One of the topics I feel most strongly about when it comes to healthcare issues we need to fix, is our broken primary care system. I’ve written about this issue before, and want to come back to it now—as the COVID pandemic appears to be subsiding. Before 2020, we were already facing a crisis of epic proportions. 80 percent of all primary care physicians were reporting feeling burned out, droves of older doctors were retiring, and critical shortages existed in most parts of the country. I am at a complete loss when I discharge patients from the hospital—who tell me they have no idea who their PCP is, because they keep seeing a different clinician every time—or that their long-time doctor has just left the practice. Stories that are becoming more frequent with each passing year.
Strong primary care is the absolute backbone of any healthcare system, and the USA is in a complete mess. COVID may have provided something of a temporary relief from packed waiting rooms, and the ability to do telemedicine may have suited some physicians—but it’s not necessarily something that is good for patients. With an aging population, we need GPs who know their patients and have an ongoing solid relationship. That’s become a rarity, not the norm.
So what’s the answer? Well, the first thing to say as someone originally from the United Kingdom—a country with a big emphasis on local primary care—is don’t look across the Atlantic for answers! Despite relatively high pay (minus the US debt load) and a traditional “gatekeeper” role, British GPs are probably among the most dissatisfied in the world (I have lots of medical school friends who are practicing there). This perspective has given me a good idea of what’s gone wrong, and I want to focus on 3 areas:
- Massive bureaucratic requirements. Modern day family practitioners are a far cry from the old bespectacled suited doctor who would enter your house with a briefcase, attend to your needs, and scribble a few lines on a piece of paper. Today’s protocols, medico-legal concerns, and overwhelming documentation requirements—have made the GP of 2021 something akin to a data-entry clerk. It’s a tragedy for well-educated, talented professionals to become robotic “click-bots” like this, who barely have time to look their patients in the eye.
- Huge patient panels. There’s simply no way that primary care doctors can have responsibility for panels of several thousand patients, and competently attend to their needs. What professional possibly could? In the US, this number of patients is needed to be financially viable, and in the UK, that’s what every doctor needs to oversee in order to provide enough care to their geographical area.
- Patient expectations and needs. One would be amiss not to mention this, because it’s very much part of what’s changed. Patients and families simply demand much more than they did in the 1970s. Treatments options have exponentially risen and there’s more to constantly learn. Add to this mix: more elderly and medically complex patients.
Whatever else may be thrown in to incentivize today’s PCPs: increasing pay to make it more comparable to specialists, reducing debt, or improving the work environment—doctors will not want to go into (or stay) in the specialty until the above 3 are addressed. We’ll continue the struggle to hire, and those in practice will constantly be on a merry go-round of jobs. In 2021, the attitude of young professionals is also different from the 1970s: the new generation expects to be happy at work, have a home life, and not come home every evening feeling exhausted.
When I was doing my residency training, I caught the tail end of when primary care was still an attractive option. Most primary care doctors who mentored me were still in their own private practices, they rounded in the hospital, and seemed to enjoy their work while feeling a sense of autonomy. It really does take a special person to do the job well and provide great care to the community. My goal for some time was to emulate them. But right now, I wouldn’t touch primary care with a barge pole. The thousands of fantastic clinicians out there right now doing the job day in and day out, I can only be in awe of. It’s an impossible thankless job. And I wish I didn’t think that.
Suneel Dhand is a physician, writer, and YouTuber. He is Founder at MedStoic Lifestyle Medicine and DocsDox . Follow him on YouTube and Instagram
You hit the nail on the head – too much paperwork/ computers for the insurance people, CYA stuff, lower pay, no respect from the public and administrators and patient expectations are very high – Dr. Google has not helped. I think the primary care doctor is gone forever, there is no money, glory or fun in the job anymore. The PA’s and NP’s can take my place.
Sad reality.
It is very hard to come down from a pedestal but it certainly has a leveling effect. Why do MD’s wear white coats and maintain a distant personal relationship with their patients? Why do they insist always in being called doctor and disparage anyone else that uses that title? Not to mention ‘allied health workers’ that are continually demeaned for what they know and do and thus keep their caste system in tact.
Reading in the NYT the other day where it was cited that surgeons have the highest percentage rate of income. Why?
It seems to me that when Medicare came into vogue and we no longer handed over our $10 or $15 for a doctor’s appointment and charts not filled with volumes of testing reports, medicine embraced the fee for service model. That certainly added to their income stream but downsides came with it as we are now seeing.
Money, management and medicine have helped to destroy a medical care system with lawyers doing their share.
Wish we knew how to fix it?