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You May Have Missed the Obituary for the Primary Care Physician
Strangely, healthcare reformers — both the Obamacare and the emerging Trumpcare varieties — still speak in pious terms about the importance of the primary care physician to whatever plans they have in store for our American healthcare system. These people are lying. Many of them are members of the enlightened leadership that has purposely and systematically wrecked primary care medicine. The primary care physician is dead, and the reformers know it. The obituary has not only been written, but has been duly published in the Federal Register as the law of the land.
The death of primary care was a culmination of two fatal disorders. The first was a chronic, debilitating illness that systematically deprived the practice of primary care medicine of its very purpose and meaning. This illness took hold long ago, back when Mr. Obama was still organizing sundry communities, and Mr. Trump was still enthusiastic about the casino business. Consider the long-term effects of this illness. if you ask a primary care physician what their medical practice is like today, you are likely to get an answer like this:
“Our pay is determined arbitrarily by Acts of Congress, like workers in the old Soviet collectives. We are directed to “practice medicine” strictly according to directives (quaintly called “guidelines”), handed down from on high by panels of sanctioned experts, and accordingly we are enjoined from taking into account our professional experience, our intuition informed by judgment, or our specific knowledge of our individual patients when we advise them about their medical issues. We are strictly limited to 7.5 minutes per patient “encounter,” and the content of this brief encounter is determined by certain Pay for Performance checklists which have been given to us by yet other expert committees. These checklists assure that most of our 7.5 minute encounter is spent asking about important medical topics such as the storage of handguns in the home and sodium in the diet, for if we skip any items on the list we define ourselves as substandard caregivers. This expediency has had the effect of greatly limiting any discussion of topics or concerns that are not on the list, and thus do not meet the approved agenda. Our every move must be carefully tabulated according to incomprehensible rules, on innumerable computer forms and other documents, that confound patient care but that greatly further the convenience of the stone-witted bureaucrats and forensic accountants who are employed specifically to second-guess every clinical decision and every action we take.
“We are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If we do not operate flawlessly according to those rules, regulations and guidelines, we are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate — that is, they have no inherent meaning. So, we must proceed under a massive quantum cloud of rules as best we can, but our actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable — until the “box is opened” (such as, through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and we who had been practicing in good faith find that we have at least a 50- 50 chance (like the cat) of learning that we are actually professionally dead.
“We have been given the overriding charge of becoming the primary mediators of covert, bedside healthcare rationing, and to this end we have been pressed to ignore the classic doctor-patient relationship by the healthcare bureaucracy that determines our professional viability, by the United States Supreme Court (see Pegram et al. vs Herdrich (98-1940), 530 US211, 2000), and by the bankrupt, new-age ethical precepts of our own profession, that require us to practice for the benefit of the collective instead of the individual patient.”
Sad!
By such insults, even before Obamacare became the law of the land, primary care medicine had been reduced to one of the most frustrating, enervating and demeaning endeavors a physician could imagine. Many if not most practicing PCPs even then were looking to either retire early or change careers. Medical students — even the most idealistic ones who were actually not lying when they said on their applications that they wanted desperately to practice primary care medicine — end up avoiding primary care in droves, especially if their training exposes them to the palpable despair radiated by actual primary care physicians in the wild.
But the second fatal disorder (either of which would have been sufficient) has nothing to do with policy or politics. Even if doctors had perfect control of the healthcare system and the political realities, primary care medicine (as we know it) would still be in trouble. This is because of an axiomatic truth revealed by the annals of human progress, to wit: As knowledge increases and technology improves, activities that used to require the services of highly-trained experts become available to non-experts who have much less training. A lot of what PCPs have traditionally done — check-ups of well patients, screening for occult disease, controlling cholesterol, advising on diet, weight loss and exercise, managing hypertension and diabetes — really can to a large extent be reduced to a series of guidelines and checklists, which can be adequately followed by individuals with much less training than these doctors receive.
When any area of expertise evolves to this level, it is inevitable (in a free economy) that lesser-trained individuals will inherit it. This event greatly increases productivity, makes the services in question more readily available to many people at lower cost, and (ideally) frees up the experts to take on more challenging endeavors. While this kind of transition is nearly inevitable, it is often painful and disruptive. The pain and disruption are being experienced by PCPs today.
It is in fact true that medicine has advanced to the point where it really would make sense to turn over to non-physicians many of the routine, mundane, and reducible-to-checklist tasks that PCPs traditionally perform. PCPs who are fighting against this inevitability are wasting their time and energy. They are fighting both history and the laws of economics, so in the end it is a losing battle. It is time for PCPs to move on.
It is of course immaterial whether you agree with me on this point. It is immaterial because this is how the Central Authority sees it, too.
My dear PCPs: Having painstakingly reduced you and your fellow PCPs to tools of the state — whose chief job is to follow the guidelines and place chits on the checklists, &c. — it is only natural for the Central Authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses and other non-physicians, who can be “trained up” much more rapidly than you, and who will work for much less money than you, and who will be much less recalcitrant about following handed-down directives than you — will fill the gap.
And you, doctor, can go pound salt.
So it was really only a formality when the Obamacare legislation made the death of primary care official. The new law did so by stating explicitly that PCPs and nurse practitioners and physicians assistants are now legally equivalent, one and the same. They are all PCPs under the eyes of the law. The actual language of the obituary is as follows:
The term ‘primary care practitioner’ means an individual who —
(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in 9 section 1861(aa)(5))
What this means is that today there is more than one pathway to becoming a PCP. You can spend four years in college, four years in medical school and three years in a clinical residency — or you can go to nursing school and do another year or two of clinical training; or go to college and train for two years to become physician assistant. Anyone who wants to become a modern PCP might reasonably find themselves having to defend their intelligence if they still, after this obituary, chose the former pathway.
And so the issue is decided. PCPs: by virtue of your specialty you have been formally (and legally) reduced to the status of a nurse-equivalent. Your specialty, as you have known it, is dead. It is time to decide what you’re going to do about the demise of your chosen career.
There are, of course, several options. Maybe we will look at them another time.
Published in General
It is so frustrating to read this.
Some of the problem is with the younger doctors. We need to get them to see what’s happening and how damaging it is to the practice of medicine.
Regina Herzlinger says in her book Who Killed Health Care? that one reason she wrote the book was that all of her incoming students from Harvard Medical School, students who had to take her course at Harvard Business School as part of their core education, simply assumed they would be working in a single-payer system.
I think that medical care is so technical that the general public cannot help straighten this out. It has to be doctors. What you are describing in giving up the preliminary checkup is really dangerous. That was when doctors got to know their patients. It was a little routine that gave them far more information than it would appear to yield to an outsider. The doctors need to convene a national conference on this topic of primary care and how they get to know their patients so as to give them good care.
It is no surprise either that the less-well-educated physicians’ assistants and nurse practitioners are claiming to have the same knowledge as the doctors. The Mayo Clinic has been pursuing this for several years now as a cost-saving measure. What began as a good idea has gotten completely out of hand now. It is infuriating.
My doctor just threw in the towel. She is 42. They want her to see 100 patients in 4 days. She hasn’t said but I think she will open a concierge practice, and I w not blame her. She gets next to nothing to see me on Medicare. It reminds me of the old joke about the butcher having a sign with pork chops being 20 cents cheaper than anyone else, but he is always out of stock.
Time for PCP’s to become shamans of the ancient art of family practice…Then, what you do will enter the realm of spirituality – perhaps free from government’s heavy hand for just slightly longer. (I’m only being slightly-facetious.) This is unconscionable!
MarciN,
It is pretty frustrating. What people have to understand is that if the government and/or insurance companies are the ones who pay the doctors, then that’s who the doctors end up working for — no matter what principles everyone started out with. To control healthcare costs (if that’s even possible) payers know they have to control utterly the behavior of doctors — and they’ve become ruthless in doing so.
There are doctors willing to buck the system, but to really do that, they pretty much have to work outside the system. And that means that patients must be willing to pay them directly. To most people, such a notion is not even imaginable.
This is precisely why I am reluctant to rail against alternative medicine. While most of it is complete woo, it does open a pathway for “medical” practice that is beyond criticism. As long as physicians disguise what they’re doing with reiki talk (for instance), they could practice real internal medicine and probably get away with it.
Not only should you not blame her, you should admire her as one who is striking out against the machine.
This is a huge, okay yyyuuugggeeee, problem.
This kills me as an ER doc, because I count on you guys to send my patients to. I really miss the days when patients had a single PCP they saw who knew them and their problems, and I could count on the patient getting real follow up. Today it just feels like I put a patch on the hole, and they just bounce back with the same issues over and over because, it’s all McDonald’s Medicine.
The latest nonsense for us is “prehypertension”. For the lay folk it’s anyone with a BP of between 120/80 and 139/89. This is what would until recent be called “normal”. Now if you show up in the ER and we get a reading like the above, we have to refer you for followup or we get a ding from the insurers and the Feds. No exceptions. Doesn’t matter that you are in the ER in pain, upset, pissed off and tired. Doesn’t matter that you are 85 years old and you need that pressure to perfuse your squash with blood. No exceptions. One size fits all. So that means we inform you to follow up with your (probably nonexistent) PCP for follow up. If you do it generates a needless visit and drains more money out of the system.
I actually have a PCP I like for the first time in my adult life (in the Navy it was either the enlisted guy on the boat or whoever was available at the clinic…) and I probably can count on being transitioned to my wife’s PA at some point.
Side question: is it better to treat healthcare like a commodity or to have it retain its special place in our minds which invites government regulation/intervention?
What a wonderful, horrible post. Brilliant. Even the parts I disagree with (…perhaps especially those parts…).
For those who find his description of primary care to be too wordy, convoluted, & disorganized, I will point out that the practice of medicine is too wordy, convoluted, & disorganized. That’s what happens when you are governed by rules no one understands.
Outstanding post. I wish I had written that. Thanks for taking the time to put that together. That was wonderful. And awful.
Thou shalt honor the guidelines above all other gods.
As much as we might like to treat healthcare as a commodity, that horse has been out of the barn for over 50 years.
I do admire her. My problem is replacing her. At my age I am more or less stuck with Medicare and fewer docs are taking Medicare patients. Any suggestions Rich?
Thanks for your ( depressing and maddening) post.
I am also on Medicare and I feel your pain. (By the way, I was not a PCP when I practiced medicine. I was a cardiac electrophysiologist.)
The Central Authority, of course, wants us Old Farts to be followed by an NP or PA, so that we will be strictly subjected to the guidelines (most of which are primarily aimed at not dispensing any new therapy or any screening tests after we are 75). So there’s that option.
Or, we can engage in a persistent search for an acceptable primary care physician. Sooner or later we may find one.
Or, we can hire our own pay-for-service doctor. (I don’t like to call them concierge doctors, because that makes them — and those of us who use them — sound like the elitist 1%). More and more of these docs are introducing payment models that are more affordable for regular folks.
The key thing to know is that our dilemma is not an unforeseen outcome, or unintended consequence. It has been planned for, and fervently prayed for.
I get that the system is rigged. My question is how do I beat it and also keep a roof over my head?
Was it 50 yrs ago that providers started saying yes to the insurance companies discounted reimbursement? Are dentists that much smarter?
It’s lots more complex than that, too complex, for me, at least, to tackle in a mere comment (especially with the word limit on comments us mere members have). I may put up a post at some point to give your issue the response it deserves.
As for dentists, yes, they are.
I gave you the three options I can think of. If any more occur to me in my travels through Medicare, I’ll let you know.
I wish I still had my textbook from my “Introduction to Healthcare Systems” class from PT school. . .
I have no love for primary care doctors. Good riddance. I realized years ago that the reason doctors get so many malpractice lawsuits is they deserve it.
Yes, let’s not let on to the fact that the main driver of healthcare inflation, by far eclipsing malpractice insurance premiums (ha!), are the providers: doctors, hospitals, nurses, etc but mostly just doctors and hospitals.
Insurance companies are tame paragons of virtue compared to the greed of healthcare providers.
While I suspect you mean to be inflammatory here, this is just a simple statement of fact. Doctors are the ones who order the tests, procedures and treatments that determine how all the money is spent.
This is why the virtuous government and the saintly insurance companies, horrified that the entire medical-industrial complex immediately heaves into action the moment a doctor sets pen to paper or mouse to screen — “My God! They’re spending OUR money!” — has pulled out all stops in utterly controlling their every action.
So not to worry. The paragons of virtue are looking out for your interests now.
If gay marriage can be normalised in a matter of months, nothing is beyond the culture.
What I meant is that most providers of medical and ancillary care agree to let the third party payer pay them less than billed when the providers agree to take patients covered by that payer. So, the amount billed gets inflated so that the providers get, sometimes, what they want to be paid. This has snowballed for any number or reasons.
Walmart can offer lower prices by buying good to sell in large quantities and the manufacturer is, therefore, happy to sell the to Walmart at a discount. For a provider of a service paid by a third party, this is just silly. The dentists didn’t fall for it and your “insurance” for their services is pretty much a discount.
Obamacare was so ineptly designed, that the disaster of a single payer will probably not come about. My view years before Obamacare was that the Democrats would succeed in creating socialized medicine and since it would run up against personnel shortages because of excess demand and inadequate supply and general ineptitude, the government world remove barriers to entry, relax barriers between professions but it still wouldn’t work. At some point someone would come up the the bright idea of privatizing it, and with the professional barriers broken a market would emerge and folks would have to figure out who was good like they do with everything else. Problem solved. Now it’s disintegrating and the Democrats aren’t there to fix it/destroy it with single payer. But the end should be the same. Open it all up. The PCP might become central again.
I still have primary care doctor, but it is getting harder and harder to keep the same one. And get this. I was in the office yesterday and I asked for a copy of my own blood test results and they charged me $3.75 for four pages. They used to hand these things out. Now they’re nickle and diming every little thing. I guess they have to given Obamacare mandates.
My Primary Care Doc, a personal friend since we were teenagers, has just moved into concierge practice only. He has always given concierge service, just never charged for it. Ever since I can remember, if I or my wife felt a cold coming on, we just called him and he would ask a few questions, then based on what he knew was “going around” would send a prescription in to our pharmacy of choice. If he thought it was more serious, he would send us to the emergency room of one of the hospitals he worked in and meet us there often soon after. It wasn’t until 5 or 6 years ago, after reading a post by Doc Jay here on Ricochet, that I realized how incredible a service my friend was performing. To not have to drive to his office and sit ill in a waiting room full of other sick people to get examined, only to be prescribed what he could do with a phone call, was a real luxury. So I started sending him a check (which I never did before) for $50 or $100 depending on what he had done. Now I am one of his concierge customers. At 70, he would have to retire without the concierge angle. I have seen what Medicare pays and it is a losing proposition.
My Doc has a website where I can log on to my account and see all of my lab tests in detail going back several years. If the government can have access to your health info, why shouldn’t you?
You just reminded me. I can swear my doctor does too, but the administrator never mentioned it when I asked for copies, and I had forgotten.