The Primary Care Puzzle: Can It Be Solved?

Lisa Rosenbaum, MD, is a national correspondent for the New England Journal of Medicine (NEJM).  She has just published Is a Long-Simmering Crisis Boiling Over? U.S. Primary Care Today.  The easy, and current, answer is “Yes.”  But this is not necessarily the final answer.  Dr. Rosenbaum begins with the description of the career arc of one Dr. H:

After her internal medicine residency, Dr. H. joined a Midwestern practice, inheriting a primary care patient panel from a retiring endocrinologist. At first, the work was hard for the right reasons. She diagnosed and treated a wide range of diseases, built long-term relationships with patients and families, and — until the rise of hospitalists — cared for them in the hospital as well. Becoming the consummate internist was exactly what she’d signed up for. “Lifelong learning and getting to help people,” she recalled. “It was the best job in the world.”

For the past eighteen years I have been involved in medical education, with the goal of increasing the number of primary care physicians practicing in rural and medically underserved areas.  Who are these doctors?  Primary care is more than what in my childhood was called the “general practitioner” Or GP. [1]  As understood today, the core primary care specialties are Family Medicine, Internal Medicine, General Surgery, Pediatrics, Obstetrics & Gynecology, and Psychiatry, with Emergency Medicine sometimes considered primary care. [2]  Emergency Medicine was not a recognized specialty until the 1970s, and when I needed stitches or an x-ray (often enough to know the Emergency Department well) before going off to university, the hospital called one of my two family doctors who then drove the half mile from their nearby houses to care for me.

That was not so long ago in human years, but it is unimaginable in “healthcare system” years.  Back to Dr. H:

She didn’t recognize that this traditional generalist role was in peril until about 15 years later, when she joined a multispecialty practice owned by a nonprofit foundation. The work was initially fulfilling, but as the insults to primary care accumulated — shorter visits, unmanageable inboxes, a staff exodus during the Covid pandemic — Dr. H. gradually lost her capacity to function as her patients’ doctor.

Like many primary care physicians (PCPs), she adjusted to the squeeze by working more. Without staff support, she roomed patients, took their vitals, and scheduled tests and follow-up. When leadership threatened to cut physicians’ vacation days if their documentation was late, she started spending hours at night charting, despite caring for a young child and a chronically ill husband. But one change she couldn’t work around was the lost capacity to see her patients when they were sick. Forbidden from double-booking to accommodate them, she often didn’t hear about patients who needed her until after a centralized triage system had diverted them to urgent care.

Urgent care.  In my recent family experience, urgent – yes, and expensive.  Care, not so much.  But the regional for-profit but technically non-profit hospitals are making a killing, which is a story for another time.  But this happened to one of Dr. H’s patients:

A patient with recurrent herpes infections, for instance, called seeking a refill of valacyclovir. The staff, following an algorithm, told her she required a clinic visit since she hadn’t seen Dr. H. for a year. With no appointments available, she was sent to urgent care, where the clinician wouldn’t prescribe valacyclovir without a culture. Dr. H. eventually received the message and refilled the medication. But as similar situations, often with much higher stakes, recurred, she began wondering: What does it mean to be someone’s doctor if you can’t be there for them when they need you?

Indeed.  This never happened in my family’s experience that I can remember.  Our doctors were there when we needed them. Always, from birth to death including general surgery that did not involve the heart or brain or bones.  And if they were unavailable, a local colleague was happy to take call for them.  It was a different time, when health care may not have been universal but few who needed care were unable to get it.  As one internist friend put it (paraphrase), “We usually got paid, but when we didn’t that did not make any real difference to us but was life changing for the patient and his or her family.”  And we were providing medical care as it was intended.

Does primary care have a future?  Whatever comes, it should.  And if it goes away, we will all suffer for its loss, as have those patients who must use urgent care for medication refills or chronic disease management.  This is not the way to go, but the slide seems inexorable.  Still, what might recover the situation?  A massive investment of time and money could work.  Primary care receives less than 5% of US healthcare spending but is responsible for 35% of doctor visits.

Nevertheless, many people (except for those who need a PCP) are beginning to believe “primary care can be delivered less expensively by advanced practice practitioners such as nurse practitioners (NP) and physician assistants (PA).”  Several friends were some of the first PAs.  They were trained well and have now retired after a lifetime of providing good care in partnership with a physician.  The same is true of the first NPs.  The angels who walked the earth while managing my chemotherapy were oncology NPs and oncology nurses.  But this was done in a large oncology practice under the supervision of five oncologists, who worked closely with three radiation oncologists on the first floor of the same building that I got to know too well.  It is not clear that NPs and PAs in stand-alone practices are the answer to the shortage of PCPs.  And there is good evidence that NP and PA programs are not as rigorous as they were at their beginnings.

But more importantly, the primary role of the PCP is to be the generalist who understands the needs of her patients through long and continuous contact and care, as the one doctor who coordinates multispecialty care when that is needed.  The PCP is the captain who leads the team providing the care. Without him a gaggle of oncologists, surgeons, and radiologists can be like the committee of blind men describing an elephant.  But these specialists are absolutely essential.  Where they are present condition-specific outcomes are better, and I have my ENT, medical oncologists, and radiation oncologists to thank for my current good health.  But my internist diagnosed the problem in the first place and started in motion the plan that resolved my cancer.  Despite difficulties the modern hospital system has put in place to improve “efficiency,” my internist continued to monitor my care until I was released by my specialists.  This was a team effort from start to finish, even if I had to pay close attention at times to all the moving parts.

These relationships may be called the “paradox of primary care”:

Despite better disease-specific outcomes for individual patients treated by specialists, population-level data suggest that places with higher ratios of primary to specialty care have healthier populations, better-quality care, greater equity, and lower costs…U.S. states with a higher density of generalists spend less and deliver more effective care than specialist-heavy states.  Others suggested that patients with multiple chronic diseases have similar functional health status whether treated by generalists or specialists, but that generalists use fewer resources.

Of course, confounders may exist and could explain these results at the margin.  A community that is willing to invest in primary care will probably invest in social services that improve health in general:

These limitations, however, seem less relevant than the belief that primary care’s true value can be captured by measurement to begin with.  And this misunderstanding is accelerating its demise…

Reinvention requires health systems to recognize the generalists value in the first place.  They don’t.  Instead, primary care has been atomized into its revenue-generating parts, leaving many PCPs unable to build the longitudinal relationships essential to this integrative function. The specter of extinction thus looms large. Primary care’s sustained relevance depends on offering a service people can’t obtain from specialists, retail clinics, or virtual substitutes. If its relational core is removed, will the public get their health and well-being needs met elsewhere? In other words, will traditional primary care’s value become invisible to the rest of us too?

This is where the naked truth of the Neoliberal Dispensation enters the discussion. [3]  We have described Neoliberalism as the dogma that “the market is the measure of all things, including those that cannot be measured.”  When it comes to health and wellbeing, MAHA and its minions beg to differ.  Only those health metrics that can be measured count, beginning with your plasma glucose level, right now:

This belief…contributes to widespread misunderstanding of what primary care is (care for the whole person from before conception to death).  And this misunderstanding is accelerating its demise.  As (Dr. Kurt) Strange told me, ‘In trying to improve the parts of primary care, we’ve actually killed the whole thing.”

And in the meantime, so-called influencer culture “has rendered the idea of a long-standing doctor irrelevant,” especially when a wearable will tell you everything you need to know, right there on your smart (sic) phone.  Just ask the current Secretary of Health and Human Services.

But, it could be that an escape from corporatized medicine may be possible.  From Dr. Rosenbaum:

Given the high rates of burnout among PCPs, one of the more surprising findings in my reporting was the sense of joy and gratification described by some of the rural PCPs with whom I spoke. Though practicing in resource-poor settings is challenging, constraint evidently breeds creativity. An uninsured patient in florid heart failure who’s declining the hospitalization that would bankrupt him and force him to sell his farm? He makes a plan with his trusted physician to come to the clinic daily for IV diuresis and weight and electrolyte checks. A woman with nephrotic syndrome who can’t get to the nephrologist at the academic medical center 3 hours away? Her physician emails with the nephrologist and learns to manage her disease himself. Does rural physicians’ gratification arise from autonomy, opportunities to treat widely varied diseases, their central role in their communities? Yes, probably all those things. But most strikingly, these physicians “meet patients where they are” regardless of circumstances. Most of U.S. primary care, constrained by large health systems, has been denied this crucial ability.

It’s no mystery why. Health care systems often profit from hospitalizations, specialty referrals, and testing. As Larry Green, a family physician and distinguished professor at the University of Colorado, told me, “Good primary care is increasingly bad for business.”

Ignoring for now the choice between bankruptcy and healthcare, this is a roundabout way of making the essential point that the rural primary care physician must be the best doctor.  Otherwise, his patients will simply die according to the first rule of neoliberalism, “Because markets, go die.”  It is heartening to see that many of our graduates come to see this naturally, and then return home to take care of their community that comprises their patient population.

And yes, by neoliberal calculations, good primary care is likely to be bad for business.  The question is, however, “Whose business?”  Big Medicine and Big Pharma, that’s who.  But it could be that as the world gets smaller as the climate changes for the worse, rural life, including rural medicine, will provide the way forward.

And what became of Dr. H, with whom we began:

She and her colleagues wrote several emails to practice leadership describing lack of staff support, missed messages, their sense of failure over letting patients down. “I cannot in good conscience with consideration of the oath we have taken as Physicians continue to practice this way for very much longer,” Dr. H. wrote. But no one seemed to care. That’s why the message I found most haunting was one about the fundamental mindset shaping primary care’s trajectory. “Perhaps this is what the administration wants,” Dr. H. wrote: “to replace the ones who know with those who do not know better, those [who] have been indoctrinated into your system which has eliminated humanity from the equation.” Dr. H.’s pleas reflect primary care’s contemporary paradox: if primary care’s survival depends on advocacy by doctors and patients, then as exposure to true primary care becomes rarer, fewer will know what’s missing.

Well, some of us will know what’s missing.  Specialty care is essential.  Many of us here today are living proof of this.  But primary care (OED) – of the first order in time or temporal sequence; of the first or highest rank – is the solid foundation of the practice of medicine.  Whether it disappears or not, this will remain true.  We cannot live well without it.

One evening while finishing her notes, Dr. H had a premonition that she would die early. “You always hear about the doctors who really care,” she told me, “the ones who tried really hard and then fall over and have an MI.” So when she glanced over at her unread journals and noticed a flyer seeking physicians for a concierge practice, something clicked. “The universe had answered my prayers for a long and prosperous career,” she said. She picked up her phone and made the call.

Funny thing about that.  The family doctors of my youth, from the GPs to the surgeons to the occasional pediatrician and psychiatrist, practiced what can be fairly called “concierge medicine.”  When you needed them, they were there.  They were also paid well enough to be at the top of the local wealth pyramid, not too different from the bank president or the children who inherited one of the lucrative local businesses (until they ran it into the ground in the third generation).  They were pillars of their local world, at times somewhat apart as befit their natural and earned authority, but nevertheless always an integral part of the community.  A surgeon was on my chemical worker father’s team in the scratch bowling league.  They were also sometime fishing partners.  This was not unusual then.  Oh, and those doctors, they all had long and prosperous careers lasting from the 1950s into the 1990s.

Final note: According to Dr. Rosenbaum, “Next time: Does concierge medicine spell a rebirth – or the death – of primary care.”  I’ll be on the lookout.  This should be good, sort of.

Notes

[1] I was very fortunate in my medical history but not all that unusual.  Until I needed a dermatologist/MOHS surgeon in my early 50’s because our sunscreen was Hawaiian Tropic that probably had an SPF of minus-500, I had never seen a specialist of any kind.  When I needed stitches or an x-ray (often enough to know the Emergency Department of the 1960s and 1970s very well) before going off to the university, the hospital called one of my two family doctors who then drove the half mile from their nearby houses to care for me, as they did for all their patients.

[2] Given that the only care many of our fellow Americans can get is in the Emergency Department of a hospital that is required by law to treat everyone who comes through the door, Emergency Medicine may be a legitimate core primary care specialty.  Every emergency room has its “frequent flyers,” most of whom are in desperate need of sustained primary care.

[3] Oddly, the thorough neoliberalization of the practice of medicine is rarely recognized by the many physicians of my acquaintance.  However, they have no difficulties seeing how the big health systems are squeezing them while at the same time making it difficult for them to treat their patients as their Hippocratic Oath requires.