Yes Cassie, there is a future in Primary Care

My daughter recently introduced me to a friend of hers via email. She is a newly minted fourth-year medical student who asked me the following question:

"I would love to hear your thoughts about the future of primary care and what it is like to work as a family medicine doctor in Louisville."

To start, I'd encourage you to read this recently published New York Times review of the state of primary care.  If you began in practice today you would quickly find yourself with more patients than you can adequately care for having just left residency and not expecting to see 25-30 patients daily. In Louisville, you will probably be employed by one of three healthcare systems. All of them have compensation based on patient volume and RVUs--I hope someone has showed you what RVUs are but I bet they haven't. Relative Value Units are supposed to measure the "time, skill, training and intensity"[1] of patient care and compensate accordingly. Unfortunately they are heavily skewed toward proceduralists. As Dr. John Mandrola,

Dr John Mandrola

a Louisville interventional cardiologist, observes in his excellent post Thirty Dollars...Really?, a doctor is paid a lot more to do a coronary catheterization than to talk about the causes behind coronary artery disease. To understand a little more why the RVU is skewed that way, here is an excellent post on the Kevin MD blog that summarizes it nicely: The Relative Value of How Physicians are Paid Needs to Change. So in today's environment you need to see more patients than you are comfortable with, spend less time than you deem adequate with them which will promote pill-pushing over explanations. This will mean your risk of burnout will be significant. It is estimated that 43% of Family Practice physicians are burnt out according to a Medscape survey done in 2013.[2]

There is some good news. Value-based care, which bases compensation on how well you take care of patients rather than the number of patients that you see, is coming. In our corporation, systems are being put in place that will help primary care doctors take quality care of their patients and compensate those that do it well better than the ones that don't. Of course how one is measured is controversial as evidenced by this NEJM article from November: Grading a Physician's Value. And data can't be gathered without an integrated EHR (Electronic Health Record) and those are far from prime time. Being a digital native,  you've likely already noticed that EHR software on your rotations is not up to the gaming software standards you are used to.

Social Media, regardless of what city you ultimately practice in, will be the best means of keeping up with the ever-changing landscape of medical advances, political hot potatoes and healthcare tech so if are not following healthcare thought leaders already on Twitter I'd advise you to start that today. Begin with Primary Care Progress (@PCProgress), Berci Mesko (@Berci),

Mike Sevilla (@DrMikeSevilla), John Mandrola (@drjohnmd), Kevin Pho (kevinmd), the Society for Participatory Medicine (@s4pm) and me (@docnieder), of course. If you haven't found ZDoggMD,

that's another must.

Primary Care is alive and, if not well, at least no sicker than the rest of healthcare in the world but I see better things on the horizon. If I were fresh out of residency today I would get my feet wet as an employed physician for a couple of years, making sure your non-compete clause does not include going into private practice but only prevents you from moving to a different healthcare system across the street. Then I'd look long and hard at the DPC movement (Direct Patient Care) and make that my goal. Taking care of patients in an atmosphere that values the doctor-patient relationship above all other business needs is what we go into medicine to do. Physicians in DPC are happier and so are their patients. While it remains a patient care area where it is difficult for lower income patients to access, this may change as this successful way of caring for patients brings down costs and increases quality. I believe that government entities will find ways of incorporating this model into their systems. The  DPC model can be affordable for people who can't afford health insurance but still make a modest living, giving them an option for excellent healthcare at low costs. For now, a physician can use the time generated by working in an upbeat and efficient model to volunteer at community health clinics like the Family Community Clinic

offered by St. Joe's on East Washington St. in Louisville.

So, yes Cassie, there is a future in Primary Care. It is an uphill battle that we need more young, dedicated and digitally savvy doctors to join. The future is exciting. The present is, well, we have a lot of work to do but our patients make it worthwhile. 


1. RVU BASED PHYSICIAN COMPENSATION AND PRODUCTIVITY. Merritt Hawkins. http://www.merritthawkins.com/pdf/mharvuword.pdf
2. Lifestyle and Burnout: A Bad Marriage. Peckham, Carol. Medscape.com. 3/27/2013. http://www.medscape.com/viewarticle/781161

Can Social Media reduce Physician Burnout?

In late fall of 2011 I was tired of medicine. While seeing patients was still enjoyable, I felt under-appreciated in my employment and frustrated by the endless BS that I dealt with--new laws undermining the trust my patients place in me, increasing requirements from insurance companies for ordering tests or medications, more forms to sign, less time with patients, a cumbersome EHR to learn, more non-CME education requirements from the system I belonged to...the list grew endless. Most of it boiled down to less control over my professional life and less time to spend with the people I enjoyed-family, friends and patients.

twitter

The following February I began writing a blog on my professional frustrations as well as the occasional reward. Shortly after that I discovered Twitter--first as a "lurker" listening in the background, then as an active participant. I met so many interesting people--physicians, e-patients, Social Media gurus, pharmacists, nurses, other healthcare providers, patient family members, the list is endless. Through Twitter my office knew early on about the multi-state fungal meningitis caused by tainted steroid vials, the Newtown shootings (unfortunately) and the Open Notes study. If Mayo and Cleveland Clinics were using Social Media to reach and teach their patients, it was likely that Social Media was not just a passing fad. Meanwhile my fascination with the phenomenon grew.

I began a master's level course on Social Media that is mind-blowing (and free) developed by +Bertalan Meskó, an MD-Phd from Hungary who is a Medical Futurist.

The Social MEDia Course

I read "The Creative Destruction of Medicine" by +Eric Topol who recently spoke  on the Colbert Report about the future of medicine. I submitted blogs and was  published by Dr. Kevin Pho, "social media's leading physician voice". In October of 2012 I attended Mayo Clinic's Social Media in Medicine Summit and met a few hundred people interested in how Social Media is changing medicine.  

In the process I found new ways to engage myself and my patients--using QR codes, putting up a white board in the exam rooms, recommending apps. 

RelayHealth

Patients now get a business card with the access site to a patient portal, my twitter handle and my blog site. They can contact me 24/7, understanding that I'll answer with the same availability as my email. 

Last year's experience served to recharge my professional gusto. Patients are more interesting, I deal with the non-stop frustrations with more aplomb and less emotional exhaustion. I look forward to seeing my new friends on the #hcsm tweetchat on Sunday night. Suddenly the future of medicine looks a lot less lonely and a lot more interesting.