The Appalling Lack of Leverage in Primary Care

A surgeon evaluates patients and performs surgery. But surgeons don’t administer the anesthesia. They also don’t sterilize their instruments or fetch them during the operation nor do they hold the retractors while also cutting or suturing. They also don’t do all the dressing changes and repositioning of patients postoperatively. They move on to other surgeries.

A whole team is working alongside with the surgeon to help the operation go smoothly without wasting the surgeon’s (or patient’s) valuable time.

Contrast that with primary care.

Some of the other people on our team, like our medical assistants, used to prioritize incoming results, reports and messages to help us get to the most important ones first.

Those days are gone.

Modern EMRs are designed to have the provider be the one who receives everything and then delegates to the medical assistants to tell the patient or have the test repeated or whatever needs to be done. (We are the first ones to see incoming results, often not until the end of the day or later! Imagine a pilot also trying to do his or her own Air Traffic Control!)

Then we have new categories working with us – pre-visit planners is one of many names for them. Their job is to look for “care gaps” and then tell the providers they need to order mammograms, colonoscopies or whatever.

(Years ago, pre-visit planning used to have the purpose of making sure we had what we needed to carry out the visit: a visit like “Followup MRI” would mean checking if the patient has had the test and if we have the result, but that’s not what today’s pre-visit planners do.)

Neither of those job functions are meant to help the primary care provider do what only people with a license to practice medicine can do.

The surgeon’s expertise is leveraged but the primary care provider’s isn’t. We are doing more and more non-doctor work, in large part thanks to our EMRs.

This explains both the doctor shortage and the burnout epidemic. And it is a perpetual motion machine: more non-clinical duties means more of us quit, which makes those who remain even more likely to burn out and quit.

The solution is obviously simple:

Hire people to sort and prioritize incoming information so the provider doesn’t waste time on routine information when their attention should go to the most important information first.

(And for any non-medical readers out there, computer generated flagging of an abnormal chemistry profile is not helpful. There is a statistical expectation that 5% of lab results will be abnormal even in normal people and therefore a panel with 20 items would be expected to have at least one abnormal result, and thereby be flagged as a priority item in the physician’s electronic inbox. A modest amount of knowledge is required for this job.)

Give the pre-visit planners authority to check with the patients by phone or electronically if they want a mammogram or colonoscopy or whatever instead of ordering the provider to do that in their next visit, which is likely to also have a lot of other requirements, like depression screening, medication reconciliation, repeating any elevated blood pressures, checking desired gender identity and whatnot.

We aren’t trying to put ourselves above our team members when we resent doing what non-physicians could do. Our visits and the billing codes they generate pay all our wages and keep our clinic doors open. Why aren’t our skills and knowledge leveraged to their fullest extent these days? They used to be…