Family medicine and the fight for the soul of health care [PODCAST]

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“Overall, the health system in the United States is still not tilting its axes in favor of either primary care or family doctor. What is worse, family doctors as a collective are more balkanized and less cohesive than ever. There is a sense among those in the field that something is not right about the specialty. Some feel there is a bait-and-switch aspect to becoming a family doctor. It ends up being something much different than what they were initially told. Others feel it is an impossible job to do well. The ask is too big for them. Still others believe sincerely in the ideal definition of the role, that of the generalist or comprehensive doctor, but find themselves working too hard or sacrificing too much to get it done. They find other niche-oriented ways to convince themselves they are doing “true” family medicine work. Family doctors everywhere are searching out more sustainable career paths for themselves, leading to so much career variety that the very label family doctor starts losing its preferred connotation.”

Timothy Hoff is a professor of management and author of Searching for the Family Doctor: Primary Care on the Brink.

He shares his story and discusses his article, “Family medicine and the fight for the soul of health care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow.

Today on the show we have Timothy Hoff. He is a professor of management, and he’s the author of the book Searching for the Family Doctor: Primary Care on the Brink, and there’s an excerpt from that book on KevinMD. Timothy, welcome to the show.

Timothy Hoff: Thanks so much, Kevin, for having me. Appreciate it.

Kevin Pho: So we’ll get into your book and excerpt in a little bit, but first off, can you share your story and journey to where you are today?

Timothy Hoff: Sure. So I was a business school graduate back in the day, many moons ago, several decades ago, and kind of fell into working in health care, like many people do. I started off working in hospital administration, actually for a department of family practice, which had a big residency program. It was an urban hospital. So in my early 20s, I really got a firsthand lesson in health care, in all its glory and all its trials and tribulations. Then I did some health care consulting. I went back for my PhD because I actually wanted to expand my consulting work, but found that I really liked all the things that academia had to offer. I kind of got pulled into it, realized I was good at research and good at teaching, and so started at the University at Albany for a number of years, in the School of Public Health, and then transitioned to Northeastern University about 10 years ago.

I do a lot of different things in my work. I do a lot of high-level academic research. I’ve written a bunch of books, four books, and a lot of articles, but I also do consulting and executive education. I try to stay in the applied world of health care, and I have always looked at the primary care part of the system as the most interesting and important part of the system. So that’s really shaped a lot of my scholarly interests, teaching interests, and consulting interests over time. So yeah, here I am in 2022 now.

Kevin Pho: So I’m interested in hearing your perspective on that intersection between business and medicine. Of course, on the show I have a lot of clinicians and physicians, and we tend to look at that intersection through a little bit of a negative lens, but now I’m talking to someone from the business side. So tell me about your perspective on that intersection between business and medicine in American health care.

Timothy Hoff: Sure. Well, I learned, when I was a 23-year-old hospital administrator handling a billing department for a department of family practice that couldn’t make any money because we were a safety-net provider, that health care in America particularly is business, and there’s no getting around that. If you don’t understand that, then you’re going to have a problem even providing care to those who need it most. So I learned that early on, and I learned that understanding the business side of it isn’t necessarily an evil; it’s a necessity.

And so that’s taken me through, really, my whole research career: what I’ve studied, the topics I’ve studied, whether it’s patient safety, health care quality, physician behavior, or primary care. I’ve always done it with an eye towards understanding the larger context around how, particularly, the U.S. health care system functions as a business, right? And that’s led me sort of to a business school. The first thing I tell my students in the health care classes I teach is that you have to understand that health care is a business, and that’s the first launching point.

And there’s actually opportunity in that. If you accept that, then there are also good things that can come of thinking like that, for example, how the private sector, how tech companies, could actually help improve health care. But you don’t get to those things, I think, if you’re sort of too rigid in thinking about health care as something that is immune from the normal economic laws of nature, again, particularly in the U.S. system. So I think understanding it now is a blend of both. There’s clinical medicine, there’s the altruism associated with wanting to serve people and making sure we have health equity, health justice, and good care for everybody, but there’s also this context that it’s valuable to make sure you appreciate and bring into all your deliberations. And that’s the context of how the system actually looks and operates on an everyday basis.

Kevin Pho: Now, what do you say to those physicians who really push back on that idea and really want to remove all business aspects from health care? Because I talked to a lot of physicians who really just want to stay away from that business side of medicine. So what are some of the things that you can say to these physicians to really help convince them of that mindset?

Timothy Hoff: Yeah, it’s a great question. I understand. When you study to be a doctor, you don’t study to take on all these other things and all these other rationales about what health care should look like and how it should function. It’s a reason why many doctors are unhappy or burned out, right? They get into practice and they realize, “Oh my god, I have to produce a ton of quality metrics to make sure the practice gets paid, or the system gets paid, or the insurance company gets to check their boxes, and then I’m doing a good job.” This is the reason why a lot of physicians now are salaried employees, right? The private practice model, the owned practice model, is sort of disappearing because physicians either don’t have the scale or resources to take it on or simply don’t want to because it’s too complex.

But we all know, whether you work for a large hospital system, an integrated system, or a physician practice that’s owned by someone else, you are still going to be asked to deal with the business aspects of your practice, whether that means seeing a certain number of patients a day, generating a certain amount of revenue, or making sure you meet your quality and efficiency metrics.

So I think for me, what I try to do in talking with people or writing about this is to try to help people understand that it becomes a personal journey. You do have to make decisions about what you’re willing to put up with in your work life and what you’re not. What kind of work-life balance do you want to have? And that may lead you to not be able to work in certain clinical jobs, which may have a heavier business emphasis or a heavier sort of revenue-producing emphasis, and to take less salary, if that’s what needs to be. And in return, maybe you can get more into those settings where the business aspects don’t show up as much.

But in everything in professional life, regardless of whether a doctor is a professor, there’s a quid pro quo involved, and we have to understand that. So I do think it comes down at some point to a personal journey and then some compromise that you have to make: “Hey, I realize if I work here, I can do good clinical medicine, but they also want me to do this kind of administrative work, to document things. And so I have to think about whether I can make that trade-off.”

Kevin Pho: All right. So let’s talk about your most recent book. It’s titled Searching for the Family Doctor: Primary Care on the Brink. Now, for those who didn’t get a chance to listen to your excerpt, can you just talk about the excerpt and share a little about your book?

Timothy Hoff: Sure. The excerpt is on KevinMD.com. It’s called “Family medicine and the fight for the soul of health care.” To me, the soul is primary care, in large part, and it’s a relational primary care system. It’s a primary care system that focuses on physicians at the center of it, the human touch, empathy, and trust. And so this book is Searching for the Family Doctor. It’s really the third, and I didn’t realize it was going to be a trilogy, but I tell people that since it’s now the third book, I guess it makes it a trilogy. And it’s really the capstone book. All the books I’ve written have dealt with primary care system transformation and what’s happening to primary care.

This book is really about the history. It weaves in the history of family medicine since the 1960s in the United States with the current everyday life experiences of family doctors. It brings those two things together, and it turns the lens a little bit on the specialty of family medicine and how it’s evolved and how it decided to sort of brand itself and grow back in the day. And it sort of critiques that, and it says, yes, there’s been a health care system that has not supported primary care, but there’s also this specialty that’s at the center of primary care that’s made certain decisions about how to embed itself in the health care system over the past 50 years, and some of those decisions may not have been good or necessarily advantageous for either family doctors today or primary care generally over the past 50 years.

And so the book then goes in and interviews about 55 family doctors at length, in different career stages, and really looks at what their lived experience is, in all its trials and tribulations. And then it kind of links that lived experience back to some of these strategic historical decisions that the specialty has made over time. So it’s sort of an on-the-ground analysis of today’s family doc, linked to the larger policy decisions of the specialty, really with an eye towards the questions: What’s the current state of family medicine? And then, linking that in, what does that mean for primary care, both now and in the future? And then my last chapter in the book is basically called “Saving family medicine, a top 10 list,” because I do think the specialty’s future health is definitely somewhat in question at this time.

Kevin Pho: So through your extensive research and interviews with the 50-plus family medicine clinicians, what are some of the major themes that you’ve uncovered?

Timothy Hoff: Yeah, so one of the big themes in the book is this notion, and again, some of this stuff we certainly write about and know anecdotally, and we hear stories, but one of the big themes is really about the sacrifices that family doctors have to make. It goes back to what we were just talking about a few minutes ago. You are told when you choose family medicine that it’s going to be a certain way. You are told that you are going to be able to be a certain kind of doctor. You’re going to be able to build long-term relationships with your patients. You’re going to be able to work on the whole person. You’re going to be able to have a wide scope. You’re going to be able to work in settings that have community health and health care justice embedded in them.

But then, for many of the docs I talked to, what happens is you go out into the real world and you end up in settings that really don’t function that way or don’t have those qualities. The workloads are extensive, your time with patients is cut short, and you’re not able to. You may be working more with a well population that doesn’t necessarily need a ton of primary care, your scope of practice becomes limited for various reasons, and you’re subject to tons of quality metrics.

So what I heard from the doctors is this notion of pragmatism in how they begin to view their careers, and how they begin to view the choices they make about their work lives, their non-work lives, and their practices. And so the themes of career sustainability are big, and I look at how this notion of career pragmatism or career sustainability among family docs, the choices they make, affects not only what kinds of family doctors they can end up being, but the health of the family medicine specialty. The specialty has become somewhat balkanized as a result of these sorts of dynamics. You have groups of family doctors doing vastly different things now. Some do hospital medicine, some do emergency medicine, some work in urgent care centers, some work in suburban practices, community health centers. So what we hear from those doctors is really all that.

And then also, from some of the business owners, the primary care doctors, the family doctors who actually still have businesses, what we heard in the book is just how precarious that state of existence is now, and how really the independent family doctor is sort of a dying breed, an endangered species that increasingly is sort of gobbled up by larger systems in the area, really just looking to use primary care as a loss leader for other kinds of services, whether it’s specialty services.

I will also say these are amazing people. When you talk to them, what comes through in the book is still their sense of altruism, their sense of dedication to the ideals of family medicine and to the ideals of primary care. And many of them are not willing to let go of those things. So what you see are people, some who are increasingly in conflict with themselves, and others who are trying to navigate their work lives in ways that allow them to remain altruistic and have these qualities they want with their patients, but also to have careers that sort of work for them and don’t burn them out.

Kevin Pho: So we’ve been talking about the shortage of primary care physicians on KevinMD for what seems like decades now. A lot of physicians are choosing specialties for a variety of reasons, and that shortage is being filled by advanced practice practitioners, nurse practitioners, and physician assistants. So from your research and your perspective, what’s the role of advanced practice practitioners in primary care going forward?

Timothy Hoff: Yeah, I think they’re a necessity moving forward, right? And I think they’re a good necessity. I think they will be needed. I’m one of those people who falls in the camp, especially in the U.S. health system, that says we are likely not going to generate the numbers of family doctors and primary care doctors that we need in the future to satisfy demand and to create a more just and equitable system, and to make sure we get primary care into areas of the country that we know don’t have a lot of it: rural areas, inner cities. So I think we need advanced practice providers very much. But there are shortages of them, too, and so we need to scale up the production of those individuals.

I also think that well-trained nurse practitioners and well-trained PAs can do a lot of what a doctor does. There may be other things in the primary care space that you definitely need a well-trained family doctor to take the lead on. But as for looking at those groups, and I say this in the book, one of the things on my top 10 list for saving family medicine is that I think family doctors need to create much more collaborative and beneficial relationships with other advanced practice providers. They need to become more. We use the term “health care team,” but we know that in most health care facilities, these things don’t function as teams. And so I think in the future, there needs to be much more coming together of those different groups, figuring out what work an advanced practice provider can do and what work a family doctor needs to do, and then how they should be working together. But there’s no question that in the future, advanced practice providers are going to be needed in very large numbers in this health care system.

Kevin Pho: So from an economic standpoint, if primary care is filled by more advanced practice practitioners and that drives the salary down, isn’t that going to paradoxically drive more physicians into specialties as the salaries of primary care clinicians go down?

Timothy Hoff: It’s possible. I think there are two levels to look at this, right? One level is the level of the family medicine specialty, the level of the specialty and the prestige of the specialty. And with the prestige comes the compensation, the autonomy, how society views them. And yes, I think that could be impacted if advanced practice providers continue to grow in scope and responsibility. Certainly to the public, that might confuse the groups in terms of their identity. So increasingly, you might have patients who ask, “Well, what can a family doctor do that a nurse practitioner can’t do?”

So that’s one level, the level of the specialty. And yes, you’re right that the growth of non-physician primary care providers certainly could bring down both the popularity of family medicine somewhat as a choice, even further, as well as some of the compensation, because you’re going to get more organizations that say, “Well, why do I need to pay $250,000 for a family doc when I can hire two nurse practitioners for that price, and they can pretty much do the same thing, in my mind?”

But then there’s also the level of the system, which is what I talked about earlier. The system needs access points. The system needs more touch points for patients to get primary care services. We have tremendous waits for people to get primary care doctors. And so I just think there’s no choice in this, unless we’re going to commit to making the family medicine specialty more robust in terms of how many doctors go into it, and that really is the responsibility of the medical profession. They probably could do it if they wanted to, collectively. And so that’s the question.

Kevin Pho: We’re talking to Timothy Hoff. He’s a professor of management, and he’s the author of the book Searching for the Family Doctor: Primary Care on the Brink. So, Timothy, there are a lot of headwinds facing family medicine today. You talk about some solutions in your book. What are some of your top solutions to sustaining the practice of family medicine?

Timothy Hoff: I think one is really that the work of the family doctor has narrowed, and it’s been narrowing over time, and chunks of their work have been given out to different specialties that have emerged, right? In the ’70s, it was emergency doctors and pediatricians. And then in the early 2000s, it was hospitalists that came along and took the hospital work. Actually, family physicians sort of gave them the hospital work, and then they took it. So I think one of the big suggestions is that the specialty has to try to find ways to expand its scope of work. They just have to. The more narrow they become, the more they’re going to be construed as not really being able to care for this whole patient or be this comprehensive care person.

So I think it’s trying to expand the work relationally and trying to become more of the liaison between different parts of the system. I’m not going to use the word care manager or care coordinator, because those terms have negative connotations, but I think becoming the liaison, becoming the person that the patient can come to trust, is going to help them navigate the system. And I think, in the process, that will develop a stronger interpersonal relationship between the family doctor and the patient. So that’s one suggestion.

Related to that is, really, that family doctors have to go all in on digital health. They just have to. The future, as we learned in the pandemic, is digital health tools, not just telemedicine. It really represents an opportunity for family doctors to be able to connect with their patients much more frequently than they do when they just come into the office. And so being able to develop a virtual part of the relationship between family doctor and patient will actually help cement the patient’s loyalty to that doctor and actually help create that kind of trust that will make the family doctor, in the eyes of the patient, have more value.

And then I think the third big solution that I advocate for is that family docs are going to need better workplace-level forms of advocacy for themselves. The professional association is the traditional model for representing physician interests. It is not aligned with the realities of being a family doctor today, where actually what you have to worry about are your everyday work conditions, the benefits you get in your job, and how your employer treats you, many of the things nurses worry about and other health care workers worry about. So I really push in the book for thinking of new models for workplace advocacy. That also may have to involve collective bargaining and things of that nature, because if not, family doctors are sort of at the mercy of the large corporations that are employing them, just like any other worker. And so those, I think, are a few of the big ones in the book that I sort of lay out.

Kevin Pho: So talking about that last piece, about how family doctors can advocate for themselves, you mentioned things like collective bargaining. A solution I frequently hear is having them more involved with decision-making in the hospital, being more involved with more committees, and perhaps even going into administration, straddling that line between administration and clinical medicine. So is there anything that individual family doctors can do to better advocate for themselves?

Timothy Hoff: Yeah, I think every family doctor does have to, in their training and in the early part of their career. First, I think it goes back to what we talked about at the beginning. They have to understand the business aspects of this. They cannot stick their head in the sand and pretend that those things are not going to impact them or that they don’t know about them. I also have advocated in other writings that medical schools have to integrate more of the business principles and business realities of health care into the training, because we’re not preparing any young medical student well enough, not just family doctors, if we don’t do that.

And then I think when those family doctors get into practice, they have to become the champions of their workplace. They don’t necessarily have to become a medical director. They don’t necessarily have to give up clinical work or be on 10 committees. What they have to do, though, is be able to understand what they need to advocate for in their workplace, for themselves and then also maybe for others that they work with. And so, for some family doctors, the things they’re going to advocate for are going to be different. For some it may be compensation; for some it may be the way the job is structured.

And then I do think at some point, we’re going to have to sort of enlighten many of them to understand that the notion of bargaining with your organization, and being able to discuss the economics of how health care is delivered where you work, has to become something that doctors become more involved in, and they have to argue with the employer to assume roles in that regard. So I think it’s not one solution, but it’s this sort of heightened mindfulness and awareness, and then the willingness to engage the employer. Because that’s what it’s all about. If they’re employees, it’s engaging the employer, because in that relationship, the employer sets the terms of the relationship, by and large.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with KevinMD?

Timothy Hoff: I’m a champion of the kind of health care system that I think your viewers and your readers want, which is a health care system that’s built on the strengths of people, a human connection. Technology plays a role, large systems and their resource availability play a role in making the system, artificial intelligence plays a role, but I’m a strong advocate that these are just things that complement the human aspect of health care. And at the center of the human aspect of health care are the people who do it: doctors, nurses, advanced practice providers, medical assistants, all the people who do it.

And so I would just say to the audience: Stay optimistic. Fight the good fight. Take that good fight local; all politics is local. So worry about your everyday world. Worry about advocating for what your patients need and what you and your co-workers want in your everyday world. But also, don’t be unrealistic, and understand the rules of the game, because once you understand those rules of the game and can get into that game, then you can make a bigger difference. So those would be my takeaways.

I love health care. I’ve studied it my whole life. I’ve worked in it. I have so much respect for the providers and the people who do it. And I would say you’re all sort of heroes. And so that’s how you should wake up every day, thinking about what you do.

Kevin Pho: The book is Searching for the Family Doctor: Primary Care on the Brink. Timothy, thank you so much for sharing your time and insight. Thanks again for being on the show.

Timothy Hoff: Thank you very much, Kevin. I really appreciate the opportunity.

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