Why I Left Primary Care, Part 3

I've been writing this post series in an effort to unpack my mixed feelings about leaving primary care to become a full-time hospitalist.  Part One described the original Dream of Family Practice which inspired me to enter primary care in the first place.  Part Two described how reality fell short of the dream.  In this post I want to examine how I feel about my decision and revise the dream to propose specific changes that might lead me--and other doctors in similar situations--to return to primary care.

First, a brief timeline of my working life to date:

• Graduated from family practice residency in 2004
• Started working at a federally-qualified health center (FQHC) in January 2005
• Full-spectrum family practice, including ambulatory primary care, until February 2008
• Now a full-time hospitalist.  Still providing prenatal care at the FQHC

I often review this timeline when I suffer attacks of guilt for having given up primary care.  I really wanted to be an old-school family doctor, and the heart of the old school is providing comprehensive health care for people throughout the life cycle.  Yet I can't be criticized for giving up too soon.  If you do the math, you can see I was in primary care for a full three years, and during that time I tried a thousand different things--schedule changes, practice restrictions, use of templates--to make a go at being a primary care doctor, but ultimately I had to admit defeat. 

The looming primary care crisis is much in the news lately.  CMS reimbursement limits, dread of authorizations and other paperwork, battling Internet health misinformation, and dozens of other morale-depleting realities of primary care are driving doctors to become hospitalists or urgent care doctors--areas of medicine in which a daily per diem is guaranteed, and when you're off the clock, no one will call you at home when a patient has a crisis.  Some tout the concierge model of medicine as a solution for primary care doctors to stay on the front lines while seeing fewer patients for more money, but I don't believe this will be the solution for most of us to stay on as primary care providers.  (I'll have more to say about the concierge model in a future post.)  Here's what I need to happen before I return to primary care:

1.  Electronic medical records (EMRs) must be generally implemented and the major bugs ironed out.

EMRs are a hot topic around hospitals and clinics these days.  A majority of health care institutions need to implement them before 2010 to stay within accreditation guidelines.  My FQHC and hospital are both planning to start EMR and I am bracing myself for disaster.  I'm not one of these EMR-will-save-healthcare visionaries, because I practice medicine every day and I can forsee a lot of hard-headed providers refusing to develop competency in using EMR. However, I think EMRs will make the delivery of health care much more efficient overall because they will

• Reduce time spent chasing records from hospital and ER encounters
• Reduce time spent reviewing trends in disease control, for example blood pressure rises and falls, glycemic control, etc.
• Streamline pharmacy refills and insurance authorizations
• Improve provider-to-provider communication
• Improve implementation of health-care screening guidelines
• Increase provider preparation for vacations, leaves of absence, etc. if their patient's anticipatable needs (medication refills, physical therapy renewals, etc.) can be flagged in EMR and pulled up before a provider leaves town for three weeks.

However, I forsee a number of barriers to smooth EMR implementation at the community level, such as

• Uneven buy-in by doctors (see above)
• Failure of one institution's EMR to communicate with another's. For example, if a medical records request is sent from my clinic's EMR to a tertiary care center's EMR, will the records arrive or will the request become virtual flotsam?
• Inevitable failure of 100% electronic delivery.  I suspect a certain critical percentage of records will arrive via FAX or other paper-based media and will have to be scanned into the receiving institution's EMR.  This will put the success of the EMR at the mercy of human memory and competence once again.
• Providers using EMR as a crutch, not a tool.  One example would be over-reliance upon progress note templates within an EMR.  If an individual doctor of mid-level chooses to rely upon pull-down menu choices, the resulting progress notes will read as "CC: f/up meds, S: No c/o, O: AVSS, NAD, CTAB, RRR, Abd SNTND w/NABS, A: HTN, incompletely controlled, P: Increase ACEI."  This might be a sufficient progress note for most encounters, but it will fail to capture the patient's ambivalence about getting a screening colonoscopy.  I think conscientious doctors who spend a lot of time documenting carefully will still communicate the nuances of a patient encounter within an EMR, but let's face it--there's more than a few slacker docs out there who write "Abd: NABS" on the patient you assess with marked ileus later the same day.  For these docs, EMR will be crutch.

Before I return to primary care, I'd like to see the first generation of EMRs run their course and the first generation of shouting matches to have taken place without me.  I'd like to see EMR become a real tool before I roll up my sleeves and jump back into primary care.

2. Patient expectations need to be re-set to manageable levels.

This item might set off a howl of protest from people who think doctors are the root of the problem in primary care.  There's a lot written about how little time doctors spend explaining things to patients, how little eye contact we make, how many opportunities to express empathy we miss.  As reimbursement approach zero and primary care offices increase productivity thresholds for doctors so a family doctor needs to see thirty patients a day just to keep his head above water, the encounter time for each patient decreases to 10-15 minutes.  In my FQHC I had the great luxury of having two 15-minute and one 30-minute slot for every hour in clinic.  The 30-minute slots are supposed to be reserved for Pap smears and other full-body exams, or procedures.  However, I ran into problems because patients often showed up for their 15-minute appointments with a list of five or more questions/problems.  These ran the gamut of complexity (and these are all real-life examples):

• "I don't think my hormones are working.  I feel hot at night."
• "I stopped taking that medicine you gave me last time--Celexapro? Is that it?--I took it for a few days but it made me feel funny."
• "I just found out my aunt has chronic kidney disease.  Can you check my kidneys?"
• "I heard that Avandia gives you heart attacks so I stopped taking it.  I don't want anything to do with it.  My blood sugar isn't bad--the highest was only 260."
• "My back still hurts.  My physical therapist says I need an MRI."
• "I got my period three weeks after the last one finished.  My migraines have been worse too.  Do you think they are connected?  My friend had a hysterectomy because her periods made her migraines worse, do you think that will work for me?"
• "I saw on TV how this vitamin supplement helps you lose weight so I've been taking it and I think it works.  The thing is, it's really expensive so I had to stop taking the Zocor you prescribed me."
• "I'm really stressed out.  I need some Xanax."
• "I read on the Internet how mammograms give you breast cancer, so I don't want one.  Nobody in my family has cancer, so I think I'm OK."
• "I'm not getting my kids vaccinated because my friend had her son get shots and now he's paralyzed."
• "I've got this bump on my back, can you look at it?  There's also one on my butt, and one on my knee..."
• "I have a question about my husband."
• "Oh, I brought my disability papers, and there's a paper to get me off jury duty, and I need you to write a letter saying I can have a service animal in my apartment."

Now, as you might have imagined, any one of these questions/problems/issues will take at least a full 15 minutes to address.  Multiply 15 minutes by five or more questions/problems/issues, and you see why primary care is hard to provide.  You might have expected to see your patient for review of heart disease and to recommend mammography, but your patient thinks you can squeeze in a few of the issues mentioned above.  No wonder they experience doctors as rushed and inattentive.

Unless some miracle occurs and doctors are suddenly given pay raises and unlimited amounts of time to spend with each patient they see, or people suddenly decide they really do want to pay $2,500/year to see a concierge physician (in addition to insurance premiums and co-pays for anything the concierge physician doesn't do) then I believe people need to accept the 15-minute office visit and its limitations, as well as a few other limits to what a primary care doctor will and will not do.  Examples:

• A 15 minute visit can cover 2-3 old issues (HTN, DM, CAD) or one new issue.  A discussion about starting or discontinuing a medication counts as a new issue.
• Multiple complex problems, such as the ones listed above, can be prioritized during an office visit but a doctor should be able to set limits on her time and ask the patient to come back for follow-up visits until the issues are addressed.  Yes, this will mean multiple co-pays to get through one list of questions.
• People cannot expect to have unanswered questions addressed in long phone calls after the doctor finishes office hours.  I used to spend a lot of time on the phone arguing with insurance companies, explaining abnormal test results and recommended follow-up, and chasing down consultants for patients with cancer or other serious medical problems, so their follow-up would be air tight.  People who call up wondering if they really, really need to take glipizide need to make a follow-up appointment.
• People need to show up on time for appointments.  Refusing to end a cell phone call when the doctor enters the exam room counts as lateness and the time will not be added on to the end of the appointment.
• Every clinic should have a zero-tolerance for screaming verbal abuse or threatening staff.  Period.

Some of these points may seem like no-brainers, but each has raised major problems for me in my former primary care career, and all of them contributed to my desire to leave. 

How to educate patients?  I think it begins with a strong clinic staff, but the doctor herself needs the backbone to stick to her schedule.  One day I plan to write a patient handout on what can reasonably be accomplished in a 15-minute visit, and a good medical assistant can help spread the word.  I'd be interested to hear any other suggestions.  Meanwhile, I will get on my soapbox to say this:  I think all the health-care websites and news agencies who insist upon publishing eye-catching (and occasionally misleading) information about medicines, interventions, vaccines, and doctors in general should be required to contribute 25% of their profit to the funding of primary care providers who are responsible for dealing with the fallout.

3.  My own expectations need to be re-set to manageable levels.

Never let it be said I'm blind to my own role in creating failure.  The health care system and my local FQHC are not the only institutions at fault in my personal primary care crisis.  I made mistakes too.  One was over-idealizing the DoFP and not putting enough emphasis upon my own preferences and goals.  I don't like to be a selfish person, so I planned my entry into clinical medicine around achieving the DoFP.  As other dreams began to compete, I experienced dissonance between my many goals:  full-spectrum family practice, home ownership in California, alternative energy, patronage of the arts, creative time off, etc.  The problem I encountered was feeling resentful of my material goals, berating myself for wanting more than the DoFP.  Yet you can't deny your own material wishes.  If you try to, they just bubble on the back burner and overflow when you least expect it.  Ultimately, I began to resent the DoFP for crowding out the other goals, and this finally created enough space in my mind to consider alternatives.

We all have to go through this process.  It's called growing up.  In high school you might dream of wearing Chanel and living in well-appointed flats in Paris, London, Florence, New York--but most of us are average working people and have to re-align our expectations.  What I've come to accept is that the DoFP is not a career model which will achieve my personal goals at this stage in my life.  I often call this the "earning phase" of my career, in which my monthly expenses have increased in sync with my earning potential as I invest in the infrastructure of my chosen life:  the house, the solar room, nights at the theater, a locavore diet.  This isn't extravagance or selfishness, it is goal-setting and choice.  Other people would choose different goals--a second house, a stay-at-home spouse--but it still comes down to choice.

I can forsee a point in the future when my goals will be somewhat more modest and I can live comfortably on a primary care salary.  This might happen, for example, after my mortgage is largely paid off, my student loans paid, and my retirement savings is on track.  I don't have any kids so this day might not be too far off.  I hope so.  The DoFP is still knocking on my door.

4.  I will have to change practice settings

I discussed some of the problems I encountered in Rural's practice setting in Part Two.  As the years go by I find I really miss the patient population I used to work with in my residency setting--Mexican itinerant farmworkers in the Central Coast.  A few reasons why:

• Mexican culture respects doctors and health care workers.  No one ever cussed out the front desk clerk in my residency clinic.
• Mexican culture also is strongly family-oriented, which suits me as a family physician.
• Mexican immigrants have a great deal of unmet medical need.  Not only was the medicine I practiced as a resident challenging, it was profoundly rewarding as well.
• As the political climate towards Mexican immigrants has become more hostile--despite the major gap they fill in U.S. "untouchable" industrial practices (slaughterhouses and pesticide-based monoculture are two examples)--I believe those of us who appreciate their contribution should stand up and provide their needed services, even if state legislatures try to limit access. 

I have decided that when I'm ready to re-enter primary care--and I really do believe the day will come--I will have to re-locate to a rural area with a migrant clinic.  I'm still examining this assumption, because I suspect I might be at risk for over-idealizing it like I did with the DoFP.  I have more experience working with this assumption, however, thanks to three years in the residency setting I described.

I will also take a closer look at any group practice I enter.  I never expect to encounter a perfect group collaboration--get more than one person in a room, you'll discover disagreements--but in the future I will demand more collegiality than I received at my FQHC.

In the next post in this series, I'll outline my recommendations to young doctors considering primary care.

Comments

[Martin]

What all primary care providers fail to tell everyone when they complain about the problems with their profession is that they are trying to see more patients to keep their salary at some level that they have established in their heads that they should make. They develop expecations based on what their colleagues make, some of which are in specialty medicine, and they believe that they are entitled to make that much money. There is no law that says you can't schedule patient visits at 30 or 60 minute intervals. Primary care providers simply refuse to consider such a possibility because it will fail to meet their preconcieved notion of the amount that they believe they are entitled to make. Despite all of your frustrations that you voiced here, that is the fundamental problem that you had. Instead of accepting what you can reasonably make by doing the job correctly, you make the mistake of trying to schedule too many patient visits in a day, and it isn't to keep your head above water as you say, it is so that you can meet your earnings expectations. My thought is that you have all set your expectations too high. Lower the earnings expectations and everything else will fall into line for you.

[liz4cps]

As a patient, I don't think I've ever been told that I was going to have a 15 minute appointment -- or any other length, for that matter. The closest I've come is when someone would talk about whether or not I needed a comprehensive appointment, but I did realize at some point that bringing a list of symptoms was not a good idea. It was counter to what I had learned many years earlier (probably when docs were less rushed) which was that I should tell the doctor everything that was going on.

I do remember wondering, occasionally, how doctors could manage their appointments and their time, but I figured that was their business, not mine. And, back in the day, I guess doctors had the flexibility to leave some unscheduled time as padding to allow for the unexpected.

I think patients do need to know more about what to expect, in appointments. Perhaps expectations need to be voiced when the appointment is made. The patient may realize then if they need more time and set up a longer appointment, and, of course, we should know how long our appointment actually is.

[Dr. Val]

Great post. I would like to mention that not all concierge practices are created equal. My doc offers a pay-as-you-go model, with a yearly fee of only $200. He charges by the hour, and patients can buy as much (or as little) time as they want. He does what's appropriate (phone/email/in-office visit) and gets paid for it. I love the convenience and pay out of my HSA. I have high deductible, catastrophic coverage in case of emergency. I save thousands/year on insurance premiums and get A+ care. I'm going to have him describe his model on my blog soon... stay tuned. :)

[Theresa]

doctorjen--I admire your partner's longevity in the profession, and yours too! A lot of nonsense has to go through a physician's hands to get authorized (jury duty, etc.), the word "gatekeeper" doesn't even begin to capture the absurdity. Maybe "gamekeeper."

Emily--Very good points. I think people are baffled by how medical offices function, what the "unwritten" rules are. What tends to happen is all fifteen patients in a morning will come in with just one extra question, each of which sets the provider back 5-10 minutes. Sometimes what I had to do was shave a few minutes off the visit of a perfectly reasonable person just to make up time--not fair! I think the public tends to attribute this rushed attitude as the fault of the doctor but I've found myself being rushed (or extremely late) simply because people's needs were overwhelming.

Thanks everyone.

[Emily]

While I'm sympathetic to the plight of family practice doctors with annoying patients, I have to say that the reason some of us complain is that even when we're NOT annoying (i.e. we come in with one question/issue) we still get the same rushed treatment. I've had visits with my doctor that were literally less than five minutes. He pretty much walked in, peered at the spot on my arm, and walked back out. That was it, and a nurse came in a few minutes later to inform me that I'd have to get the mole removed but not now, later, I'd have to make another appointment. This after I had made the appointment specifically to have the mole diagnosed and likely removed - the staff knew this and had not mentioned that it might be a problem to do both diagnosis and treatment at the same time.

Had there been better communication on the part of both staff and doctor, I would have been much less irritated. So I guess I'm just saying that not all of us are nitwits with questions like you listed. And there just might be some of the fault at the doctor's door, too.

[dragonfly]

Those scanned masses of past notes on EMRs (in Australia a program called Medical Director is used in a lot of GP surgeries) are highly frustrating......

Loved your list of real life questions...have seen lots like it and sometimes it makes one want to tear ones hair out...

[doctorjen]

Sigh. I'm sort of fantasizing over your series on leaving full-service family practice lately. In general, I can't imagine doing anything else - but you hit the nail on the head with your list of things that were bothersome about it, and right now all of those things are bugging me. Today, I saw a young woman who brought a list with 17 issues to be addressed! At least I had the courage to tell her we were going to have to prioritize. I also saw a newly diagnosed cirrhotic gentleman who is really struggling emotionally with his diagnosis, an 88 yr old lovely woman who needed medical clearance to take a driver's test, and poorly controlled bipolar client who can't get a psych appt for 3 mos because he's not suicidal. I filled out multiple notes to get back into school, to get out of school, to prior auth meds, tests, or referrals, and received a note from one lady who hasn't seen me in a year wanting me to fill out medical leave paperwork for the 20 something days she's missed due to her migraines! I also saw 3 inpatients this morning.
The paperwork/prior auth/formulary change requests/FMLA/disability/medical clearance/DME forms are going to put me over the edge. I'm happier with my compensation model that you were with yours, but my practice still makes below the national average for a family doc because we a are a rural private practice that is heavily medicare-medicaid dependent. My 2 partners who own the practice are not holding out on me, or overworking me exclusively, and are wonderful colleagues to work with - but we are all over-worked and underpaid and generally stressed.
If you get that handout written on reasonable expectations for clients I'd love to see it! I'm awaiting your recommendations for young doctors, too - although I've been in practice longer than you have. I've been practicing full service family practice including maternity care and attending births since 2 weeks after finishing residency in 2001. I tell my senior partner sometimes that I just don't think I can do this for 30 years, and he says he's been saying that for the last 26 years.