The Demise of Primary Care

Sayed K. Ali, MD, and Ahmad Mudassar, MD

The art and practice of medicine was once challenging and thought-provoking. The ability to heal and improve quality of life was the soul of medicine. Unfortunately, with the age of electronic records, performance metrics, and pay-for-performance measures, this talent has gradually faded away. Added time constraints and the increasing need to see more patients in a day have made history and physicals obsolete.

A Case Study

Mrs Rodriguez, a 57-year-old Hispanic female, presents to see her primary care provider for her annual exam. She has a 30-minute appointment slot since she is not a new patient. She checks in punctually, but by the time she is transferred to the exam room, it is already 10 minutes into her appointment. The medical assistant, in addition to taking her vital signs, asks her an array of questions on her drinking and eating habits, exercise, smoking, advance directives, living arrangement, history of abuse, mode of travel, preferred language—and many other standard but monotonous questions. Mrs Rodriguez politely answers all the questions wondering what these questions have to do with her visit today.

Reconciliation of her current and over-the-counter medications takes an additional few minutes as our patient tries to recall the names and doses of her medications which she best remembers by shape and color. She thought of bringing them in this morning, but alas the bottles were too many to fit into her handbag.

As she tries to find a comfortable position on the cold pleather examining table, her primary provider walks in. He politely shakes her hand but then shifts his focus to his glowing computer screen, going over her vital signs, laboratory values, and medications. He too does not spare her and he continues to question her on her vaccinations, colonoscopy, mammogram, Pap smear, weight, last eye exam, and other measures that will determine his productivity and quarterly performance. By the time he is done, Mrs Rodriguez’s appointment time has almost come to its end. The provider bids her farewell, hurriedly heading to his next patient, and advises her to return in 6 to 12 months.

As she leaves her provider’s office, she realizes that she did not get a chance to discuss her chief complaint; her sub-acute back pain that has been bothering her since her grandson moved in with her. Feeling dissatisfied with her overall care, she wonders if she should change her primary care provider. This scenario, even though a little embellished, is unfortunately becoming a reality.

Today’s Reality

Many patients, in addition to feeling rushed, also feel an absence of empathy from their providers. This leads to a lack of trust and a wavering relationship between the patients and the provider. Providers on the other hand, feel that there are too many reminders and preventative cues that have to be addressed during the visit to avoid scrutiny. Electronic documentation takes precedence over frank and meaningful conversations with patients.

The primary care provider has over time, evolved into a glorified desk clerk—an expert in asking questions, checking boxes, and focusing on electronic documentation. The electronic system has forced many to ensure that reminders and such measures are routinely addressed during patient appointment. These measures are in turn used to evaluate the provider’s productivity and performance. The more productive one is, the more lucrative the monetary award. Paradoxically, such measures are frequently changings (e.g., new cholesterol and hypertension guidelines) and hence not utterly evidence-based or up-to-date, which results in unnecessary appointments, tests, and procedures.

The concept of doing no harm appears greyer than ever. Are we indirectly harming patients using tools that measure provider performance rather than patient outcome and satisfaction? Has primary care medicine become a barrage of non-evidence-based questions that determine one’s productivity?

Physician Burnout

The lack of career satisfaction and the demand to increase productivity, with no substantial raise in wages, has driven many away from primary care. Many of my fellow physician colleagues feel burned out, with the constant monotonous practices that hinder critical thinking and medical investigation. With the endless demand to increase productivity, it’s more convenient to simply consult the subspecialist. However, this does not ease the burden of care; the primary care provider is still held responsible for the overall outcome.

Furthermore, in the academic settings, medicine residents don’t feel enthusiastic about choosing primary care as a profession. They are fully exposed to the monotony and dissatisfaction of primary care during their continuity clinic. Regrettably, the challenge of taking care of patients has been replaced by tedium and ennui.

If we are to truly bring back the concept of primary care and to help rekindle fruitful relationships with our patients, it is imperative we re-evaluate our way of practicing medicine. It is crucial to fully interrogate the standards used to evaluate primary care. Medical lobby groups and organizations with their ever-increasing memberships fees should play a more vibrant role to help advocate for the ultimate change of primary care and the survival of the primary care provider. It’s still not too late to revive primary care medicine.