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1. Well at least you agree that paying PCP’s more to spend longer amounts of time with patients face-to-face is worthwhile. That is a place to start. Correct that business doubles for the two physicians in the same town, but in reality if patients are established with a PCP, have trust and rapport, then they tend not to over utilize health resources. They are less likely to be hospitalized and more compliant according to most studies as well. Again, it is as good a place to start as any. Thanks for reading.

2. Agreed. If it were simple, we would have fixed the healthcare system already. And, yes, primary care docs did not step up to the plate back when the RVU system was being updated and we have paid for that dearly.

3. I cannot answer if the area was served “adequately” but it was certainly closer to “adequate” than the situation is now. When I first came back to practice in my hometown there were 25 pediatricians and now we are down to 15 FTE pediatricians to serve a population of 250,000 in this county and surrounding areas. If I could find a pediatric NP willing to come to this area, it would be great!.

   The studies do show those raised in rural areas tend to settle back in rural areas so that is an effective way of trying to recruit applicants but it is not nearly enough as you said.

   Telemedicine is absolutely a way to help reach rural patients. This is one positive side to technology! We do not have pediatric beds at our local facility and all must travel to Tacoma or Seattle if admission is necessary. Most significant traumas are often transported by helicopter.

   It IS an uphill battle , except after MACRA goes in effect the grade of steepness will increase significantly, making our job more difficult than it already is.

4. “10% of physicians practice in underserved areas despite the fact 25% of the U.S. population live in those areas.”

   That may not be solved with more docs. Rural poor areas with little good insurance are not places docs want to practice. I read a report that most doc practice close to where they were trained – hence over supply there/under supply elsewhere. Find out where their wives want to live and you’ll know where they go.

   Giving docs more money so they can see less patients is not going to solve this either – although I agree with more money for PCPs and longer patient/doc face-to-face. If there is one doc in a community and another sets up practice the business is not cut in half, it’s doubled – not good for controlling costs.

5. Niran,

   Thanks again for your response. I suspect at least part of the problem on the payer side is that Medicare’s Resource Based Relative Value System Update Committee (RUC) is dominated by specialists and they have the political power to protect their reimbursement rates at the expense of primary care. In theory, commercial payers have more room and opportunity to innovate as they move toward more value based payment approaches as opposed to pure fee for service. Presumably, if it were an easy problem to solve, we would have solved it a long time ago.

6. Have the rural areas you describe EVER been adequately served by MD’s as opposed to NP’s at least since 1965 when Medicare and Medicaid became law? Doctors, their spouses and families, at least for the most part, prefer to live in an urban or suburban environment. They like being reasonably near a big airport, concert venues, sports arenas, museums, good restaurants, shopping, etc.

   There may be students coming out of medical school who grew up in a rural area, like the lifestyle, and want to practice medicine there but probably not nearly enough to serve the rural population which is itself shrinking in many areas as the agriculture industry consolidates.

   Perhaps advances in telemedicine can be at least somewhat helpful to rural patients. Mobile clinics might be another possibility. Critical access hospitals are harder and harder to sustain as occupancy rates shrink so more patients may have to be transported by helicopter to a more distant facility. Even if doctors can make significantly more money in a rural area than in a big city, it’s an uphill battle and the secular trend is probably negative.

7. I figured this would come up when I wrote this piece. I think the shortage depends on where you live. 10% of physicians practice in underserved areas despite the fact 25% of the U.S. population live in those areas.

   Today, I felt more like a family doc than pediatrician. I saw 15 patients, and 4 were adults ranging from ages 25-49. All have private insurance and excellent jobs. They cannot find any local MD’s taking new patients. I have provided 6 physicians names to one guy and all are retiring or have closed panels. When adults are seeking out a board certified pediatrician for primary care, there is either a shortage or she is single. I am not single 🙂

   Personally and professionally, I am seeing effects of the shortage before my very eyes in my hometown. It might not be everywhere in this country, but there are pockets of trouble looming up ahead. New York City is unlikely to see massive shortages any time soon, but what if you live somewhere smaller and more isolated. Don’t those individuals deserve high quality health care? Access is a large part of that.

8. Barry, I suspect you and I see eye to eye on many things. I agree with you that different physicians are motivated by different things and specialists tend to have more intermittent relationships with patients. However, those of us who went into primary care tend to thrive on these long-term relationships and will miss that part of medicine.

   Your desire to print out your lab results and other records has many potential solutions. First, I photocopy any labs a patient would like and hand them directly to the patient. Second, is to develop a device where you could store or scan your own records and then you have access anytime you want. Third, I now have patients take pictures of growth charts, immunization records, etc… on their phone which works great. We just did it last week with an xray on a fracture I sent to the specialist! He loved it when the mom whipped out her phone and had two films stored for him to review. Fourth, you could have this whole portal deal which in my mind is the least efficient method I can imagine, but whatever floats your boat. There are so many ways to skin a cat… why can we not utilize whichever one is effective, affordable and efficient at the same time?

   I love that you notices primary care accounts for 6% of costs. We do not break the bank in any way, shape or form, but slashing reimbursement is often the answer for these health care executives you mentioned.

   The ideal answer is as you said, “more money will allow primary care doctors to see fewer patients per day and spend an adequate amount of time with each one, refer fewer patients to specialists and keep more of them out of the hospital.” You are absolutely right on target. It is a better system for patients, physicians, and payers all around. Why can they not see it? Or if they do, why are they not shaping reform around this very important premise?

9. “…in light of the looming physician shortage.”

   Seems all I can find is the AAMC making this claim. Self serving?

10. Sounds reasonable to me.

11. I have worked with both PAs and NPs and respect their appropriate use. As with MDs there are good ones and bad ones. While I don’t have any problems with them being used collaboratively, I do have a big problem with NPs being totally independent. For one, you are correct, medicine has more chance of becoming “cookbook”, although I think it’s headed that way anyway. Secondly, what’s the use of someone going through all the years of med school and residency, plus MoC and taking tests every ten years, when one could get NP certified for much less time and money? Is that what we really want, less educated practitioners?
    I am concerned that with the changes in the VA and the trend toward states granting independent practice for the NPs that insurance companies and even the government will question the value of well-trained Primary Care doctors, and will tend to promote those who could be manipulated into purely protocol based practice (such as NPs).
    Again, let me emphasize, I feel that NPs can make a good contribution to our health system if used appropriately, but are not a complete substitute for physicians.
    As far as nurses used for triage and basic questions, I think that is appropriate to help steer patients toward the appropriate care, or to answer basic health questions.
    While some may disagree, I believe there is a major shortage of physicians on the horizon, especially Primary Care, and especially in rural and underserved areas. Not only do we need to make sure we allocate manpower the best we can, we also need to make sure those practitioners have the time to devote their efforts to treating patients, not EMRs.

12. Thanks Perry for your insight and perspective. The blog post you linked to is very interesting as well. I’m curious about what you and your colleagues think about the growth in the number of NP’s, their willingness, through training, to follow rules and protocols and the increasing political pressure in many states to allow them to practice at the top of their license without direct physician supervision. Nurse hotlines operated by health insurance companies are also increasingly prevalent. Is all of this good, bad or indifferent as far as you can tell and do you see it as an attempt to de-skill primary care by converting more of it to algorithms and “cookbook medicine?”

13. Niran,

    Thanks for your response. I understand everything you said about the personal rewards from primary care, including pediatrics. There’s lots of variety in terms of the issues that you have to deal as well as the opportunity to build personal relationships and make a positive difference in individual lives which is very satisfying. I get all that.

    However, with all due respect, I think different people have different personalities and different skill sets. They find personal satisfaction in lots of different ways. In medicine, I never met any of the radiologists that read my images over the years but I’ll bet they find it satisfying when they identify malignancies at an early stage when they can still be successfully treated. The same goes for pathologists. I owe a deep debt of gratitude to the cardiothoracic surgeon who performed my CABG in 1999 though I’ve had no contact with him since then. I’ve gone to dermatologists who had the personality of a wet dish rag but they were really good at dermatology and I appreciated their talent and their care. Positive personal chemistry is both important and helpful for a good long term doctor-patient relationship in primary care. It’s not nearly so important for surgeons and other specialists that the patient may only see once or twice or for a brief period.

    As for electronic records, I appreciate the ability to print out my test results and bring them to other doctors and hospitals as needed. I like the idea of maximizing the probability of avoiding duplicate testing and adverse drug interactions that could occur if multiple doctors treating me aren’t fully aware of what each one did or is doing. My ideal solution for the problems that afflict primary care, including the increasing need to deal with electronic records, is to pay them more so they can afford to hire some help to absorb most of that administrative burden and so they don’t have to see as quite as many patients per day to make a good living. Maybe that would induce more medical students to choose primary care who currently choose to become specialists mainly for financial reasons especially if they have a lot of student loan debt to pay off.

    I’ve read that primary care only accounts for about 6% of healthcare costs in the U.S. Any health insurance executive will tell you that primary care doesn’t break the bank like hospital based care can. To the extent that more money will allow primary care doctors to see fewer patients per day and spend an adequate amount of time with each one, refer fewer patients to specialists and keep more of them out of the hospital, we will all be net better off in my opinion. Hospitals and specialists would lose some business but that’s a good thing.

14. Barry,
    I am not Japanese and have never been involved with their health care system.
    As for #2, you are making numerous assumptions about your hospitalized care. There will always be ‘handover’ mistakes or issues that get lost in translation while going from provider to provider, until something goes wrong. Only then, will you become all too aware of the pitfalls of not knowing your physician intimately.

    Mayo Clinic may make fewer mistakes by looking over each others shoulders, however this autonomous lone ranger has been voted best physician in the county for the past seven years! That includes all those hospital physicians you sound fond of. I doubt the Mayo Clinic physicians provide better quality or relationships with patients than my father and I have for three generations, but it might be equivalent.

    #3, Absolutely and unequivocally, our productivity is significantly reduced by electronic systems as they are now. For what purpose are we required to do this?

    #4 You are absolutely correct everything in life involves trade-offs. I control my schedule and how long I spend with my patients. I charge for non-covered services, which is a significant portion of administrative burden. I am lucky indeed.

    I am on the admissions committee of my medical school. These young people are dedicated, brilliant, and empathetic souls; many want to return to their own home states (all of which are terribly underserved) and practice medicine. They have the same dream I did when I embarked on this career. It is important this opportunity is available to them when they finish their educations.

    The large point is this: Those able to remain detached from their patients are more likely to suffer from burnout because they never get to see the fruits of their labor. They may have “work-life balance” (this is debatable), however they are dying inside because they went into this profession to do what I do every day: form meaningful relationships.

    A major reason I do not yet suffer from burnout I believe is that when I come to work, I get to see my friends, parents in my community, children who go to school with my own children, and families I grew up with myself. When I volunteer in my children’s classroom, I watch children who I resuscitated at birth win the reading competitions, the 7 year old who broke his arm play another day on the field, the one recovered from meningitis ace his math test. Seeing the positive differences I have made right before my eyes prevents burnout for me. Those Relationships are vital.

    These connections are disappearing from the practice of medicine altogether and It is a terrible shame. This is the “art” as Perry so eloquently noted below. Thank you for reading and sharing your perspective.

15. Barry,
    You might find this essay interesting:

    http://www.kevinmd.com/blog/2016/10/art-medicine-dead.html

16. Barry,

    I think there is a distinct difference in expectations of the current generation of practitioners and the newer grads/applicants. When I and my colleagues attended med school and did residency, we were training for assessing, diagnosing and treating individual patients. We had some autonomy, although at that time HMOs were the rage and managed care was beginning to creep into the physician-patient relationship. Over the course of the last 5-10 years, being a physician has evolved into becoming a data-entry clerk, with more stringent requirements and strictures that take away from the physician-patient encounter, and in my opinion actually contributes to errors and misdiagnoses, simply because there is little time to spend actually assessing the patient.
    Newer recruits are of a generation that thrives on technology and in many cases becomes a substitute for personal interactions (which scares me). They are also as you say much more interested in lifestyle and balance, and are willing to give up autonomy and freedom to work under someone else, with someone else’s rules. While I understand this, there is something to be said for the individualist practitioners of the old days, many of whom helped forge new treatments and diagnostics for the medical field. I fear this will be lost in the new world order.
    Interestingly, we visited with some old friends from out-of-town this past week. They informed us that their grandson who was pre-med was being “recruited” by several med schools. This was unheard of when I applied over 30 years ago.

17. As a patient, I wonder about a few things.

    First, as I understand it, a typical patient encounter with a primary care doctor in Japan lasts about three to five minutes and they seem to be OK with that even if they have to wait several hours in the waiting room to see one of the more popular doctors. How do patient expectations get set in different cultures? Some primary care encounters are simple and can be easily addressed in five minutes or less. Others are more complicated, especially if they involve elderly patients with multiple co-morbidities.

    Second, if I need inpatient hospital care, there are likely to be multiple doctors and nurses involved in my care. Electronic record systems give me more confidence that they all know what the others did and are doing and they all know what drugs I take without having to rely on often illegible paper charts. Moreover, in a collegial environment and culture like the one practiced by the Mayo Clinic, mistakes are more likely to be caught before they can cause harm when doctors are looking over each other’s shoulder as compared to when they’re all freedom loving, autonomous lone rangers. No?

    Third, I can empathize with the attitude among primary care doctors, especially as it relates to electronic records. They see a much wider variety of issues and complaints as compared to specialists and they generate much lower practice revenue so it becomes harder for them to make a living if electronic records reduce their productivity as measured by the number of patients they can see each day. The problem must be even worse in rural areas where it can be hard to attract doctors and their families to the rural lifestyle and environment even under the best of conditions.

    Finally, if there is so much burnout among doctors, why are there lots of people still applying to medical school even though they presumably have some inkling about how the physician world works today as compared to back in the pre-electronic record days? A lot of the younger people are attracted to hospitals and larger group practices because they can more easily work regular hours, achieve better work-life balance and don’t need to deal with the hassles of running a small business. Everything in life involves tradeoffs.

18. All is not lost. Our patients and ourselves hold the power to change this system and its disastrous misdirection. The time is coming– my hope is we recognize the moment, step up, and take control of what ails us. Thank you for reading and commenting. Wow! 5 board certs; I am impressed.

19. Dear Niran. I hear and share your plaint. All we can hope is that all is not lost: http://www.necn.com/on-air/as-seen-on/WEB-the-take-a_NECN-398292291.html
    Nortin Hadler