What happened to the family doctor?

What happened to the family doctor?
They're overwhelmed with patients and paperwork and they're leaving the field. Solutions could include patient-centered medical homes, healthcare coaches and fee changes.

By Cathryn Delude, Special to the Los Angeles Times
June 27, 2011

The days of the old-fashioned family doctor who knows us intimately and treats our kids — and our grandkids — are fading fast.

Instead, we're more likely to find ourselves searching for a doctor who will take our insurance, then waiting weeks for an appointment and hours in the waiting and exam rooms. Our doctor will rush in and rush through a series of pokes and prods and a checklist of questions, check off some codes on our record, then rush out again.

None of this makes us very happy — or, for that matter, the doctor either.

Primary-care doctors take care of the young, the old and the in-between; the sick, the well and the dying. Ideally, they're familiar with us and our family history, have a comprehensive overview of our various ailments and medicines and provide us continuity in the world of fragmented medical specialties. But their trade, they say, is getting trickier and more time-consuming, and that's fast making them an endangered species.

Patients, they say, want more from their doctor these days — more office hours, more email and phone contact, more follow-up, more coordination with specialists and insurers, more discussion about options and more expertise on more topics (aided and abetted by that constant TV-ad refrain, "Ask your doctor if X is right for you").

And the healthcare system expects more of doctors too — more preventive services, more care for chronic diseases, more healthful lifestyle coaching, more screening for depression and risky behavior (guns? cigarettes? bike helmets?), more delicate discussions (prostate biopsy? end-of-life wishes?), more documentation and now electronic records too.

Numerous studies have found that when primary care works well, patients are healthier, with better management of chronic diseases and fewer emergency-room visits and hospitalizations. All that saves healthcare dollars too.

But many doctors say there is not enough time in a typical 15- to 20-minute office visit to cover all the tests, inquiries and procedures recommended by medical schools, the U.S. Preventive Services Task Force and other organizations — even when dealing with a healthy patient.

"It's almost overwhelming," says Dr. Christine Sinsky, a primary care physician at Medical Associates Clinic and Health Plans in Dubuque, Iowa. "I think many of the new expectations are laudable and yet can't be delivered by one person working all by themselves."

And so doctors must give some things short shrift. A conversation about prostate cancer screening that would ideally take 10 minutes gets maybe a minute, says Dr. Mark Friedberg, a researcher at the Boston office of the nonprofit Rand Corp. who practices two mornings a week at a Brigham and Women's Hospital clinic in the Massachusetts city. "Physicians don't have time to really do optimal primary care," he says.

The situation is worse, he adds, when you factor in the increasing number of patients with complex conditions such as asthma, diabetes, obesity or heart disease. They require more frequent visits, and the list of steps recommended for their care is steadily growing.

Rushed office visits are only a part of the problem: Growing too are activities outside the exam room. Every prescription refill request should trigger a review of a patient's medical records. Every lab test, imaging result and specialist report should be interpreted in light of the patient's overall treatment plan.

Doctors are now meant to keep registries of patients with chronic diseases and periodically reach out to them to make sure their conditions are managed.

"It's common to have two hours of documentation work to do at home after the kids are in bed," Sinsky says — and there's no formal way to bill for these tasks or receive productivity Brownie points for doing them.

Studies back up these doctors' gripes. It would take 10.6 hours a day for a physician to follow all the treatment recommendations for patients with 10 common chronic diseases, including diabetes, heart disease, high blood pressure, depression, asthma and arthritis, according to a 2005 study in the Annals of Family Medicine. That doesn't leave much time for a 6-year-old's school physical or his mother's brush with the flu.

Activities outside the exam room consume about 20% of a primary-care doctor's workday, according to a physician survey reported in the Journal of General Internal Medicine in 2010. This tally includes telephone and email interactions that often substitute for office visits.

Many of us prefer these virtual visits: Our time is precious too. But they are a problem for doctors because most healthcare insurers, including Medicare, reimburse doctors only for face-to-face visits, a payment model called fee for service. And even many aspects of office visits are essentially free, because primary-care doctors must bill for their time using only five codes for Medicare and most commercial insurers.

"If you can't find a code that describes what you are doing, you don't get paid," said Dr. Roland Goertz, president of the American Academy of Family Physicians, which represents more than 100,000 doctors and medical students.

But for many primary-care doctors, the frustration is not so much about pay as about all the things that interfere with their ability to spend adequate time with their patients.

The number of U.S. medical school graduates opting for primary care dropped almost in half between 1999 and 2009, according to the latest statistics, though the trend has reversed a little in the last two years. They're flocking instead to specialties such as anesthesia and dermatology. Meanwhile, primary-care doctors are leaving their practices to become specialists or employees of hospitals, with set hours and salaries.

The trend comes at a point when they have a pivotal role to play in a nation suffering from more and more chronic diseases and higher healthcare expenses, experts say.

So what's to be done?

Four physician groups — the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Assn. — believe the answer lies with a different way of patient care, known as patient-centered medical homes. It's an idea that germinated in the late 1990s as a way to provide patients more access to primary care — with longer office visits and office hours, more convenient electronic scheduling, a team approach to managing patients' health and more email and telephone contact with physicians.

To date, more than 100 primary-care practices in the U.S. — a tiny fraction — have restructured themselves as patient-centered medical homes. Some are pilot programs funded by President Obama's Affordable Care Act.

For these "homes" to work, experts say, medical practices need to move away from paying doctors just for face-to-face visits to a system that pays them a set amount for each patient, including services outside the exam room, so that the doctor can focus on keeping patients healthy rather than checking off codes.

The medical homes also require well-functioning teams of doctors, physician assistants, nurses and other staff that share responsibility for patient care, says Sinsky, whose 115-physician group in Dubuque was an early adopter of the model. "That's hard for small or solo practices. It requires more infrastructure, and that doesn't happen for free," she says.

And there are other complexities. Ideally, the medical home model would give doctors more time with their patients — to make this happen, some advocates suggest that doctors should have fewer patients. But this could exacerbate the shortage of primary-care doctors, Sinsky says.

Another suggested alternative is scheduling fewer individual office visits with patients and more group visits — say, bringing together several obese patients to meet with a nutritionist — and offering more care remotely, such as having diabetes patients email their blood sugar or blood pressure results from at-home monitors rather than come to the office for them to be checked.

An even better solution, some say, could be to relieve physicians of more tasks that support staff could reasonably do — such as renewing prescriptions or ordering routine tests.

"You don't need a doctor to order a mammogram every two years for a woman 55 years old," says Dr. Thomas Bodenheimer, a professor of family and community medicine at UC San Francisco who practiced medicine for 32 years. A healthcare coach — who is a trained medical assistant — could do that just as easily, and could also handle a good chunk of the counseling about healthful living and disease management that is a key part of primary care.

Finally, perhaps it's time to allow doctors to focus on medicine and let the mass media and public service outreach handle topics such as seat belts, sun block, domestic violence and drugs, says Dr. Victoria McEvoy, medical director and chief of pediatrics at Mass General West Medical Group in Waltham, Mass. Obviously, adolescents should be discouraged from alcohol use, for example — but McEvoy notes that there's little evidence to suggest that advice from a physician actually convinces a risk-taking teen to lay off.

There are some nonmedical issues that just might stay in the doctor's office, though.

"I write letters to the electric company on behalf of my diabetic patients, pleading with them not to turn off the power. The cost to the system would be just too great if the insulin pump failed," Friedberg says. "No dermatologist will ever help you with your power bills."

http://www.healthkey.com/la-he-primary-care-doctors-20110627,0,5337248,full.story