Cutting Through the Chaos in Primary Care

\r\nHe has published in several medical journals, including recent research on use disparities in telehealth visits & effective community outreach interventions to encourage COVID vaccination. His weekly MedPage Today column, \u201cBuilding the Patient-Centered Medical Home,\u201d focuses on improving patient care.<\/p>“,”affiliation”:””,”credential”:”MD”,”url_identifier”:”fp4223″,”avatar_url”:”https:\/\/assets.medpagetoday.net\/media\/images\/author\/Pelzman_330px.png”,”avatar_alt_text”:”Fred Pelzman”,”twitter”:””,”links”:null,”has_author_page”:1,”byline”:”Contributing Writer, MedPage Today”,”full_name”:”Fred Pelzman”,”title”:”Contributing Writer, MedPage Today, “,”url”:”https:\/\/www.medpagetoday.com\/people\/fp4223\/fred-pelzman”,”bluesky”:””}]” categoryimage=”https://assets.medpagetoday.net/media/images/articles/Pelzman_icon_120px.png” categoryimagealt=”Building the Patient-Centered Medical Home”/>

Working at the faculty practice of a large academic medical center — the primary outpatient teaching site for 140 internal medicine residents — can be a tough place to inspire. They spend one quarter of their residency learning how to take care of non-hospitalized patients, addressing the acute and chronic health needs of people living their daily lives and coming in to see their doctors. Given the current state of healthcare, it’s no surprise that the newly minted physicians who rotate through this practice are just not choosing careers in outpatient primary care internal medicine.

During the rest of their training, primarily on the inpatient wards and sometimes on subspecialty electives, they’re exposed to a lot of the “gee-whiz” really cool technology-based stuff; doing procedures; taking care of critically ill patients in the intensive care units; meeting mentors who are doing sexy stuff, like electrophysiology studies and endoscopies; or they are getting involved with research around cutting-edge tertiary and quaternary care health science.

Unsurprisingly, spending time seeing outpatients, trying to juggle incredibly challenging sick patients facing the myriad social problems we are often powerless to address, in a chaotic and desperately under-resourced system, is often not an inspiring environment. This makes it tough to encourage them to choose this as a life.

Recently, we got feedback from the residents in our program. We heard how frustrated they are by their lack of administrative time, lack of supportive staff, the volume of patients they’re expected to see in such a short amount of time, and the general chaos that exists at the practice.

Along with our ambulatory chief resident and our faculty and staff, the leadership of our practice is doing what they can to examine each of their issues and help find ways to make life better for them.

We need to create a place where trainees can learn outpatient medicine and feel safe, like they are being taught in a healthy environment where their needs are being addressed. We also need an acknowledgment that burnout exists for them as well as for the rest of us.

We’re looking at all the different roles and chores and items they need to do to take care of patients in the hope that we can find things we can fix, or at least improve. And for those that we can’t, maybe we can continue to challenge the powers-that-be to look for more support and resources and personnel to help us do the challenging job of taking care of primary care patients in the outpatient setting.

As you know, I truly believe the only way to fix our shattered healthcare system is to rebuild and revolutionize and prioritize the primary care base of doctors.

This necessitates finding ways to improve the continuity of care, so that doctors see patients they know, and patients see doctors they know. There is something irksome about doing an annual physical exam for a patient you have never met before. Continuity improves provider and patient satisfaction, and leads to better compliance, better health education, less over-testing, and less over-treatment.

Stricter rules about managing very late arrivals, setting expectations for patient and staff and provider behaviors.

More support filling out forms, getting prior authorizations, making space for everyone to practice up to their licenses.

Time to thoughtfully review test results and get the support needed to make the best decisions for patients based on these results, and ways to implement this successfully.

Access to timely specialist referrals, e-consults, and imaging, to safely create a plan for every clinical situation that might arise.

And robust mental health pathways with access to therapists and providers to prescribe complex psychiatric treatments, and support for the primary care provider who manages these issues on their own.

So much of whatever is broken in our healthcare system needs to be fixed; we need to make things right and less chaotic.

And, even if some of these more global problems — like equity and safe housing and food security and access to unbiased information — can’t be immediately addressed and completely cured, creating a safe and comfortable place to learn to practice medicine, to get to do this job we all love so much despite its challenges, is the best way to inspire the next generation of primary care doctors to carry on this fight.

Perhaps there are solutions in better systems programming and artificial intelligence, ways to streamline the practice and eliminate some of the burden that falls on the shoulders of the doctors, whether they be residents or attendings.

Just looking to the experience of medical students in our practice — when they shadow interns and residents and faculty members and see providers rushed and patients feeling like they’re not being listened to — I can’t say I blame them for not thinking about choosing this life.

For each and every one of us, there is something or some group of things that made us choose this life, one that’s not easy, one that in its current iteration certainly seems to be overwhelming us all, but still the vast majority of us love it when we wake up in the morning and get to come do this.

My dream is that we can create a world where trainees will feel this overwhelming pull to this life, and once again choose it for themselves.

And if artificial intelligence and other smarter ways of doing things need to be a part of that, then bring it all on. Calm out of chaos.

Please enable JavaScript to view the comments powered by Disqus.