Want to know why residents don't chose primary care? Read this.

I just got a taste of improved access, and I gotta tell you, it sapped my energy.

It reminds me of the old standup comic one-liner, “I just flew in from Vegas, and boy, are my arms tired.”

Today was the department of medicine housestaff picnic (pretty much a guarantee to cause the weather to change from clear skies to rain), and so our practice, which is usually bustling with dozens of internal medicine residents seeing their patients, was a veritable wasteland.

A few of us old-timers were left behind, and we divided up the coverage for the residents’ patients. During each practice session, three attendings were designated to cover the work of approximately 30 residents each.

This represents six to seven of the “pods” in our patient-centered medical home paradigm. As you may recall, residents are grouped into pods which make up the core of the team, along with one attending, a nurse practitioner, and additional clinical and support staff.

So my afternoon session went from supervising four residents in practice while they saw their patients and covering the phone calls of my own patients, to just simply covering all of the phone calls and urgent issues that came in for those 30 residents who were away having hot dogs and playing baseball.

When I logged onto the system and clicked on their in-baskets, the avalanche began. There were already a dozen or more messages left over from the morning, things that had been started but could not be completed, awaiting more information or action, or maybe just ignored. One message had been “pended” and passed along for someone else to do for over 2 weeks.

Try as I could to clear the queue, I blinked and more and more high-priority urgent messages flashed on the screen.

The messages ran the gamut from the simple to the sublime, from true clinical urgencies that required a doctor to intervene right away to the absolutely absurd.

One of the registrars sent every single message marked red flag, high priority, for simple things like refills or plain FYI messages (clearly in need of a little education in messaging etiquette).

Innumerable messages just said “call patient.”

These led to phone calls that often discovered that what the patient had called about was a request for an appointment. So once we got the patient on the phone we were forced to route the phone conversation electronically back to the person that sent us the message in the first place, that initial contact on the phone who never asked what the call was about.

And the deluge continued.

“Needs a refill on his cholesterol medicine.”

“Needs a refill on his allergy medicine.”

“Needs a refill on some medicines, cannot remember which ones.”

“Need to refill all his medicines, just filled at the pharmacy but lost them, wants new prescriptions called in and someone has to get approval from his insurance company for early refills.”

“All of her medicines need prior authorization since none are on formulary.”

“Allergic to generic” (one of my favorites).

“Needs a refill on pain medicines.”

These last four (and many others like them) need a check on the state’s prescription monitoring system (a cumbersome site which adds at least 5 minutes to every refill) to assess for doctor shopping, recent refills, evidence of abuse and overuse. And all of this came on the day after the American Academy of Neurology came out strongly against the use of opioids for non-cancer chronic pain.

But it’s easier to just refill on patients you do not know and do not have time to get to know.

At the end of the day I realized that only a tiny fraction of the messages the residents were getting came through our electronic patient portal, which allows patients to request refill of their medications with a click of a button, request appointments, request referrals, or send non-urgent questions for clinicians or other members of the team.

Try as we might, we’ve been unable to get much penetration into the resident patient population for use of this incredibly simple and beneficial tool which exists as part of our electronic health record.

Many residents say that their patients are unlikely to use the system, or don’t have computers, but there’s also the sense that many providers feel this is yet another way for patients to “bother us.”

Time for a change of mindset.

As you can imagine, it is easy after a day like this to understand why residents are not inspired to pursue careers in primary care. It’s not like the clinical experiences are not valuable and rewarding, but all the stuff that layers on top makes it hard to see the forest for the prior authorizations.

Seriously, an oncologist cannot order a wheelchair for the debilitated terminal lung cancer patient they saw last week? No, only the primary care physician can handle that highly complex task.

Seriously, a neurologist who sees a patient twice a month (and who is never seen in primary care clinic) cannot fill out home care orders? No, too messy and beneath them.

The work has to be done, the calls have to be made, but we need to re-engineer the system so that the lives of doctors are once again about doctoring. That is why we went into this field.

Gotta run, the calls are piling up.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.

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