through the

piles of paperwork and lab data daily. Our days are divided into

15-minute sessions, back to back. We move frantically from exam room

to exam room, trying desperately not to fall behind in our schedule.

We are given incentives to see patients as quickly as possible. We

live in fear of litigation.

We are drowning, and in this overwhelmed state we lose our ability to

take good care of people. Outwardly, we may feel resentful and

burdened. Underneath, many of us feel loss, deep sadness, and personal

failure.

This rift between patient and doctor is painful and destructive to the

core of medicine: the therapeutic relationship. In an environment

where patients and doctors don't know each other well and appointments

are rushed, it is inevitable that more medical errors occur and that

resources are wasted as expensive tests are substituted for

communication. By contrast, research indicates that medicine practiced

in the context of solid primary care relationships allows for earlier

detection of chronic diseases, and, ultimately, better outcomes and

monetary savings, to say nothing of patient and doctor satisfaction

In this election year, patients and doctors need to come together to

support healthcare reform aimed at revitalizing primary care. To

begin, our medical reimbursement system must be restructured. Our

payment system values invasive treatments and procedures over time

spent talking with your doctor. We need to reset these compensation

levels to favor communication, care coordination, disease prevention,

and chronic disease management. Doctors should be rewarded for keeping

patients well. Incentives should be based on quality outcomes and

efficient resource use, not on patient volume.

Most important, primary care physicians should be valued as team

leaders and advocates, poised to help patients navigate the complex

medical system. There is no reason why so many patients like Mrs. J.

need to feel lost and abandoned in a country that spends far more on

healthcare than any nation in the world.

Dr. Annie Brewster is an urgent care physician at Massachusetts

General Hospital.

http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2008/05/29/the\

_crisis_of_primary_care_physicians/