Why Primary Care Is Struggling
As a devoted follower of The Nocturnists podcast, I was thrilled to dive into their new series on uncertainty in medicine. In episode three, they share the harrowing story of a woman who suffered mysterious complications after a knee replacement, and how her primary care physician served as her counselor, investigator, and advocate. She sat with the patient in her grief, left no stone unturned, and listened when the patient finally discovered the breakthrough she needed in order to heal. It’s an inspiring listen, and I highly recommend checking out the episode here.
A connection they drew halfway through the episode is what really caught my attention: that primary care is struggling to retain physicians because of a lack of preparation to face high degrees of uncertainty. According to the episode, over 100 million Americans lack regular primary care, so the lack of access is clearly dire. But as someone who’s doing a mid-career switch from primary care to palliative care, I knew what turned me away from primary care was much more complex than uncertainty. After all, I feel that I’m trading the relative certainty of satisfying diagnoses like pityriasis rosea, mononucleosis, and cholelithiasis for the biggest unanswerable question of them all: how much time do I have left?
So if it wasn’t uncertainty, what was it? This question got me thinking about my own reasons for choosing primary care back in medical school and the subsequent struggles I’ve identified over the years. As an idealistic student, my inspiration was the hardest-working physician I’ve ever met, who served at a local federally qualified health center. Her days were incredibly chaotic, but she faced it all with a smile and never complained. I admired her compassion and found that we had similar values and ways of viewing the world. My advisor’s caution that I “scored well enough on Step 1 to do something else” merely cemented my idea that serving in primary care was a worthy cause and would ultimately be the most rewarding path for me. I was well-educated on the need for primary care but not the challenges. Years later, here are my reflections on the greatest difficulties I’ve faced as a primary care physician.
Scope and Time
When I read a note from an ER visit or specialist visit in which something wasn’t fully addressed, I cringe when I read “follow up with PCP.” Certainly I agree with them that continuity is important and that a single visit can’t fully address or resolve many problems, but primary care simply doesn’t have the resources to serve as the catch-all it’s intended to be. There’s nowhere near an adequate amount of time to address multiple concerns that span various organ systems, along with psychological impacts and socioeconomic barriers. While knowing that they face their own sets of challenges, I sometimes read specialists’ notes with a twinge of envy wondering what it would be like to have more time to address one organ system when I get 15 minutes to address three, plus an FMLA form. This isn’t the fault of the specialists - it’s the fault of a system that pays lip service to the importance of primary care but doesn’t back that up through appropriate allocation of resources.
I won’t even venture into the ways that our compensation structures funnel complaints into the primary care system under the guise of continuity of care, when in actuality we’re containing costs for insurance companies at the expense of the undervalued and undercompensated PCP’s time with their family. And sometimes their sanity. Physicians often run behind in clinic because they spent more time with patients in crisis, but this places unintentional stress on other patients who need to be seen on time so they can get back to work or pick up their children. Then the physician compensates with their own unpaid time, working through lunch and spending their evenings catching up on several hours worth of notes and messages. When I’ve been gifted extra time with a complicated patient due to a cancellation or no-show, I’ve been baffled to learn that it’s not the complexity or scope that overwhelms me but simply the mandate to handle it all in an impossible amount of time. I can feel myself breathing easily again, and I leave the visit more satisfied that I gave it my best and did right by the patient, even if I didn’t “fix” anything. Because I was able to be with them. What if this were the norm rather than the exception?
Opposing Stakeholders
I’ve always been very aware when I’m in the room with the patient that there are multiple stakeholders present and that they often have diametrically opposing agendas. Juggling these can feel like a sisyphean task, and it requires - you guessed it - more time from the physician to try to satisfy or work around each of these competing interests. There’s the patient’s agenda, which may be medical but may also be psychological (they’ve stopped taking their medications due to depression because their romantic relationship just ended) or economic (their asthma has been worsening recently because they can’t afford their inhaled corticosteroid). There’s the physician’s agenda, likely meaning whatever the physician has identified as being an imminent threat, whether it’s a blood pressure of 180/115 or an A1c of 14. Or both.
“Primary care is written off as runny noses and ankle sprains, and that narrative completely misses the chronic devastation we serve witness to every day.”
There’s the agenda of the pharmaceutical industry - your patient is interested in this new, expensive treatment option because they saw a convincing ad on TV, but it’s going to require you to complete a lengthy prior auth process before it gets denied. There’s the agenda of your accountable care organization: this patient has overdue preventive care items that might affect your reimbursement if you don’t meet your metrics, but the patient keeps scheduling last-minute urgent visits instead of a physical so you find yourself putting out fires instead of discussing cologuard. And there’s the agenda of the insurance company, who’s going to deny the pap smear on the 22 year old who had LSIL last year, because they only cover the preventive screening interval of once every 3 years. They’re also going to deny a GLP-1 for the patient with a BMI of 43, bilateral severe knee OA, and uncontrolled HTN despite three agents - because they don’t yet have diabetes and can't afford a sleep study to confirm their suspected OSA. These challenges are present in other specialties for sure, but the breadth of scope, limited time, and lack of support staff tend to compound these issues in a primary care setting.
Health Disparities
By far the biggest source of the burnout I’ve experienced in primary care is that we are on the front lines of the failures of society to care for those who are most vulnerable. As someone who went into medicine to help people, feeling that I’m a broker who has to divvy out different treatments to the “haves” versus the “have-nots,” rather than being able to offer everyone the standard of care, is a deep moral injury that I will never feel settled with. I routinely incorporate cost into my conversations with patients on how to proceed, whether it’s regarding labs or imaging for a workup, treatment options, or specialty consultation, and I try to be very clear that I’m in no way profiting off whichever choice they make, despite my appearance of a conflict of interest. The real conflict is that I walk in the balance between missing a consequential diagnosis and committing someone to crippling medical debt.
I also grapple with the seemingly impossible mission of helping someone improve their health when our society requires a certain percentage of the population to remain financially subjugated in order for our power structure to continue to operate as it does. The United States has some of the greatest income inequality amongst developed countries, and for those at the bottom it’s difficult to meet their most basic needs, let alone invest time, energy, and money into caring for their health. I’m tasked with helping a person with diabetes control their blood sugar when they’re working night shifts in a warehouse, struggling to sleep during the day, relying on a neighbor to help care for their three children, and driving for gig economy rideshare and food delivery services with every spare moment. Even if I help them find affordable medications, develop a feasible system for taking them, make healthier food choices, and get the recommended amount of exercise, this person still struggles to survive. The devastating scale of these disparities is seen most clearly in primary care, and primary care physicians are tired of feeling that their inability to fix the system is somehow a personal failure.
Conclusion
I know some people may rush to emphasize how important it is to find primary care providers who persist despite these challenges, and I completely agree. There are many physicians for whom primary care can be a sustainable choice with the appropriate supports and boundaries. However, I feel strongly that we need to explicitly acknowledge what a challenging environment primary care can be, so that our physicians go in with their eyes wide open and stop wondering what’s wrong with them when they experience burnout. These problems need to be addressed by the system that created them, but until then we need to care for the physicians who are suffering under its weight.
When they hear I’m going into palliative care, many people respond, “What a sad field to go into. It must be so hard.” I respond that at least people acknowledge that palliative care is hard. Primary care is written off as runny noses and ankle sprains, and that narrative completely misses the chronic devastation we serve witness to every day. An ironic twist in the Nocturnist podcast episode is that the hero physician in that story was also in the process of leaving her job. I have to contend with my own guilt over leaving, but we have a crisis of burnout on our hands, and it’s time to stop blaming physicians for not trying hard enough.
This is why I started EmpoweredMD. To be the voice that says resiliency training, while helpful, doesn’t solve systemic injustice. We have to take control of our own experiences and restructure our expectations and responsibilities within medicine. We need to feel empowered to make the choices that are right for our own well-being and stop believing the lie that we’re only worthy when we’re serving. By taking care of our own health first, we can then show up for others as our best selves. If you’ve resonated with this article and want support in your journey, please sign up for a complimentary coaching consultation with me today.