I really tried to have AI come up with an innocuous-sounding title for this piece: “Caring Hearts, Lighter Wallets: The Financial Reality of Primary Care.” But my poor judgment prevailed so I just decided to insult all of my colleagues right from the start. I assure you, for better or worse, that this article is my original opinion although with AI editing for grammar and clarity (but unfortunately not brevity). First things first: I love being a primary care internist, otherwise I would not have done this for 36 years. Developing long-lasting relationships with patients through thick and thin and caring for multiple generations of the same family is a privilege that primary care has afforded me. No regrets about picking this specialty. Well, maybe just one, a relatively recent one.
The reality of “pajama time”
“Pajama time.” All of us in primary care are all too familiar with this concept: the many hours we spend after office hours doing chart work mostly at home. “Pajama time.” How cute is that phrase! It conjures up a scene of physicians gathering for a sleepover in their pajamas and white coats and stethoscopes, bouncing up and down on the bed all the while giggling and having pillow fights. But the reality is that “pajama time” refers to a soul-sucking activity that robs us of precious personal time, isolates us, and damages our most meaningful relationships, with spouses, significant others, our children, and other loved ones. It is a term I deeply despise and I believe it should be banned as belittling and insulting to primary care physicians. Yes, it has always been a part of the job, but with the advent of the electronic health record the burden has become overwhelming. A recent study documented that primary care physicians spend approximately 62 hours per week providing patient care. If we are seeing patients in the office for 36 hours a week and are only compensated for that “face-to-face time” then that translates into over 25 hours per week of uncompensated medical care.
The compensation dilemma
We all recognize that this after-hours work is a crucial part of primary care. But for most of us this additional time is entirely uncompensated because most compensation models are productivity based: RVU reimbursement is based on face-to-face time only. After hours “work” is actually a misnomer since uncompensated time does not qualify as “work” by definition. In a free market “work” means “fulfilling duties regularly for wages or salary.” So technically, all those extra hours should be called charity, volunteerism, or even a hobby, all terms for uncompensated activity. The data for developing RVUs came from a 1988 Harvard study that gathered a panel to conduct time studies and estimate the work involved in a wide variety of patient care services. The resulting system was authorized by Congress with the intent that RVUs reflect the time and intensity required to perform a service, but EHRs did not exist in 1989 so obviously that system was built entirely around face-to-face encounter time. But the new EHR era resulted in an explosion of inbox management time for primary care physicians and the original RVU formula was never updated to reflect the current reality of the time spent managing an entire patient population. Sure the new Medicare add-on code G2211 is a step in the right direction. But it only applies to Medicare patients and can only be billed during an office visit.
A double standard
Why are primary care physicians expected to routinely perform hours of uncompensated work when no one would dare ask the same of other specialties? Imagine requiring surgeons, or for that matter anyone, in a free market to perform hours of work without pay. An absurd concept right? Yet because primary care physicians are conscientious, caring, and driven by a sense of duty and responsibility, we willingly do it all the time. A cynical person might argue that the medical system is deliberately taking advantage of our virtues. Hence, fools! This double standard extends to other areas affecting primary care. When surgical specialties request the latest cutting-edge equipment, arguing that the latest Roto Rooter 2000 will not only improve patient care but can also be marketed as the newest whiz-bang technology to attract new patients to their facility in a competitive market, capital expenditure funds materialize readily. But when the request is for something as unglamorous as extra staff to help primary care physicians reduce their administrative burden and prevent burnout, the money mysteriously disappears. And when you stop and think about this situation from a purely financial perspective: Why would a health care system spend money on extra support staff if physicians are already doing the work for free? Interesting how the mantra of “practicing at the top of your license” does not apply to physicians mired in inbox tasks.
And when primary care physicians argue for compensation for all of those extra hours, administrators are quick to point to national data that does not support such demands. National compensation data are based only on RVU productivity and not total time dedicated to managing patient care. The justification for their current compensation formulas are not based on silly concepts like logic or fairness but essentially boils down to: “Everyone else in the country does it this way.” That argument sounds exactly the same as the one I used to make as a kid: “But mom, all the other kids are doing that!” Predictably l always lost that argument. Health care leaders seem puzzled that fewer medical students are choosing careers in primary care. But we are not. Ask those of us on the front lines and we can give them an earful of the many challenges we face. Now to be clear, no one is arguing that primary care physicians are destitute. The issue is one of fairness, pure and simple. We are expected to be the “quarterback” of each patient’s medical team knowing every detail of each patient’s health from head to toe (literally from the ophthalmologist to the podiatrist) and everything in between, while often being one of the lowest-paid members of that team.
What do we do now?
First, our compensation models should evolve. Maybe a fraction of an RVU credit for inbox tasks completed or provide paid time off to partially compensate for all the after-hours work and, of course, insist on appropriate investments in AI tools that will ease the burden of our inboxes. I do not know the exact solutions but we should all be demanding ideas and advocacy from the “leaders” who represent us, the American College of Physicians, the American Academy of Family Physicians, and others, to make a forceful argument that primary care physicians deserve to be compensated for the entire scope of the work involved in managing a patient population. In other words, fools everywhere. Stand up and rip off those pajamas!
Armand Rodriguez is an internal medicine physician.
