The primary care crisis has been well documented. Experts cite low pay, lack of respect and administrative burden, all of which have contributed to burnout and a growing shortage of primary care physicians (PCPs). But even if we solve those problems, are PCPs well-prepared to care for an increasingly older, sicker population saddled with psychiatric disease? For many PCPs practicing today, the answer is no. There are myriad reasons for this, many of them beyond the PCP’s control. The fact remains, however, that in order to survive, let alone thrive, primary care must demonstrate its value. We do not just need more PCPs, we need PCPs who are exceptionally well-trained in three critical areas: motivational interviewing, geriatrics, and psychiatric care.
The critical role of motivational interviewing
Preventing and treating chronic disease is a cornerstone of primary care, and behavior change is critical to achieving that goal. Yet most PCPs are simply not up to the task. A wealth of evidence supports motivational interviewing (MI) as an effective technique for helping patients resolve ambivalence and empower them to change their behavior. Yet medical schools and residencies fall short when it comes to training doctors in this technique. As a result, PCPs resort to what comes naturally, telling patients what they should and should not do (the “righting reflex”). This is ineffective and can often make the problematic behavior more entrenched. Apart from leading to better patient outcomes, MI has the potential to reduce physician burnout by shifting the burden of change from the doctor to the patient. Learning MI takes time and practice, but it can be implemented quickly and effectively, even in a busy office setting.
Addressing the needs of an aging population
By 2030, roughly 71 million Americans will be age 65 or older, meaning about one in five Americans will be seniors. Diseases often present differently in the elderly, medications must be used with caution (or not at all) and certain psychosocial stressors (e.g., loneliness, loss of independence, etc.) affect them disproportionally. Addressing multimorbidity, coordinating care, deprescribing, ensuring smooth transitions of care, and having goals of care discussions should be fundamental skills for any PCP, not just specially trained geriatricians. Yet PCPs routinely report feeling undertrained to care for older patients, and primary care practices often lack time, expertise, and resources for comprehensive geriatric assessments. As such, seniors are often left overmedicated, overwhelmed and left floundering in a byzantine health care system.
Managing the surge in psychiatric conditions
In addition to getting older, the U.S. population is becoming more depressed and anxious. Over one in five Americans experience mental illness each year. And it is PCPs, not psychiatrists, who prescribe the majority of antidepressants in the United States. It is, therefore, essential for PCPs to be competent at diagnosing and treating a range of psychiatric conditions. This includes not only managing medications, but guiding patients to evidence-based therapy (simply providing the patient with a list of therapy search engines is not enough). Yet studies have shown that PCPs feel ill-equipped to effectively address psychiatric conditions. Patients are, thus, left under-diagnosed, under-treated and either left to suffer or seek out potentially expensive care from psychiatrists or, increasingly, psychiatric nurse practitioners. This burdens an already strained mental health care system and results in unnecessarily fragmented care.
The path forward for primary care
Ensuring PCPs have the skills and knowledge to perform motivational interviewing and effectively care for geriatric and psychiatric patients requires both training and time. In addition to more education in medical school and residency, PCPs must commit to regular continuing medical education (CME) in these areas. Programs like Train New Trainers, a part-time, online course aimed at training PCPs in primary care psychiatry, and the University of Massachusetts’ Certificate of Intensive Training in Motivational Interviewing are two examples of high-quality, high-yield programs that can fit into a busy PCP’s schedule.
Even with proper training, PCPs may reasonably protest that there is not enough time to do these things in a rushed office visit. As a profession, we need to thoughtfully delegate appropriate tasks, such as routine preventive care (e.g., ordering standard cancer screenings) and straightforward acute issues, to nurses, advanced practice providers, and artificial intelligence (AI). Doing so allows physicians to focus on more complex care and practice at the top of their license. While some situations may require physician input (e.g., determining whether a patient should go to the emergency room (ER)), issues like simple lacerations or uncomplicated upper respiratory infections rarely do. Administrative tasks, such as completing forms or navigating insurance requirements, should be handled by nonclinical staff or supported by AI.
Primary care is in crisis. Saving it will require a wholesale retraining of its workforce and reconsideration of how that workforce uses its time, with the aim of addressing the needs of an older, increasingly complex patient population saddled with chronic disease and poor mental health. Doing so effectively will increase provider and patient satisfaction, lead to more cost-effective care and restore primary care to its rightful place as the foundation of our health care system.
Justin Oldfield is a family physician.
