Is Primary Care Dying?

1. Is Primary Care Dying? Gregory Sheehy, M.D., Clinical Professor of Medicine Department of Medicine, Section of General Internal Medicine University of Wisconsin Medical School Madison, WI January 26, 2005

2. Objectives: • To evaluate the Cause(s) for declining interest in primary care. • I have not received any compensation for this talk.

3. I knew a doctor once who was honest, but gentle with his honesty, and was loving, but careful with his love, who was disciplined without being rigid, and right without the stain of arrogance, who was self-questioning without self-doubt, introspective and reflective and in the same moment, decisive, who was strong, hard, adamant, but all these things laced with tenderness and understanding, a doctor who worshipped his calling without worshipping himself, who was busy beyond belief, but who had time—time to smile, to chat, to touch the shoulder and take the hand, and who had time enough for Death as well as life.Now there was a professional.LaCombe MA. “On Professionalism.” Am J Med 1993;94:329

4. The good physician treats the disease. The great physician treats the patient.-Sir William Osler

5. American Medical News, September 20, 2004 Primary Care Physicians are caught in productivity squeeze. • 2003 was the 3rd consecutive year where increases in production outpaced increases in compensation per the Medical Group Management Association (MGMA). • The increase of 6.1% in median gross charges for Primary Care was matched with a 2.4% increase in compensation (specialists, on the other hand, had an increase of 4.4% in charges and an increase of 7.8% in compensation).

6. Pay across the country is generally based on productivity with formulas based on RVUs. How are groups dealing with this situation? • Reduce salaries of Primary Care Physicians. • Cut the value of RVUs. • Try to get physicians to work harder.

7. Hospital Inpatient E&M–Patient examples from CPT/AMA INITIAL HOSPITAL VISITS (99221-99233) 99221–Initial hospital care (typically 30 minutes) which requires documentation of : • detailed or comprehensive history • detailed or comprehensive examination • medical decision making that is straightforward or of low complexity • Initial hospital visit for a healthy 24-year-old male with an acute onset of low back pain following a lifting injury. • Initial hospital visit for a 69-year-old female with controlled hypertension, scheduled for surgery. • Hospital admission, examination and initiation of treatment program for a 67-year-old male with uncomplicated pneumonia who requires IV antibiotic therapy.

8. Mortgaging Our Future—The Cost of Medical Education Morrison, Gail. N Engl J Med 2005;352(2):117-119. Summary of the Past 20 Years (1984-2004) Medical School Cost Tuition and Fees Public Schools $ 3,877.00$16,153.00 (317% inc) Private Schools $12,973.00$32,588.00 (151% inc) If one adds $20-$25K in living expenses/books/eqmt, the cost of a medical education today (4 years of medical school) is about $140,000 for public and $225,000 for private schools.

9. Mortgaging Our Future-The Cost of Medical Education, cont’d Concerning Trends: • 60% of the medical students come from families in the top quintile of income. • A recent study confirms that the #1 reason that underrepresented students did not apply was because of cost. • Hispanics account for 12% of the population but only 3.5% of the physician work force. • 1 in 8 Americans is black, fewer than 1 in 20 physicians are black.

10. The Future of Primary Care Medicine Whitcomb ME & Cohen JJ. N Engl J Med 2004;351(7):710-712. Their thesis is that the fall off in Primary Care interest relates to the way students perceive the specialty…and that, paradoxically, the medical schools’ successful efforts to get students involved in primary care during their first two years of medical school has caused part of the decline in interest in primary care.

11. The Road Less Traveled—Attracting Students to Primary Care Fincher RE. N Engl J Med 2004;351(7):630-632. She cites five reasons for this fall off in students going into Primary Care: • Lower Remuneration than other fields in medicine • Educational Debt • Demands on practice • Demands for a better lifestyle outside of medicine • Frustration created by administrative work

12. Letters to the N Engl J Med re articles from Whitcomb and Cohen as well as Fincher, N Engl J Med 2005;352(1):93-95 Barry Saver, M.D.: “It seems unlikely that anything short of complete reform of the U.S. health care system will make primary care attractive to large numbers of medical students.”

13. Letters to the N Engl J Med re articles from Whitcomb and Cohen as well as Fincher, N Engl J Med 2005;352(1):93-95 Caroline Poplin, M.D., J.D.: “People do not go to school for decades at tremendous expense to work on a production line, and that is what primary care has become. Productivity—patients per hour, not improved health—has become critical, whether we work for ourselves or others.”

14. Letters to the N Engl J Med re articles from Whitcomb and Cohen as well as Fincher, N Engl J Med 2005;352(1):93-95 Terry Rustin, M.D.: “…family practice is no longer a viable specialty. The exponential growth of medical knowledge prevents any single physician from being adequately versed in all areas of medicine.”

15. American Journal of Public Health, 2003;93(4):635-641 On the issue of Preventive Care—The authors estimated physician time necessary to do all services recommended by the US Preventive Services Task Force (USPSTF). Assumption One: 2,500 patient panel Assumption Two: 43 hour clinic work week Conclusion: 7.4 hrs per day required to do preventive health work My conclusion: “The core question is who are we? Are we preventive health providers or are we internal medicine specialists?

16. Conclusions/Solutions: • Be patient…allow market forces to work. • Just say “no”…do not allow others to dictate what kind of specialty we are. • Do not give up skills • Increase availability • Reorganize clinic structure • Enforce the role of subspecialty consultation • Stay current • Be happy