The Incredible Shrinking PCP: Growing Pains in Primary Care

Unless changes are made, and soon, the looming shortage of primary care physicians we've been hearing about for so long will become a reality as older doctors retire and new medical school graduates opt to enter subspecialty practices that promise more money, shorter hours, and fewer headaches. A substantial decline in the numbers of primary care physicians will produce effects that ripple throughout the healthcare system--those physicians who do elect to practice primary care medicine will be forced to see more patients than ever before, yet patients will find it increasingly difficult to obtain treatment.

What can be done to avert this crisis? Some in the industry have proposed substantive changes to the primary care reimbursement model that would place less emphasis on procedures performed and instead base compensation in part on time spent with patients. Advances in healthcare information technology may also help alleviate some of the financial pressures on harried primary care practices by increasing efficiency and streamlining workflow. The number of US graduates entering family practice residencies dropped by 50% between 1997 and 2005. Half of internal medicine residents chose to go into primary care in 1998; nowadays nearly 80% of internal medicine residents choose to become subspecialists or hospitalists.

The American Academy of Family Physicians documents a similar crisis in family medicine. In an effort to alleviate some of the financial pressures associated with primary care practice (higher overhead costs and lower levels of compensation on average compared to other specialties), some primary care physicians are converting to a "high-tech, low-overhead" practice model, a trend that, if it catches on, could help off set the decline in primary care medicine, according to a Wall Street Journal article cited by iHealthBeat. Such a move would also theoretically enable PCPs to exercise greater control over their time; instead of rushing through visits or overbooking in an attempt to maximize the number of patient visits, PCPs could schedule fewer appointments and spend more time with each patient.

"PCPs are really getting the squeeze, which means they either have to see more patients, schedule shorter visits, or work longer hours," says MDNG editorial board member Gary Stephen Nace, MD, Associate Professor of Clinical Medicine at the University of Illinois College of Medicine. "In terms of lifestyle, you really don't have nearly as much control as you would in a subspecialty, particularly something that's more associated with shifts, like anesthesia or radiology."

On average, primary care physicians see approximately 15-20 patients per day in an eight-hour day. Add to that the 30 minutes spent on paperwork, charting, and handling referrals per individual, and you end up with rushed patient encounters.

Flying Solo

Increased access to information technology is enabling patients to take a more active role in their healthcare and more effectively manage their health. More informed patients tend to adhere better to treatment plans and require fewer explanations from their physicians regarding their care. This can be especially beneficial to the solo practitioner, whose already limited time is spread even thinner by rising demands.

Healthcare technology (in the form of the Internet) not only can give patients the freedom to learn all they can about their conditions and treatment, when applied to practice in the form of telemedicine (visit mdng.com for more on this subject from the American Telemedicine Association), it can also alleviate the need for an in-person visit in some cases, relieving some of the stress on the physician's schedule. Healthcare technology can also be used to streamline medical practice, making it more efficient.

One example of tech's contribution to this process: practice management software programs for physicians. "Traditionally, physicians are not doing very well when it comes to applying modern business solutions, and certainly not in more innovative practice management concepts, so I think it's going to take the rare entrepreneurial physician to implement that successfully," says Dr. Nace, about PCPs' implementation of technology. John Wasson, MD, Professor of Medicine and Community and Family Medicine at Dartmouth Medical School, spoke to MDNG about "How's Your Health?" (HYH) an online tool for healthcare improvement intended for use in the primary care setting and funded by The Commonwealth Fund and other organizations, is a free online survey that "lets people assess their health and receive information tailored to their particular needs." Used by thousands of patients, the survey, which takes about 10 minutes to complete, is designed to better engage physicians and patients through a series of multiple-choice questions about symptoms, medications, diet, emotional issues, and other topics. "HYH is designed as a non-commercial service," says Dr. Wasson. "It has organically grown from more than 25 years of research and development," he says. "For these reasons, it really works well. As Don Berwick, MD, of the Institute for Health Care Improvement said, "[HYH] is a national resource."

Wasson mentioned in a recent report by the Institute for Healthcare Improvement (IHI) that he "realized that physicians and their patients just weren't on the same page." And as technology advanced, physicians had even less time to devote to quality patient care. "Healthcare produces jargon," says Dr. Wasson. "The term patient-centered care seems to have originated as a reaction to paternalistic "doctor-centered" health services. Collaborative care [self-management] results when doctors and members of the healthcare team actively engage patients in evidence-based decision-making and management based on what matters to the patients. Patients should become better "self-care managers" as a result of collaborative care," taking the burden off PCPs. "Collaborative care is associated with improved patient outcomes."

On October 3, 2006, the Centers for Disease Control (CDC) and the National Business Coalition on Health (NBCH) convened an expert panel to discuss HYH and other health risk assessments (HRAs). The final report is pending, but it was recommended that the content for these assessments address "what is the matter" (eg, bioclinical information) and "what matters" (eg, the functional and psychological behavior orientation that leads to behavior change). HYH is clearly linked to well-accepted, noncommercial HRAs. "[Solo docs] who use HYH checklists find that it greatly augments their ability to be on the same page with their patients," says Dr. Wasson.

"The term patient-centered care seems to have originated as a reaction to paternalistic "doctor-centered" health services. Collaborative care [selfmanagement] results when doctors and members of the healthcare team actively engage patients in evidence-based decision making and management based on what matters to the patients."

Dr. Wasson lists the following steps physicians should take in order to most effectively access/navigate the HYH survey online:

• Go to the "For Businesses/Physicians" section to review all components of HYH and read strategies and approaches adopted by other physicians who have used this resource.
• Ask all members of the staff to complete HYH once truthfully, and then a second time as a "sick patient." In this way, they will more completely see how HYH customizes inquiry and information.
• Discuss how the office would fit HYH into everyday work. As pointed out in "For Businesses/Physicians," an office usually staggers implementation in some way until everyone is comfortable with their role and what to do with HYH results.
• The physician orders HYH and considers also having the information feed into a Docsite registry so that the office can generate a list of patients by categories such as confi dence and pain.
• The physician customizes the website and sets up a new e-mail dropbox into which the patient e-mail will be received.
• The physician tests the system as though he or she were a patient.

Medical blogs also provide a helpful forum for physicians to exchange information and gain insight on working with their patients, courtesy of the Internet. Robert M. Centor, MD, Professor and Director, Division of General Internal Medicine at Huntsville Regional Medical Campus in Birmingham, AL, started his own medical blog in May 2002, called "DB's Med Rants." He told MDNG that about four or five months before starting DB's Med Rants (the "DB" stands for "Dr. Bob's") he stumbled upon related blogger sites. "I found Medpundit and said "that's pretty cool, and I think I could blog about that, because I know medicine. I decided to start a medical blog because there were only two or three at the time. I started Med Rants, and over the first couple years, I was trying to find my voice, like anywriter."

Since its inception, Dr. Centor's blog has had more than one million visits, with approximately 10,000 hits per week. Clearly, blogging could ease some of the burden on solo docs, who feel not only strained for time, but pressured to be "in the know." They are "trying to harness technology to make family practices more manageable and profitable," according to the WSJ article cited in the iHealthBeat piece mentioned previously. At the same time, trying to sign up new patients while retaining current ones and managing costs can prove difficult without the cushion of a larger practice environment.

Playing Favorites

Increased patient loads and the lack of control over scheduling are often cited among the chief reasons that students select specialty practice over primary care medicine. "PCPs are the first point of contact, so it's really not surprising that folks are migrating away from primary care,” says Dr. Nace. "We see it in internal medicine all the time in our training programs." The American College of Physicians (ACP) claims that internal medicine physicians are still trying to figure out how to reverse the trend of students electing to enter subspecialty practice instead of primary care medicine. The decrease in PCPs' salaries over the past eight years is certainly another contributing factor in this shift.

The "high-tech, low overhead" model of solo practice--often referred to as a "micropractice"--is a developing trend that could help partially off set the decline in primary care. New technologies are making it easier to efficiently run a profi table solo practice, which may make the prospect of doing so more appealing to students who are attracted to the freedom of solo practice but not to the difficulties of doing so as a PCP. That being said, a survey conducted by The Commonwealth Fund (CWF) of 1,837 physicians across the US found that, despite the advantages greater use of health IT could provide to solo practitioners, physicians who practice in large medical groups are more likely to adopt and use IT than solo practitioners.

The survey also found that only one-quarter of solo physicians practice in a high-tech offi ce where technology is used routinely to improve operational effi ciency and clinical care. Among the 13% of solo practice physicians polled in the CWF survey was Dr. Greg Hinson, a MA-based family physician who once relied on handwritten notes and has since moved to practice management software programs to accommodate his patients' needs. He told Health Data Management in November 2005 that when researching EMR (electronic medical record) companies, he found that the market was less than friendly to small practices.

When he described his small staff to prospective vendors, they "would stop Hinson midsentence and say, "You can't afford us." After a year of doing his homework, he settled on eClinicalWorks' EMR, which, according to Dr. Hinson, "provides everything from health maintenance alerts to pediatric features like growth charts."

A May 2006 article in USA Today profiled a like-minded solo physician, Dr. L. Gordon Moore, who runs his office with the aid of one nurse and a computer loaded with state-of-the-art practice management software. His two-room "micropractice" based in Rochester, NY seeks to increase quality of care and time spent with patients (look for our article on micropractices in the August issue). He attributes part of his efficiency to TransforMED, a "not-forprofit practice redesign initiative of the American Academy of Family Physicians (AAFP) focused on studying and implementing transformed models of high-performance practices that meet the needs of both patients and practices."

In a nutshell, the initiative helped him streamline his workflow management with the aid of technology. Dr. Centor supports the use of Internet-based programs to more efficiently manage his practice. "I use UpToDate all the time if I'm a bit confused about a medical problem and need to get some information," he says. "It's the easiest thing, and it's great because it means that physicians don't have to go to a library. It's a lot easier to search things online."

Easy access to the Internet and the vast and increasing amount of information, Web-based software applications, and other online resources have been immensely beneficial to physicians, especially to those in solo practice. Whether improved information technology and other tools can help stem the decline in the numbers of PCPs by mitigating some of the less attractive features of primary care medicine remains to be seen.

Special Treatment

Perhaps the decline of primary care medicine can be addressed in part through better terminology and semantics? Which leads to the next question: Are PCPs actually specialists, or "jacks of all trades" The New England Journal of Medicine touched on this debate, citing PCPs' ability to function as managers, educators, and counselors as one reason why they should be more appropriately labeled primary care specialists.

When we examine the differences between primary care and specialty practice, career satisfaction certainly becomes a factor. In fact, the Journal of the American Medical Association (JAMA) claims overall physician satisfaction levels between 1997 and 2001 did not change dramatically. However, "declining income, threats to physicians' ability to manage their day-to-day patient interactions and their time, and [obstacles] to their ability to provide high-quality care," are mostly associated with decreases in overall job satisfaction.

A Community Tracking Study (CTS) Physician Survey was conducted in which physicians indicated how changes in their practice environments affect their general career satisfaction. "The strongest and most consistent predictors of change in satisfaction were changes in measures of clinical autonomy, including increases in hours worked and physicians' ability to obtain services for their patients." Changes in exposure to managed care were loosely related to changes in satisfaction. The study suggests that changes in physician career satisfaction may be influenced by three general factors: changes in the physician's practice environment (eg, solo practice vs. large practice), including the income derived from practice and hours worked, changes in physicians" perceptions of their ability to provide high-quality care to their patients, and changes in the economy.

When it comes to career satisfaction, physicians' main concern frequently seems to be over one fairly obvious issue: reimbursement. "Our reimbursement system is as irrational as a reimbursement system can be," says Centor, about primary care. "What it means is we see patients faster than we should. You really should never feel like you have to rush a patient visit. Patients should get the right amount of time. We don't attend all the issues; we cannot attend all the prevention because we're not getting paid for it. But the incentives are much greater for doing than for thinking."

Would a reimbursement model that focuses more on the "specialized" aspects of primary care--diagnostic acumen, continuity of care, etc--and more accurately takes into account the increased time primary care physicians must spend with patients be a fairer system, and thus improve the reimbursement climate for PCPs vis a vie their colleagues in specialty practice? Dr. Nace agrees that PCPs are poorly reimbursed relative to the time they must devote to patients, as compared to reimbursement for performing procedures. "And so the [PCPs] are really underreimbursed," he says. This is exacerbated by the fact that "primary care practices are also traditionally expensive, with overhead expenses of 50-60%."

The average income of specialists has remained about the same, according to a series of surveys conducted by the Center for Studying Health System Change (HSC). The HSC surveys also reported that the incomes of primary care physicians have remained about one-third less than those of most specialist physicians. "The tendency is clearly toward sub-specialization," says Nace.

Whither Primary Care?

Is there light at the end of the tunnel? Perhaps improvements in technology coupled with a seriously revamped reimbursement model will help stanch the bleeding in primary care and avert the shortage in family medicine, general internal medicine, and other areas of primary care practice that have long been predicted. It's probably still too early to tell what the final outcome will be, but most every expert we spoke with agrees that something must be done, and soon. And what about the solo practitioner? Will this type of practice, traditionally associated with primary care, flourish in the face of advances in technology?

Dr. Centor actually sees a movement away from solo practice, down the road. "Solo practice will continue to decrease in our society, for different reasons," he says. "If you're a solo doc in a small town, you're always the doctor--every hour of the day. And a lot of people don't want to do that. You want people to cover you at night. You want to be able to take vacations. And it's just a different expectation. There will be less and less docs in solo practice" over time. And so evolution continues its steady march.

Oncologists Also Falling Short: Patient Demands, Diagnoses Increase

A March 2007 report by Newsweek stated that during the next decade, it will become increasingly more difficult for patients to find new oncologists. This gradual decline may be attributed to an explosion in the number of cancer patients, creating an increased demand on the already limited supply of oncologists. The main reason for this is the baby boomer generation. As this group passes age 65 years--the age at which cancer rates rise significantly--oncologists may be slow to keep up with the demand.

During the next 10 years, it's predicted there will be a 48% climb in cancer incidence and an 81% hike in cancer survivors, making the ability to schedule appointments with an oncologist. The anticipated shortage is due not only to rising demand, but also to the limited rate at which new oncologists are entering the field (approximately 10,400 medical oncologists are currently employed in the US, with only 500 new physicians entering the field each year). Adding to the impending shortage is the fact that nearly half of currently practicing oncologists are nearing retirement themselves.