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‘Used to’ don’t live here no more: The changing role of primary care

Posted by Adair Parr, MD, JD July 15, 2011 at 3:53 PM

By Trudy Singzon

I’ve left the cold summer weather in San Francisco for the hot, humid weather of my hometown in central Pennsylvania. It’s my grandmother’s 85th birthday and most of our extended family is in town for the celebration. I grew up in a small town where my father was a primary care physician and my mother was a school nurse. I spent my childhood going on home visits with my father and to community blood drives with my mother. On the weekends, I frequently went to the local community hospital to go on rounds with my father. (Don’t be alarmed. This actually this meant sitting at the nursing station and making get well cards while he rounded on his patients.) It was not uncommon for my parents to field medical questions in the grocery store, after church, and during holiday picnics. We often got calls for advice at our home. Obviously, these early childhood experiences influenced me: I am now a family physician in a community health center. When I have occasion to return to the area where I grew up, I often reflect on my decision to be a family physician and how primary care has changed since my childhood years.

Since I took a non-traditional path and made the decision to apply to medical school in my late 20s while working as a health consultant, I knew that the world of medicine that I was about to enter would be very different than what I had experienced as a child. I was already aware that few primary care physicians were in solo practice anymore and, once in medical school, I was repeatedly told that primary care was a dying field that should be avoided. But I was stubborn and already in my 30s, so I didn’t listen to that unsolicited advice. I became a family physician because I believe in the importance of primary care and in the value of knowing patients as people in the context of their families and their communities…and I’m happy to report that I love being a family physician today.

But my role as a primary care physician is a lot different than what I witnessed as a child. My father was in solo practice and in the early years, my mother was his office manager, nurse and accountant. He rounded on patients in the hospital early in the morning before his clinic day and then after a full day of seeing patients in clinic, he returned to round once again on his hospitalized patients. He seemed to always be on call and most weekends included visits to the hospital. These days, in contrast, hospital-based physicians called “hospitalists” care for most patients during their stay in a hospital and most primary care physicians take care of patients only in the outpatient clinic setting. Still, it seems there’s a lot more to do in primary care these days. In fact, most studies reflect the fact that there’s too much to do and this is resulting in both unhappy patients and unhappy primary care physicians.

Like most primary care physicians these days, I struggle to provide the best care that I can in a health care system that expects me to cover all preventive care, chronic disease management, and also address patients’ concerns (which may or may not be aligned with my own) in just a 15-minute visit. Each day that I’m in clinic generates hours of non-visit work. There never seems to be enough time in the day or during the 15-minute face-to-face visits. I am often frustrated when it seems that I spend more time doing paperwork than practicing medicine. But ultimately I stay late or come in during my days off because I want to do what’s best for my patients.

But I’m also lucky in that I have a lot of help: my nurses and medical assistants (MAs) who help the clinic day run as smoothly as possible; a nutritionist who sees individuals as well as runs group visits; a pharmacist who runs a blood pressure group as well as seeing individual patients for blood pressure checks and medicine reviews; several volunteer health coaches that have been trained to coach patients about chronic disease self-management; and a diabetes educator that runs group diabetes visits as well as individual sessions (and I’m sure I’ve forgotten someone). In February, a new team of behaviorists and behaviorist assistants joined our clinic. The goal of this model is to provide co-located, brief interventions on a wide variety of behavioral and psychosocial issues. Our behaviorists provide brief counseling and can link patients to community resources. The behaviorist assistants can assist patients with forms for various programs, including disability, and they are my go-to consultants for a myriad of community resources such as housing, food, and so much more. So all of these people help to make my job much more doable.

Over the course of the past year, we’ve also participated in an access improvement pilot project that allowed us to work down our backlog of patients waiting for appointments and has improved our average clinic wait time from 45 days to 15-20 days (depending on provider vacations/absences) for a non-urgent appointments. We have also restructured our templates and can usually see patients with more urgent needs on that same day or within 48 hours, depending on the severity of the need. But what I feel we gained the most from this project was a culture of change…and there certainly has been a lot of change over the past year.

The majority of our patients are now assigned to a primary care provider and we now try as much as we can to see our own patients because we know that this is both more efficient and better care for our patients. Our medical assistants now review the charts of patients coming in the next day and fill out a card to inform the primary care provider what health care maintenance is due. We huddle before each clinic to discuss any staffing issues and any clinical issues that the MAs have discovered during their chart review, and to give the behaviorists an indication of what patients they might be seeing that day. The goal is to have a proactive approach to the clinic day. Our redesign and quality improvement efforts continue even now that the access improvement project is over. We continue to work on reducing our backlog of patients, but we’re now also working on improving office efficiency and workflow. We’re now piloting agenda setting forms so patients and providers can make the most out of the visit by knowing at the very beginning, what topics the patient would like to have addressed. And slowly but surely we’re moving toward team-based care. But we still have a lot of work to do and there are always improvements that can be made.

Primary care physicians can no longer be everything to everyone and we can’t do it all alone. There’s simply too much that needs to be done to appropriately care for a panel of patients (even when the panel size is right-sized.) Physicians need to learn to work in teams and adapt to the ever-changing landscape that is the field of primary care. Change is hard. But it is possible…even in a resource-poor community health center. And change is necessary. We need to remember that as physicians, we are actually trained to adapt to change…remember residency? On a busy night on the wards, as new labs come in, admitted patients suddenly become ill, and new patients are admitted with unclear diagnoses and perhaps vague symptoms, we were trained to adjust care plans accordingly and reprioritize constantly. Medicine as a field is constantly changing. If the content is constantly changing, why is it so difficult to believe that the context must also adapt?

We owe it to our patients and to ourselves to believe that we can improve care. And we must learn to rely on others to help us to do this. In my clinic, I believe the key to our ongoing success is the interdisciplinary redesign team that continues to meet (even though our pilot ended in March) to work on redesign and process improvement efforts. We continue to work on simultaneous efforts to improve care including backlog reduction to improve access, various quality improvement projects, redesign pilots to improve our clinic flow, and efforts to move towards true team-based care. We are hopeful that this will eventually translate to improved patient satisfaction and patient-centered outcomes but in the meantime I know that with all of this help, it’s making my job as a primary care physician much more feasible and, on most days, more enjoyable.

When I made the choice to become a family physician, I knew that my role would be very different from the primary care physician that my father was when I was a child. But to quote my soon-to-be 85-year-old grandma, “used to don’t live here no more.” (She’d probably want me to tell you that she doesn’t actually speak like that but it’s a phrase that the older folks here say whenever anyone protests that “we used to” do it this way, etc.) So given that, it’s time to move forward.

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