Vinod Kurup

Hospitalist/programmer in search of the meaning of life

Sep 9, 2006 - 4 minute read - Comments - informatics medicine

Is Primary Care Dying?

Dave referenced an interesting article in the NEJM titled “Primary Care – Will it Survive?" These two quotes summarize the problem:

A 2006 report from the Center for Studying Health System Change reveals that from 1995 to 2003, inflation-adjusted income decreased by 7.1 percent for all physicians and by 10.2 percent for primary care physicians.


It has been estimated that it would take 10.6 hours per working day to deliver all recommended care for patients with chronic conditions, plus 7.4 hours per day to provide evidence-based preventive care, to an average panel of 2500 patients (the mean U.S. panel size is 2300).

Compensation is down and responsibilities are up. I’ve been especially aware of this as more than a few of my colleagues have left, without being replaced. So not only do we have more to do per patient, we have more total patients per doc. This will worsen as the population ages. These conditions are leading to a decrease in the number of students and residents who choose primary care, which of course creates a vicious cycle.

primary care over time

One of the interesting solutions proposed in the article was a heavier use of web-based solutions:

A more thoughtful solution to physicians' time constraints requires a combination of team care and electronic encounters. Nonphysician team members working with Web- and e-mail- based patient portals can perform routine preventive care functions and manage less complex chronic care. However, forging cohesive and efficient teams is a challenge, and few payers adequately reimburse these services.

I’m interested in creating those types of solutions. The problem is that when you use these solutions and begin to speed up patient care, the temptation will be to increase the number of patients seen, rather than to spend more quality time with each patient. If you do that, you begin to break the doctor-patient relationship - a relationship that is more valuable than the purely technical aspects of care alone.

Comments from old site

In decline, yes

I'm not sure about dying. But conditions may have to get really bad, or more likely, a high-profile personage will have to die because of the lack of good primary care before things change.

A recent conversation with a colleague from residency, a general internist in private practice, revealed a high level of frustration with policy makers who are totally disconnected from front line realities. In large part I agree with him.

Policy makers are busy studying questions like this:

"Television Watching and Other Sedentary Behaviors in Relation to Risk of Obesity and Type 2 Diabetes Mellitus in Women" (JAMA. 2003;289:1785-1791)

in order to come to conclusions like this:

Obesity is an important problem, but please, do we need a study to prove that watching TV doesn't help you get thinner? Next will be a guideline that primary care docs quantify how many hours each patient watches T.V. .....

My friend detailed regulatory changes in nursing home care that make it harder for him to do the right thing for patients.

Perhaps another way that the internet can play a positive role in this mess is to channel such feedback to policy makers who truly are interested in change or to expose to the public eye frustrations voiced by docs in private.

Prem Thomas 2006-10-03 14:47:01

So true

Next will be a guideline that primary care docs quantify how many hours each patient watches T.V. .....

I laughed out loud when I read this. Because it's so true. Lately it seems that everyone has another 'pet' project that we need to implement. HIV screening for everyone - only takes a few minutes. Depression screening for everyone - just a few minutes. And it's hard to argue with it because they seem like worthwhile to do, yet it really squeezes the time that you have with the patient.

Vinod Kurup 2006-10-04 12:50:17

From a Patient's Perspective

As a patient with chronic depression, I find dealing with primary care physicians to be such a frustrating and humiliating experience, I stopped going. Every ailment I have presented to a primary care physician has been quickly dismissed as being "all in my head," with no real analysis of my symptoms. Even potentially serious conditions, such as 12 years of infertility or rectal bleeding, are dismissed as being pychiatric in nature. How a primary care physician can make a determination that my symptoms are baseless, without doing blood work or even a basic physical exam, is amazing to me. That's why I have totally given up going to the doctor all together.

Unregistered Visitor 2007-01-30 10:32:45