Can the Practice of Primary Care Medicine ever be Practical Again?

A pandemic era post from July 2021

I wrote this when I was working for a fairly traditional primary care office, a Federally Qualified Health Center, which did have a somewhat preferential pay rate from Medicare and Medicaid, in part because we offered sliding feee to uninsured patients, in part because we offered a few “enabling services” as the bureaucrats call it. But we weren’t staffed to do public health work for entire populations. My current practice is better equipped to do that as it is in large part reimbursed on a per-member-per-month basis. This means we have the resources to reach out to the populations we manage and offer them immunizations, screening tests and advice without dragging them into the office one by one to do this for them (and bill their insurance for our efforts). Here’s the post from four years and one major job change ago:

When I first lost power and then saw my generator fail during a storm last winter, two other failures struck. As I scrambled to fill my water containers for the horses, the failing generator delivered just enough electricity for dim lights and a slow trickle of water. And then, when the power came back on, I had no water and the furnace didn’t work.

I trudged through the snow to the pump house up in the woods and found the water pump clicking as if it tried to start, but couldn’t. I ended up a day or two later with a whole new water pump.

The furnace had power, but I saw a red light with what looked like a stick figure repair man. Other furnaces I’ve had all had a reset/start button. Not this technical wonder that I never had to mess with before.

The repair man showed me that the stick figure light was, in fact, a recessed reset button. He pushed it and the furnace started instantly. But he didn’t leave. He said he was going to make sure there were no other problems. That took half an hour and I later got a $250 bill for the emergency repair call.

I felt stupid for not having pushed the red light on my own and I don’t mind paying $250 for my stupidity. But did he really have to spend half an hour making sure that a furnace that fired and delivered heat REALLY was working?

This long story makes me think of how we practice medicine these days. Nothing is quick and easy. Everything has to be comprehensive. But some problems are really simple enough that we shouldn’t have to belabor them like my furnace repair man. His job was, or should have been, easier than the plumber’s.

Primary care, with our ongoing patient relationships, is in theory ideally suited for quickly taking care of minor problems. After all, we already have background information on our patients and shouldn’t have to start from scratch.

But, we are disincentivized and downright punished if we do just that. This is because some well meaning bureaucrats imagined that while patients are in our clutches, we might as well screen them for this, that and the other, update their immunizations and, God forbid, not let them leave if their blood pressure should happen to be out of range because they are in pain or in a hurry.

So, instead, our patients end up going to walk-in clinics, seeing providers they don’t know who practice without the shackles of the family doctor of record.

I think we need to stop pretending that today’s primary care is patient centered. It is not. It is a vehicle for top-down government control of people’s care decisions and doctors’ behavior.

Take a lesson from the pandemic:

When this country faced a public health emergency, the directives and recommendations were broadcast by the government and its agencies directly to the public. And when mass immunizations needed to be done, they took place in large arenas, even parking lots and also pharmacies. Primary care offices were deemed a last option, presumably because the Fed realized how stodgy our work flows are because of how they designed us.

We desperately need a public health system in this country. The past year has demonstrated that mass communication and mass interventions are better vehicles for public health than clinics historically geared up for treating patients one by one.

So, please take public health off our plate, because we don’t have the resources for mass education – we have doctors, PAs and NPs working in professional isolation with full schedules. Each provider is aided by one medical assistant. Primary care clinics usually don’t have registered nurses, health educators, PR people or the kind of support it would take to treat entire, even small community, populations.