Sunday, November 29, 2009

Primary Care's Problem: Putting the Sexy Back

Hugh Laurie can't do it. (We need to cut back on over testing, doctor, and those pills!...)

Marcus Welby can't do it. (Who? You mean that OLD guy?)

8% pay raise through cost shifting can't do it. (And you want me to fill out how many forms?...)

Calling their clinic a "medical home" and flooding it with angry people who can't get an appointment won't do it.

So how do you do it?

How does one go about putting the "sexy" back in primary care?

This is one of health care reform's biggest problems and right now, just about every piece of legislation promised to further overwhelm primary care doctors with more hoop-jumping than ever before. From ICD-10 with it's 150,000 billing codes, to mandates to purchase expensive medical record systems that, so far, have proven their worth to administrative collection agents in their protected silos well before they have proven their worth to our nation's health. Or to pay for performance, a form of least-common-denominator medicine that forces compliance before enabling innovation in health care efficiency. Primary care is no longer sexy, it's becoming cookbook. So much so that nurse coordinators have become the new buzzword for primary care - not exactly a reason to enter four long years of medical school and three more years of residency training. Who wants to go to school of become a doctor only to find out that you're really going to school to become a nurse manager?

And then there's the academic mega-centers' disdain for private practice care. The not-so-subtle elitist attitude that private doctors in the community aren't nearly as good as the academic megacenters' specialist care, while they, themselves, have never set foot outside their pearly gates to work in the trenches lest their white coat become soiled.

Primary care is not about medical robots, waterfall lobbies, big screen TV's and marble floors. But those things are sexy. And we all know that Americans, like bugs, are drawn to bright and shiny objects. We love the whizbang, the big buildings, the nice decor. We scream for the latest and greatest hospital additions with computer technology and the latest robots, only to turn around the next day to scream about our hospital bills. God forbid we put two and two together.

Primary care doctors are up against all of this and the marketing efforts they employ. No wonder they cannot compete.

Putting the sexy back in primary care will involve anything but more bureaucracy and oversight. Congress does not get that these aren't sexy. To them, the tombs of legislation are what's sexy ("See all the work we did?")

But what's sexy to doctors is using independence and entrepreneurism in medicine for the patient's benefit. That's sexy.

And unless our legislators get that, primary care will go the way of the dinosaurs and the great paucity of care providers imposed by bureaucratic doctrine, will continue unabated.


Addendum: Today we find that general surgeons are way ahead of primary care doctors in bringing sexy back to their profession.

It seems some are leaving the drab of emergency room call to fill SWAT teams in a "national movement" to embed medical professionals "so that help is at the ready should something go wrong."

Pitty the poor ER patient who finds the general surgeon is out on a drug bust.


Anonymous said...

Wish this had been two separate blogs. But the one that riled me was the doc playing cop. As though there isn't enough going on at Stroger to keep him busy. Giving the cops ER training is fine, but for goodness sake do it in the hospital - not in a crack house. And if this is the next "new" thing, we really are stupid. Docs carrying guns - wait 'til the NRA gets ahold of that brilliant idea.

Michael Kirsch, M.D. said...

Wes, you are not alone. Specialists like me are also being de-sexified and neutered in order to morph us from physicians into health care providers, or some other dehumanizing term. In gastroenterology, we have pay-for-performance and other qualityu initiates that were conceived by bean counters somewhere in the land of make believe. All of this stuff is really pay-for-documentation that confers no health benefit to a living breathing human being.

With regard to your comments regarding tertitary centers’ disdain for those of us who do real doctoring in the streets, I know this issue well. When I was in training in a rather well known medical center in Cleveland, we would also snicker at the plebian physicians in the community whom we had to rescue routinely. Five minutes after I graduated and left rarified academia, I became the snickeree.

ShrinkingDoc said...

It's not sexy--understatement. Piles of phone messages and crazy forms, hours of call, more money for freezing a wart than taking care of someone with 5 serious medical problems, expectations to screen and deal with more and more at every visit all the time, all he things you mention, Dr. Wes...

I completely believe in primary care in theory--we're all going to get worse medical care in the future because we're not going to be able to find good primary care docs. It just plain sucks to DO IT.

I got out of it because of life circumstances and burn-out. Life's different now, but I can't see going back when I can work in urgent care--fewer hours, more money, less paperwork, sleeping every night, more variety. I feel like a lazy loser and a traitor, but it wouldn't make sense.

Isle Dance said...

Putting two and two together, indeed.

Keith said...


I been trying to do sexy all my life, but it just isn't working out.
But you are right; the day to day care of patients can be a grind. It is much easier in most cases (not all) to do your procedures or read your studies and leave all those mundane issues to someone else to deal with at the end of the day. It takes too many years to realize the principal benefits of primary care which are the ongoing relationships you have with patients over the course of decades. They become more than just your patients.

Anonymous said...

And then there's the academic mega-centers' disdain for private practice care. The not-so-subtle elitist attitude that private doctors in the community aren't nearly as good as the academic megacenters' specialist care, while they, themselves, have never set foot outside their pearly gates to work in the trenches lest their white coat become soiled.

Where I live - everyone knows the townies (versus the gownies at the university) are much better! Our university hospital is good, don't get me wrong, but the private docs in town are superior to them!

Dr. Val said...

Wes - Dr. Alan Dappen and I are bringing sexy back to primary care! We've fired the middle men - we don't take insurance - and have returned to the way medicine used to be practiced: pay as you go, time-based billing. That frees us up to make house calls, office visits, phone calls, emails, webcam interviews, texts, etc. Whatever is convenient and necessary!

We charge $300/hour for our time - most complaints take 10 minutes to solve (that's $50 bucks), we answer our own phones, have almost no need for office staff, and have reduced unnecessary office visits. We keep people out of the ER (by heading off problems early - from their homes) and most of our patients get all the primary care they need for $300/year.

Alan and I are having FUN - we use microphone dictation/customized EMR/GPS guidance/iPhones/Twitter/webcam/decision-support EBM tools... and offer convenient, rapid triage by docs.

Do we make a ton? No. But we make almost as much as we would taking insurance - without the drudgery and waste of admin burdens.

The rate limiting step is consumers finding us and being willing to pay $50 dollars for immediate MD care rather than their $20 copay for a visit 2 months later. People are starting to do the math/convenience equations... But a rise in high deductible/HSA insurance models would put patients back in the drivers seat and be the tipping point we need.

Alternatively, smart hospitals might hire us to reduce their readmit rates - which will ultimately affect their reimbursement.

Exciting times...

inchoate but earnest said...

Up the sexy quotient by leaving the stupid out - stupid being whines along the lines of 'if only we could return to the days when people just accepted what doctors said/did as healing gospel'.

I'm sure Dr Kirsch doesn't mean to come off as a prima donna for whom data capture/reporting is only for the "little people", but man, if you can only BOAST of being better, rather than demonstrating it, well, that's just a turnoff. (As you've done the same riff elsewhere, Dr K - WSJ Health Blog - I'm guessing it's not a one-of-a-kind thing with you).

Dr. Val may be getting it - not completely clear from his (her?) post, but closer....

Michael Kirsch, M.D. said...

To the anonymous inchoate commenter, I assure you that I am no prima donna. Yes, I did get your 'Leona Helmsley' veiled reference. My point is that I don't think that the current 'pay for performance' models will measure or reward true medical quality. I don't think that what should matter to patients can be easily counted. If you couldn't reliably measure a work of art's worth, would you use its weight as a quality measurement just because it is easy do? The current quality programs are crude and incomplete. Excellent physicians can rate low on their grading system, and vice versa. I think that their value has been overestimated and misunderstood by the public. This is my not so inchoate, but earnest view.