A wise man once told me this story and how it relates to the current primary care crisis:
Bernie paced nervously across his bedroom. Back and forth. Back and forth.
“Bernie, what’s the matter with you?” his wife called from the bed, annoyed at Bernie’s pacing.
Bernie stammers, “It’s Reginald, our neighbor. I owe him $50,000 tomorrow and I don’t have the money to pay him.”
Bernie’s wife calmly walks over to the bedroom window and opens it.
“Hey, Reginald!” she shouts, “Bernie doesn’t have the money so he’s not going to pay you tomorrow!”
She calmly moves back to the bed and gets under the covers. “There,” she says. “Let him worry about it all night and you go to sleep.”
Bernie is the primary care workforce community. We are nervous. We are pacing back and forth because we can’t possibly go on providing care through 30 15-minute visits a day, lacking the technology to appropriately coordinate care and watching our colleagues choose more lucrative specialties like radiology and anesthesiology.
Reginald is the U.S. healthcare system, and the people. Reginald assumed he would be getting that money just as the system and the people assume primary care will always exist. However, they, like Reginald, may be in for a sleepless night, unless some key forces align.
First, let me explain what primary care is as defined by the late health policy expert Barbara Starfield: It is the component of any healthcare system which allows people first contact accessibility, coordination, comprehensiveness, and continuity of care. In other words, (ideally) call or come by anytime, let us make sure your stomach expert talks to your eye expert, we know medicine from the abdomen to the zygomatic arch, and we will stick with you as you grow old.
Even when primary care doesn’t match these ideals (one study showed that 58 percent of primary care practices turn on an answering machine telling patients to dial 911 for emergencies after 5:00 p.m.), numerous studies demonstrate that the more primary care practices a geographic area contains, the better are its population’s health outcomes (less hospitalizations, less uncontrolled chronic diseases) and the lower are its population’s healthcare costs.
That matters, because the problem of rising healthcare costs is noted by some to be the greatest threat to the future of the U.S. (and the main reason certain lobbying groups are making change difficult).
Unfortunately, medical students didn’t get the memo as only about 9 percent chose adult primary care careers in the last few years. A third of U.S. doctors and half of all doctors in other wealthy countries work in primary care.
Meanwhile, current primary care doctors are retiring at a rate faster than most other specialties. But who can blame them? They get paid less, and their job, when it entails seeing dozens of patients a day in back-to-back appointments, is much less fun than other physician specialties. Therefore, we have ourselves a primary care workforce shortage. Even if healthcare reform is able to give us insurance, it doesn’t mean people will have access to a primary care practice.
So, Reginald, we have a problem. And it isn’t a problem that Bernie is going to be able to fix alone; we need to think together on this one. Just look how popular WebMD and other medical advice sites have become, and look at the popularity of yoga, acupuncture, and farmers markets. Health is being incorporated into good ideas, and we need these ideas to help transform primary care. This isn’t just a primary care doctor’s problem anymore, it’s our problem.
Do you think primary care is an important part of healthcare? Let us know in the comments.
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Dave Margolius is a physician in San Francisco, California. He is originally from Cleveland, Ohio, and attended Brown University for undergrad and med school. He is currently doing his residency in internal medicine at UCSF. His main interests are in health policy, improving primary care, and healthcare for all.