Thursday, October 1, 2009

Taking the Pulse of primary care medicine

Previous posts may have implied that restoring an adequate supply of U.S. primary care physicians is all about money - that is, less student loan debt and reducing the salary disparity between "front-line" clinicians and subspecialists. If only it were that simple! Alas, even if student loans were forgiven and salaries were doubled, it is unlikely that students would immediately flock to family medicine, pediatrics, and general internal medicine. The reason: time - or more precisely, a lack of it.

Paul Gross, MD, an academic family physician at Montefiore Medical Center in New York and editor of the online magazine Pulse: voices from the heart of medicine, recently wrote a poignant piece about the challenges of family doctoring in the context of 15-minute (or shorter) appointment slots. In "Late Again," Dr. Gross observes:

"The joy of primary care is also its curse. With each patient, I have to keep track of everything--the trivial and life-threatening, the physical and mental, the acute, the chronic and the preventive. And try as I might, I simply don't have enough time. ... My colleagues and I are often still seeing our morning patients at 1:00, when our afternoon session is supposed to begin. Lunch hour? Wouldn't it be nice. And I have it easy. One hears of offices scheduling patients every ten minutes--every ten minutes!--and doctors "seeing" fifty patients a day.

Doctors talk of running on a hamster wheel. Patients complain that their doctors seem distracted, don't take the time to listen, and run late--as I routinely do. Am I a bad doctor--disorganized and inefficient? Or maybe I'm doomed to fall short as I bump up against powerful economic forces--the 'do-more-with-less' pressures that make medical administrators everywhere create schedules like mine, designed to bring in enough money to keep health centers afloat but which end up hustling me and my patients along at an impossible pace. As a nation, we are now trying to fix our foundering healthcare system. Before we set new rules in place, shouldn't we first ask this basic question: how much time is actually required to see a patient?"

As all physicians know, time spent with patients doesn't include time spent documenting visits, reviewing test results, making referrals, filling out administrative paperwork, et cetera. A 2007 study in the Annals of Internal Medicine estimated that doctors in an academic geriatric practice who saw only 14 patients per day (most docs in private practice see 30 to 40) spent nearly 8 hours per week on these non-reimbursed tasks. This reality has led some solo family physicians to adopt a no-frills practice model that relies on few (or no) staff, leading to lower overhead costs and more time to see patients. Unfortunately, more time per patient means fewer patients per day, so such a model applied nationwide would require training even more family physicians, in addition to the ones we already don't have.

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