A lot has been written about physician burnout, often it is attributed to the administrative burden, with some estimates that U.S. physicians spend an average of 1.84 hours a day completing documentation outside work hours. I’ve felt for some time that the administrative burden in primary care is increasing, but not due to the commonly cited endless EHR clicks or the burden of insurance companies’ forms and prior authorizations. It’s the way the role of the primary care physician has changed and how impossible it is to coordinate care across an ever-expanding range of health care settings.
When I first started practicing in 2008, there were no urgent care centers, walk-in clinics, telemedicine providers, or online “solutions” targeting patients with complaints of hair loss, decreased libido, ADHD, and menopause. As a result, I saw my patients much more frequently, typically a few times a year, and I knew them much better. The coordination of care was mostly limited to specialists and hospitals. At the time, not all patients had copays, and for those that did, they were in the range of $5 to $20. Depending on the plan, preventive visits were often subject to copays. Although I did schedule patients for dedicated preventive visits, I was much more flexible about visits and mostly focused on what was most important for patient care. If a patient came in for a blood pressure follow-up, I would remind them that they were overdue for cervical cancer screening and write their prescription for a mammogram. Because I saw patients frequently, updating the chart at the preventive visit wasn’t laborious because many updates were made throughout the year.
In the past, the day of a primary care physician consisted mostly of follow-up appointments and sick visits with a few preventive visits mixed in. Today it’s the reverse- most of the day is preventive visits. These appointments are a nightmare; frequently, they consist of a catch-up for an entire year or more. In addition to screening, immunizations, and anticipatory guidance, there is the piecing together of the hodgepodge of care delivered in urgent care or the prescriptions started by nameless online providers. Patients come in with a list of all the things they want to address, a list of the new prescriptions they want you to take over, and the doctor is faced with a dilemma. Do I address the patient’s needs or stick to the preventive visit agenda and tell them to make a follow-up, which they often won’t do due to the high cost of their copay or their deductible?
When I finish seeing patients, there are messages, labs, and documents to review and charts to complete. To complete many charts, I log into the hospital EHR, which is part of a health care exchange, to review the care they have received across settings so I can make sure that I’m not missing the abnormal lab, the diagnosis they don’t know about, the reason the medication was discontinued. This work cannot be delegated to a medical assistant because half the time, I don’t even know what I’m looking for, I know that more information is needed for me to care for my patients well.
The current state reminds me of the attempts to control a pest by introducing a natural predictor resulting in the unintentional extinction of another species. In this case, insurance companies promoted urgent care and telemedicine offerings to reduce avoidable ER visits and made preventive visits $0 to encourage care; in the process, they created a system of fragmented care and what is feeling like the eventual death of primary care.
Leslie Saltzman is an internal medicine physician.
