Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Moral injury from a primary care perspective

Talal Khan, MD
Physician
October 23, 2019
Share
Tweet
Share

The backbone of a great health care system is its primary care task force. From Singapore to France, elite health care systems rely on these cerebral doctors to provide preventive, urgent, and acute care along with chronic disease management. Primary care doctors have a broad-ranging impact from health care access, cost control, and impact on mortality and morbidity rates.

I was a graduate of a class of 50, of which only a couple went into primary care. Like my peers, as a second-year resident, I also wanted to be an interventional cardiologist. The idea of putting stents for ST-elevation myocardial infarction seemed heroic. Fortunately, I did not match in cardiology. I ended up going to an underserved area in northern Maine to deliver primary care. This started a love affair that is one-sided as primary care does not love me back— and here is why:

In the past 15 years, I have seen the corporatization of health care and a war on physician autonomy in general and primary care in particular.

Primary care physicians have been relegated to triage workers for big health systems and insurance companies. The devaluation is so extreme that in many areas of the country, they are losing out on competitive jobs to physician assistants and nurse practitioners. These physician extenders are valuable assets to the health care system but also more likely to sing the tune of the administrators and regulatory bodies.

The infliction of moral injury for primary care started with the widespread adoption of electronic health records.

These extremely clunky and physician-unfriendly systems were designed to give out cookie-cutter medicine with tools like checkboxes and templates. They dish out electronic documents that have mostly garbage information with a few lines of useful information.

Electronic health records impacted primary care in particular who earn their living with cerebral work and do not perform procedures. They are underpaid and lack political clout and resources to take short cuts like using transcription and medical scribes. Primary care physicians are impacted more by these changes as we are responsible for the majority of work in the health care system. It is no secret that all medical supplies from wheelchairs to alcohol swabs to incontinence pads, personal care attendants, and visiting nurses need signatures by primary care physicians. Also, any test ordered on our patients, even if it is on Mars, becomes the responsibility of the primary physician.

We are also supposed to track preventive services, consultant notes, and recommendations and held accountable for patient outcomes and keeping their complete records. The fragmented electronic health care system has challenged us like never before.

Moral injury happens when a person does not get professional or personal satisfaction from their work. Being held responsible for everything but having zero authority creates a sense of sadness, decreases self-esteem and morale. This is what is going on for most primary care physicians in the country — orphaned by the system, burdened by insurmountable tasks, and being replaced by providers with less training, with a threat of a lawsuit hanging on your head by mistakes made by the very providers who are replacing us. This sort of institutionalized abuse would drive anyone to feel injured, depressed, and irrelevant.

In a typical day, I see a lot of patients, renew prescriptions for patients, follow up on tests and emergency room records, go through records of patients hospitalized, review care plans of visiting nurses, sign paperwork for a patient to get their diabetic supplies, wound care equipment, appropriate housing, disability equipment, home modifications to prevent falls and physical and occupational therapy. The list is endless. In between, I also triage calls and make critical decisions that cut down on emergency room visits.

It would seem like that a person who does all this is a hero. It would be great if I could pretend to be Superman as I work like him. The injury occurs as I am expected to be superman but made to feel like Lex Luther.

The government and insurance companies are setting up roadblocks for patients to get care. It is a work of god and pages of documentation to get some patients the medicine, medical supplies, or necessary diagnostic tests. We are juggling a million tasks. And at the end, the patients are not happy as we did not complete that one form that was needed for them to get their preferred medication, or the test that their consultant suggested, or the number of home care hours that their home agency required.

Replacing the injured primary care doctor is in process.

ADVERTISEMENT

Family medicine, pediatrics, and internal medicine doctors are retiring at a fast rate, and medical students are not going to these specialties.

Corporate health care has already found their replacement. As the injured physicians hang up their stethoscope, I hope that the system will appreciate the next generation of physician extenders and not inflict deep wounds on the gatekeepers of health care. Injury to the front-line soldiers of health care can only result in defeat and eventual pain and sorrow for the whole system.

Talal Khan is a family physician and can be reached at Personal Primary Care.

Image credit: Shutterstock.com

Prev

Physicians: Constantly focus on raising your game

October 23, 2019 Kevin 0
…
Next

An American reporter looks at Germany's health system

October 23, 2019 Kevin 7
…

Tagged as: Practice Management, Primary Care

Post navigation

< Previous Post
Physicians: Constantly focus on raising your game
Next Post >
An American reporter looks at Germany's health system

ADVERTISEMENT

More by Talal Khan, MD

  • COVID-19 and a call for unity

    Talal Khan, MD
  • Black lives will not start to matter until Black health matters

    Talal Khan, MD
  • The scrubs must rise against the suits

    Talal Khan, MD

Related Posts

  • Primary Care First: CMS develops a value-based primary care program for independent practices

    Robert Colton, MD
  • Primary care makes a difference for patients and the nation

    Glen R. Stream, MD
  • The many benefits of strengthening the primary care workforce

    Nicole Liner-Jigamian, MSW
  • Primary care faces a very difficult winter

    Ken Terry
  • The biggest health care fix: a relentless focus on primary care

    Suneel Dhand, MD
  • The hidden work of primary care

    Michelle Nall, MPH, ANP-BC

More in Physician

  • Why judgment is hurting doctors—and how mindfulness can heal

    Jessie Mahoney, MD
  • Why evidence-based management may be an effective strategy for stronger health care leadership and equity

    Olumuyiwa Bamgbade, MD
  • The gift we keep giving: How medicine demands everything—even our holidays

    Tomi Mitchell, MD
  • From burnout to balance: a neurosurgeon’s bold career redesign

    Jessie Mahoney, MD
  • Why working in Hawai’i health care isn’t all paradise

    Clayton Foster, MD
  • How New Mexico became a malpractice lawsuit hotspot

    Patrick Hudson, MD
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • 5 blind spots that stall physician wealth

      Johnny Medina, MSc | Finance
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Recent Posts

    • Why judgment is hurting doctors—and how mindfulness can heal

      Jessie Mahoney, MD | Physician
    • Why medical schools must ditch lectures and embrace active learning

      Arlen Meyers, MD, MBA | Education
    • Why helping people means more than getting an MD

      Vaishali Jha | Education
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • Why evidence-based management may be an effective strategy for stronger health care leadership and equity

      Olumuyiwa Bamgbade, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 2 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How New Mexico became a malpractice lawsuit hotspot

      Patrick Hudson, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • 5 blind spots that stall physician wealth

      Johnny Medina, MSc | Finance
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why flashy AI tools won’t fix health care without real infrastructure

      David Carmouche, MD | Tech
  • Recent Posts

    • Why judgment is hurting doctors—and how mindfulness can heal

      Jessie Mahoney, MD | Physician
    • Why medical schools must ditch lectures and embrace active learning

      Arlen Meyers, MD, MBA | Education
    • Why helping people means more than getting an MD

      Vaishali Jha | Education
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
    • Why evidence-based management may be an effective strategy for stronger health care leadership and equity

      Olumuyiwa Bamgbade, MD | Physician
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Moral injury from a primary care perspective
2 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...