A Plan to Refocus Primary Care

I’ve written my share about the plight of the primary care doctor in general and the primary care general internist in particular. I’ve sang the praises of the job, bemoaned the disrespect, predicted a frightening future, and shamelessly recruited trainees to my field. In this post a fellow Chicago Internist, Caspian Kuma Folmsbee, makes what I think is a terrific argument that part of our specialty’s problem is that we have drifted away from our true mission, healing the sick. In the process of this evolution, we have made the job less enjoyable and less attractive to trainees.

I, for one, am ready to sign this manifesto.

Adam Cifu

The exodus of primary care providers from the profession as well as the waning interest of trainees in the field has resulted in a crisis. There is no shortage of publicity for this crisis in the lay press and the medical literature. The causes are numerous — burnout, reduced time spent with patients, EMR, and misguided metrics — but so far solutions remain half-measures and the problem continues to grow.

As a primary care doctor who cares for patients and trains doctors who might join me in my field, I feel that the true cause of the crisis is that the core role of the primary care doctor has been lost. Instead of focusing on treating the sick, the primary care doctor now spends a majority of his or her time treating healthy people.

Over the last 50 years, the field of preventive medicine has exploded. This includes cancer screening, preventative treatments, and lifestyle counseling. Our guidelines give these activities high importance despite a weak evidence base. As an example, the recent guidelines for the primary prevention of stroke features diet and exercise recommendations as part of their “Life’s Essential 8” as well as a call to screen for social determinants of health in all patients. These guidelines overestimate the usefulness of such recommendations, adding to the burden on physicians.

Not only do recommendations like these consume time spent with patients, they confuse learners who come out of training with the distorted view that all recommendations are equal. They think that recommendations to treat patient with a statin after an MI are equal to those suggesting statin therapy for healthy people with a 10 year cardiovascular risk of 10%. This oversimplification has led to generations of doctors learning and teaching the importance of time consuming interventions; interventions that are based on weak recommendations that do little to help patients.

To be clear I am not arguing that evidence-based lifestyle modifications are not worthwhile. I am asking us to think about when and where this counseling should take place. It is sometimes important to know the activity levels and eating habits of a patient, and help them to make changes if warranted, but the medical community needs to take step beyond recommending the counseling so broadly. Diet counseling has long been known to be of limited utility even when done consistently over many years. Why are we teaching learners that spending precious minutes on this activity when they are with patients they have never met is a worthwhile use of time?

Is the time spent counseling changing patient-centered outcomes? If so, in what settings? How much time is needed? Do we really think it is the job of a primary care doctor, with 7 years of medical training, to educate people on the basics of a healthy lifestyle?

Let’s go further. Is it a good use of limited time with patients to recommend tetanus shots and flu shots? Is it a good use of our time to place orders for a colonoscopy or Cologuard and explain the differences? Sick patients can no longer see their primary care doctor. They are routinely forced to see urgent care providers who lack any long term relationship with them. This concept is not new; a recent publication in the BMJ pushes for a change. The US should take lead in reimagining primary care.

How can we save primary care?

Let go of vaccines

Vaccines and vaccine counseling should be done in the pharmacy, vaccine drives, or schools. It should not take up precious time during a physician visit.

Let go of cancer screening

Cancer screening is low yield when it comes to absolute health benefits. The time of physicians should be spent with high risk individuals or assisting patients when they have questions about screening modalities.

Let go of behavioral counseling

Physicians should stop wasting time outlining DASH diet or calorie restriction strategies. They should stop copy forwarding asinine advice of 150 minutes per week of strenuous exercise in our notes. They should pursue detailed information about patient’s lives when it is critically important or warranted for building relationships.

Let go of the “yearly physical”

Physicians should not be obligated to go through a checklist for asymptomatic patients or complete unproven interventions such as wellness visits.

But if not physicians then who?

Campaigns should be led by our schools and communities. Children (and young adults) can be taught about healthy diets or, better yet, live it through better school lunches. Communities should focus their efforts (guided by public health departments) to find unique ways to reach their members. Efforts to invest in infrastructure to encourage activities and eradicate food deserts should be pursued. The obvious argument against this call to action is the current state of our education system and public health infrastructure. But all progress must start somewhere, and primary care is drowning. Resources need to be better utilized, and physicians cannot sustain this model any longer.

So what should doctors do?

Let doctors be doctors. We treat sick people. We guide them during their darkest moments and help them make decisions armed with a deeper understanding of their values and the harms and benefits of our treatments. We should be allowed to focus our time on optimizing medication regimens tailored to the reality of the patient’s life.

Primary care desperately needs a paradigm shift. Evidence-based medicine has yielded treatments that are effective, but also complicated treatment plans and extended the lives of our patients. This has led to comorbidities that the best trials can never account for. We need more time for physicians to think deeply about these issues while partnering with patients. Freeing us from low yield behavioral interventions, means more time understanding values and preferences which might actually lead to true shared decision making.

Let us be primary care physicians that can help sick patients navigate through the complexities of modern medicine. We must retake our role as healers before it is too late.

Caspian Kuma Folmsbee is a primary care provider in Chicago. He publishes at Kuma’s Substack.

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Photo Credit: Usman Yousaf