Family Medicine and Primary Care: Challenges Mount, But Solutions Exist

In the 1969 feature film Butch Cassidy and the Sundance Kid, our heroes face an impossible choice: to either be captured by the pursuing posse, or jump off a cliff into a raging river. An embarrassed Sundance at first declined to jump, confessing he couldn’t swim. Butch chuckled and assured him it didn’t matter; the fall would most likely kill them both. Similarly, difficult choices face today’s primary care providers. They must either: spend long hours navigating the myriad of escalating requirements of the healthcare industry (payers, regulators, EHR) to fulfill a myriad of escalating requirements, or work tirelessly to maintain a delicate balance of professional and home life. And for most, neither is likely to happen. Primary care systems nationwide are in crisis. As systems rapidly adopt changes to their care models, providers are put at risk. They are expected to respond to rapid and often haphazard implementations of electronic health record systems, worsening reimbursement, and an increasing demand for quality measure reporting. These, and many other factors, contribute to provider burnout that has becoming increasingly common. 1 As even more time is needed to keep up with the demands of the EHR and other administrative tasks, less time is available to attend to the needs of patients.

Frustrated Providers Providers spend increasing amounts of their time outside of clinic hours corresponding with patients via email, Epic

MyChart, and text messages. This time is usually non-reimbursable but takes its toll on providers available time. They are also expected to increase productivity as reimbursement lags, and commonly see their professional life infringing on home life as “pajama time”—a term used to describe EHR and other work done at home —an average of 86 minutes of additional time per day—that could not be fit into the clinic day. 2 Current practices such as limited clinic visit lengths and productivity needs force a lessening of connections between providers and their patients, connections that providers often cite as the most enjoyable part of their practice. While attempting to balance work and home and lessen the effects of burnout seen in the majority of primary care providers, many choose to work other than full-time as a career choice.

Future Career Choices Affected Traditionally, medical students chose their specialty focus based on their own unique passion and interest. They were often influenced by faculty mentors or those practicing in specialties that the student might have an interest in pursuing. Students might come to family medicine and other primary care specialties with an altruistic view of the world or as a way to serve their communities. In our residency program, we look to acquaint medical students with Family Medicine as a specialty that provides continuing and comprehensive care for individuals and families, seeing the relations with patients as a special and trusted bond. But it is increasingly difficult to teach learners the joy of practice while at the same time acknowledging the difficulty parsing time among numerous priorities. As new providers become familiar with the workload required to care for their patients, their enthusiasm wanes. They are more often seeing primary care specialties as less desirable as they recognize the increasing level of work expectations (both in hours and in intensity) that will be placed upon both them and their families as they start out their careers.

Debt as New Focus Specialty decisions are also often based on future compensation rather than personal passion. As the level of debt (medical school tuition and living costs) that medical students incur rises, loan repayment becomes a significant influence on specialty choices. The increasing debt load that many residents carry further dampens their

passion for Family Medicine and other primary care specialties. Medical students regularly speak of their specialty choice as driven by the need to repay their student loans, rather than a choice based on a passion for the specialty itself. Many come to residency training with significant debt (often more than $350,000). They are increasingly resigned to paying off their debt throughout their career or choosing to live an austere lifestyle for many years to repay their debt more rapidly.

Solutions But solutions to these worrisome issues, e.g. increased administrative workload, lack of home/work balance, student debt, do exist, if we can muster the courage to act. Restructured financing of medical education could make a significant difference in the number of students choosing primary care specialties. The elimination of medical school tuition (as NYU has done) or a wider use of forgivable loan programs (based on specialty choice) are two innovative ways to reduce or eliminate medical student debt. Such plans would both promote freedom in specialty choice and enhance career satisfaction. Such programs, properly focused, could also address the critical shortage of primary care providers. Those who are in charge of federal healthcare budgets (such as CMS) acknowledged that the coding expectations placed on systems is convoluted and excessive. Counting elements in a physical exam or the number of problems addressed in a visit is a tedious and inaccurate process to measure care. Within the next year, new E&M coding regulations will be deployed that will hopefully lessen some of this coding burden. It is a modest step at best, but at least acknowledges the administrative burden placed on systems to simply ensure they are properly reimbursed.

Team-Based Care Approach To reverse the concerns of overwhelming administrative work and provider burnout,

the clinic care model needs to change. It is evident that the model that places the provider at the center of all patient care activity is flawed. Such a model is not built for current and future patient or system needs. To embrace a truly patient-centered focus, systems must align with patients and providers. Meeting the patient where they are comfortable (home, clinic), communicating with them in ways that work best for the patient (clinic visit, email, text), and encouraging the team to be the source of care are all ways that the present model can improve. Developing a sophisticated practice infrastructure for form completion (a significant clinic and provider burden), chart updating (meds, problem lists, allergies, results), healthcare staff trained to review patient registries to encourage needed care in a timely way, shared in-box responsibilities, and quality measure reporting are important ways to meet the needs of patients and payers, and reduce the overhead burden placed on providers. To bring about this transformation from provider to team, from individual to group care, regulations must be examined to allow others (besides the provider) to initiate, complete and be reimbursed for the care provided to the patient. Systems must demonstrate a willingness to move beyond viewing the clinic visit as the anchor point for where and how all care is provided, and move to a multi-dimensional view of care provided by a variety of resources, in a multitude of ways, dictated by the needs of the patient, not the requirements of a system.

Care Model Change Roadmap Care model solutions will vary based on the type of practice and the needs of the patient. Some ideas that have been shown to be successful in practice include: • Proactive planned care between visits • Team-based care that includes expanded rooming and discharge protocols, standing orders and panel management • Shared clerical tasks including documentation, order entry, and prescription management

• Protocols that allownursingand support staff wider latitude for handling traditional provider work (inbox messages, initiating orders, results communication) 2

Patients See Change Coming Patients can sense opportunities other than clinic visits to obtain care. Smart phone apps assist patients to collect data for their own use and share with their providers. “Dr. Google” is often the first place patients turn to with a health concern. Enhanced EHR access (such as Epic Open Notes), group visits, telemedicine (Virtuwell and online “clinic visits”), all let patients access care in convenient and timely ways. When patients have the opportunity, they show interest in more varied ways to access care. Telehealth, especially in more sparsely populated areas, can allow patient access to primary care providers and other healthcare professionals that might not otherwise be available. As healthcare systems fail to embrace the changes that patients clamor for, they face an overtaxed system where ED visits are often the default care site available. But if primary care practices can embrace, and regulatory agencies can support, improving care models and systems can reverse their role in the growing career dissatisfaction among providers, and primary care can remain the most effective and comprehensive care model for patients into the future.

Jerry Potts, MD is the Chair, Department of Family Medicine, Hennepin County Medical Center. He can be reached at jerome.potts@ hcmed.org; (612) 873-8077.

References 1. 10 Bold Steps to Prevent Burnout in General, Internal Medicine J Gen Intern Med, Jan 2014; vol. 29 no. 11: 18–20. 2. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations, Ann Fam Med, Sep/Oct 2017; vol. 15 no. 5: 419-426.