Making Life Better at the Bottom of the Healthcare Pyramid

Every day, we all get calls, emails, texts, and chats, from patients, friends, and colleagues. It seems like everyone is looking for a new primary care doctor.

Sometimes it’s because someone has moved to a new city, or they got a recommendation from a patient who has had a good experience with us. Sometimes it’s a patient asking if we can take on their family members. Sometimes it’s our specialist and subspecialist colleagues saying they have a patient they are managing who “desperately needs a good PCP” — can we help?

But more and more often, it feels like we hear that access is a major issue — that no one takes their insurance anymore, or their provider went concierge, or no one takes Medicare, or they lost their job and changed insurance and had to go on to a plan with a narrow network of available physicians.

Most of us here in primary care are already stretched thin, burdened with a large panel of patients, provider burnout, an endless barrage of paperwork and deluge of in-basket messages and tasks, 20-minute appointments that just aren’t long enough by any stretch of the imagination, and a global lack of institutional support and resources to help us really do the job of primary care really well.

Many of the solutions that we are seeing to these problems seem to try to squeeze out a little more around the margins: better scheduling, lower no-show rates, overbooking, adding on video visits. New little tweaks to make us more “efficient”, like voice recognition to cut down on typing in the exam room, and artificial intelligence and virtual assistants to help us get certain things done.

These problems seem more amplified in primary care than other areas of medicine. I know my colleagues in specialty and subspecialty areas are also overworked and overburdened, but it seems like they often have resources that we just don’t. We are at the base of the healthcare pyramid, a major point of entry, a place where everyone should go and where everyone should have care — the kind of quality, continuous care that can help them navigate an incredibly messy system.

When our colleagues call for help, we almost always respond if we can, finding a way to squeeze one more patient in. When our patients do us the honor of asking if we can take on their children or their parents, it’s pretty darn hard to say no. But lately it feels like we’re trying to drink from a firehose as we try to get everybody in.

All the efforts at practice improvement that we can work on will only go so far — squeezing blood from a stone.

Yes, we need these innovations, we need these better ways of doing things, and we should all have all the tools and all the resources we need to ensure that our patients get the right care at the right time. We need to continue to speak out to ensure equitable care, to insist that every patient gets the care we think they need, that no one should be denied care because of their insurance or some formulary rules or other factors beyond their control. But we’re never going to have enough places to put them all unless we have more people coming into the fields of primary care, willing to do this incredibly challenging but incredibly rewarding job.

These days, it’s gotten exceptionally hard to hire in primary care, and I can’t say I blame residents or younger folks looking for a career when they think about choosing this life, or choosing the life of a specialist or subspecialist or surgeon. Part of the change that needs to happen in healthcare is to find a way to ensure that this life, this critical role in healthcare, is just as attractive as any other, for medical students, for residents, and for junior faculty just starting out.

Some of this may be a leveling of the income disparities, alleviating the potential downstream burden of trying to make a living as a primary care doctor in this world today. Some of it will almost certainly be finding better ways to do all the things we do, ways to close the gaps, and ways to make sure no one is missing out on anything they need. And some of it will be fixing the house we live in, saying no to the endless systematic barriers that have become part of our lives that really have nothing to do with providing healthcare to humans.

If we do all these things to make the life of a primary care doctor better, then more people may choose this life, so that the foundation of healthcare that is primary care doctors can widen and become more solid and more stable, and better able to support the rest of the system that sits on top of us.