Doctor Or Administrative Assistant?

It is currently estimated that by 2025 there will be a shortage of nearly 46,000 primary care physicians in the United States.  This is of critical importance, considering that 32 million more Americans will receive health insurance coverage under the new Patient Protection and Accountable Care Act (PPACA), and they will need physicians to provide their care.

Primary care (family medicine, general internal medicine and general pediatrics) comprises the specialties that provide preventive and wellness care to avoid future illnesses and that deal with undifferentiated complaints and help determine the best approaches to diagnosis and treatment.  It's not that other specialties don't do that to some extend, but it is the foundation of what primary care physicians do.  Health care systems that are strong in primary care tend to provide better care for less cost.

It is even more concerning, then, that so few United States medical students are interested in primary care careers.  This article in the New England Journal, and this associated commentary from the New York Times, show some of the reasons for this

The article shows that this practice's physicians saw an average of 18 patients per day.  This is what most of us went to medical school for: to provide care for patients.  Beyond that, though, physicians handled nearly 24 phone calls daily, 20 lab reports, 17 e-mails, 12 refill requests, 11 imaging reports and 14 consultation reports.  This is also appropriate (mostly) because these directly affect patient care.  (I say mostly because a large portion of the phone calls involve insurance company authorizations, etc).

The problem: administrative and paperwork requirements far outweigh the patient care.  For the 18 visits, there were nearly 100 other tasks to be accomplished.  An even greater problem: physicians are not paid for those 100 non-patient-care tasks.  So, in this practice the non-reimbursed services outweighed the income-generating services by 5:1.

I suspect most physicians did not enter medicine to make a lot of money.  There are other better, easier, more lucrative careers IF one is only seeking higher incomes.  However, medical practices cannot stay open to provide medical care if they cannot pay the bills.

We desperately need to bring medical students into primary care careers, and there are many ways to do this.  However, we also need to fundamentally change the way that health care is provided and reimbursed.  Articles like those noted above show some of the challenges; now we need to look for solutions.

We need to return focus on the patient, on the heart of what makes medicine such a challenging and rewarding profession.  We need to find ways to de-emphasize these non-clinical tasks OR we need to decide that these tasks are necessary to provide care and we should reimburse for them.  Health care delivery models such as the patient-centered medical home (PCMH) would account for this and allow for reimbursement of asynchronous care (care when the patient is not directly in the office).

Whether with the PCMH or another innovative model of care, we must reinvigorate our nation's primary care workforce--both to make the PPACA successful, but also for the better health of all.

Decalogue

In medical school and residency, all of us are vulnerable to influences that will color how we practice and how we approach patients and medicine for the indefinite future.  I tell students that their practice style will be based on things they saw preceptors and teachers do that they choose to emulate, and an active avoidance of things with which the student was uncomfortable.

In school, I read the following comments by G. Gayle Stephens, M.D.  Dr. Stephens was one of the early proponents and defenders of Family Medicine when the specialty (then know as Family Practice) was developing out of the previous general practitioner (GP) model.  I found these ten points spoke very deeply to me, and I have tried to use them as guideposts along the way.  I cannot claim that I was always successful, but I do believe I have done my best.

A Decalogue for Family Practice Residents Entering Practice--G. Gayle Stephens.

1. Don’t give up the reform ethos.  Keep on the side of responsible change in education, practice, and social justice.

2. Don’t lose faith in the power of relationships and the therapeutic use of self.  (Or, don’t hire anybody to save you from spending time with patients.)

3. Don’t turn your practice into a mere business.  It may not be less, and it should be a great deal more.

4. Learn to distinguish between uncertainty and ignorance; only the latter is remediable and potentially culpable.

5. Find some way to practice charity; i.e., willingly give a part of your services consistently to those who cannot pay.

6. Try to see that the groups in which you hold membership are at least as moral as you are.

7. Humanize and personalize the Microsystems in which you work.

8. Act at all times as if the patient is fully autonomous; the weaker the patient is, the more vulnerable you are to violating his/her personhood.

9. Reflect on your professional experiences.  Within the bounds of protecting patients’ privacy, think, talk, and write about your clinical stories.

10. Worry less about patients becoming overly dependent on you than about your becoming undependable.

 With the increased stresses likely to result from the Patient Protection and Accountable Care Act (PPACA) and as new systems of health care delivery and payment are tested and enacted, I think this ten points will continue to show the way to be a good physician in difficult times.

Empathy

If you ask people what they want in a physician, most people will list a few key characteristics.  Usually, these will include knowledge and competence, availability, and empathy and compassion.

It's distressing, then, to read that medical students start to lose empathy as early as their first year of medical school.  Empathy scores fall off after the first year, and then take another step down at the end of the third year after completing clinical rotations.  In the first case, this is apparently due to the stress and hardship of med school.  In the second case, the researchers think that this is related to the fact that hospitalized patients are sick, that the work can be hard, and that teaching physicians are rushed and may not provide the mentorship and teaching students were hoping for.  The drop after 3rd year might also be impacted by the fact that students care for patients whose illnesses can result at least in part from choices they have made: smoking, substance abuse, obesity, etc.

It is difficult to put in 2 long and hard years of classroom learning to prepare yourself for clinical rotations.  It is even harder to adjust to the fact that some of the patients you care for on the wards are there in part because of what they did to themselves.  I suspect it is easier to be empathic when caring for a child with cancer or an older patient who broke a hip in a fall then someone shot by a rival gang member or a lifelong smoker with end-stage emphysema.


This is a shame, because most students enter medical school with a strong desire to help others and a wish to make a difference for the better in peoples' lives.  Reading medical school applicants' essays reveals a group with great hope, energy and passion to enter a healing profession.  To see this energy start to lag within a year is troubling.

Some students fare better than others.  Women sustain empathy better than men, and students entering primary care and generalist specialties do better than those who enter Radiology and Surgery.  But it is evident that our medical education system has to do better.

There are ways to address these concerns.  At VCU School of Medicine, Project Heart matches students with mentors who help work through these issues during the pre-clinical years.  The Foundations of Clinical Medicine teaches clinical skills in the M1 and M2 years, but also teaches how to work with patients and how to handle difficult situations.  I don't know how VCU School of Medicine compares to other schools, but I am glad that this problem is recognized and is being addressed.

There are other ways to address this, including matching students with mentors who embody the desired qualities, asking students about their emotional or personal reactions to patients being cared for, and addressing non-empathic behaviors that might be demonstrated during patient care (whether student, resident, attending, nurse, colleague, etc).

Medical education has changed a lot in the last 10 years.  Gone are the days of 36- or 48-hour on-call shifts, and the system has shifted toward a more humanistic perspective.  Addressing medical student burnout and empathy are important next steps.

Do Americans Support Health Care Reform? Rhetoric Versus Reality

I've made many claims in this blog that the rhetoric used by the opponents of health care reform leads to misconceptions about the bill overall, and that the components of the bill are popular amongst Americans. Today, the Kaiser Family Foundation released a poll that backs up these claims.

This poll looked at public awareness about the bill, and shows that a small plurality of the public support the bill (46% to 40%). This isn't the important point, though. If you shift the question to ask about the specific reforms the bill brings about, public support is very high. In fact, a majority of people polled support all 11 reforms that go into effect this year. Most of the time, this support is by large margins:

So, nearly 2/3 of those polled agree with the reforms coming into play over the next 8 months.  I would consider this solid support.

Even more interestingly, take a look at the support when broken down by political affiliation:

So even Republicans support these reforms, except for the future limits in Medicare provider payments.

Just wondering: if the American public overall supports these reforms, and if Republicans support these reforms in large amounts (and independents support them even more strongly), what exactly are the Republicans fighting against?  Policies and reforms that both make insurance coverage available to 32 million more Americans and that are also strongly supported by the public at large?

This, to me, is another example of what dishonest rhetoric leads to.  Calling the bill "Obamacare", "socialized medecine" or "a government takeover of health care" polarizes the discussion, even though the programs put in place by the bill receive wide support.  Health care reform's opponents use fear to galvanize opposition without allowing people to discuss and understand what really will happen when this law is fully in place.

That's because, if Republicans and other health care reform opponents engage in honest discussion, they lose.  Even in their own party.

Health Communication And Social Media

A brief note to mention something really interesting, but still in the works. The last two weeks, I've participated in an online Twitter discussion regarding health care and social media. These conversations tend to be focused on one or two issues, but have started me thinking more about what this medium could provide over time.

I have 2 major questions right now:

1) what do patients want from health care providers on social media? Do they want providers to act as information aggregators, or is the hope that providers will provide direct patient interaction?

2) how can health care providers find good patient-centered resources to follow? I understand that interest and professional groups have accounts, but how many can one follow and really stay on top of things?

I think this is a conversation that is in the early stages and, if to reach maximal benefit, would require major discussions of issues such as online privacy/confidentiality, the HIPAA privacy laws, provider liability, etc.

Not something with any definite answers, but an interesting set of questions.

Next Steps For Health Care

Now that health care reform has been passed and enacted (no longer a bill, but a law), health care will become available for millions who have lacked access until now.

The next big question, then, is where will these patients go? American Medical News published an article indicating that by 2025 the nation will lack nearly 160,000 physicians that will be necessary to provide care for the nation. 46,000 of this anticipated 160,000 physician shortfall are primary care physicians--the very core of a cost-effective and patient-centered health care system. This issue has already developed in Massachusetts, where state law has extended health care coverage to essentially all of the state's residents. The article notes that 40% of family physicians and 60% of internists in the state have stopped accepting new patients, and the wait for a new-patient appointment with a primary care physician is up to 44 days.

Passing health care reform is a tremendous accomplishment. However, it is necessary to take the next steps to truly reap the benefits. At the heart of the efforts is the need to increase the numbers of medical students choosing primary care careers.

There are innumerable reasons medical students choose specialties other than primary care; probably as many reasons as there are medical students. Lifestyle, income, prestige, etc--all of these play a role. There has been a trend in medical students choosing the better-paid and better-lifestyle ROAD specialties (Radiology, Orthopedics, Anesthesia, Dermatology), while primary care specialties have struggled to attract high quality applicants.

There are many steps to addressing this issue. We need to make primary care more appealing to students, which will require addressing the costs of medical education, the payment structure of a health care system where procedural specialties are paid better than "intellectual" specialties, looking at concerns of physician burnout, etc.

Passing health care reform was a critical step. Now, we have to turn our sights to the next steps to make the promises real.

Non-partisan Assessment of Healthcare Reform

A week or so ago, I saw a Republican "assessment" of healthcare reform law. Simply reviewing the language makes it clear that you can't really expect an unbiased opinion.

I realize that similar claims could be made towards the Democrats summaries, though.

So, I submit a summary from the non-partisan Kaiser Family Foundation. This provides a thorough overview of the changes the law brings into effect.

So, I hope this further clarifies what is REALLY happening, and not what either side would like us to believe MIGHT happen.