Sunday, December 19, 2010

Our Growing Primary Care Gap (#2)

Previously I wrote about our growing primary care gap. This gap is still growing and it begs the question:   "WTF...Why?"   I will speculate from the perspective of someone who recently completed eight weeks of Family/Ambulatory Medicine in South Central Los Angeles. 

1. The Art of Rushing
Preceptors and med school counselors herald primary care as "the next big thing." One common theme discussed in their motivational sessions are the proposed changes in compensation that are slated to take place across our country. These changes are aimed at increasing compensation for primary care specialties in an effort to increase the number of students pursuing careers in primary care. Still, there is prevailing cynicism in me; although I believe these changes are an important step in closing the primary care gap, there are considerable factors far more important than compensation which affect a student's decision to pursue primary care.

One of these factors includes the unavoidable time pressures faced when caring for so many patients and the burden of working with insufficient resources (e.g. uninsured/underinsured patients). This was far too common from my experience in outpatient clinics. I felt constantly rushed to see patients and to quickly write my notes. Whenever a referral needed to be made for specialty care, a long 1-3 month waiting period was implicated. This environment is not conducive to good health delivery, and as a result, it becomes increasingly difficult to advocate for patients. We should all strive to be expedient, resourceful, and professional but individual efforts ultimately succumb to systemic barriers and failures. Not only did this hamper my educational experience but it was a "turn-off" whenever I wondered how my future as an internist would unfold. How can clinicians feel satisfied in the quality of their work if something is constantly rushing you-- indirectly hindering your ability to provide the best care? As any student in any field, it's important to remain optimistic, make efforts to become part of the solution and change what needs to be changed. 

Another factor often forgotten but important to consider is how the doctor-patient relationship is strained when a patient's visit feels rushed.  One memorable case, which to this day I regret having experienced, was not being able to fully address issues of depression among several of my patients that came for non-psychiatric care. At the end of the day, it seemed like I short-changed them. Still despite all this, I remain optimistic that primary care medicine in our country will assume its deserved place...

2. Paperwork.
Though I actually enjoy writing thorough H&P's,  far too much of the paperwork required to complete during visits are meant to "cover you ass." Its important to understand how and why clinicians chart in specific ways -- this necessity stems partly from the current state of litigation and tort reform in our country, but this becomes far more taxing in primary care when many patients need to be seen in one day. Doing detailed and comprehensive charting is good medicine, but i'm still not sure how i feel about practicing defensive medicine where the focus is not the health of the patient but rather to safeguard against possible malpractice liability.

On a different note, I'm a writer at heart and I don't mind pen and paper, but still... the hell with paper...dare I say... bring forth electronic health records.

 3. Debt
The mean debt for the average medial student in the U.S is an outrageous $156,456. Add to this number the debt that many student accrue during undergraduate education, and then you have an even larger debt. To add insult to injury, then consider a resident's modest fixed salary while his/her debt accrues significant interest for 3-7 years during post-graduate training. Many of us have chosen a career in medicine because we genuinely desire to help people, but believing that income/debt are not essential aspects of career satisfaction or that they are unimportant motives in career choices, is very naive and unrealistic.

4. Our Health Delivery System
IMHO, our health care model is the underlying reason why our country has one of the worst health outcome measures despite being the one country in the world who spends more of its GDP on health care. These poor health outcomes are not a result of poor quality of care rendered (i feel), rather by the lack of access to preventive care services coupled with the high costs of obtaining care.  What is most baffling to me, however, are the patient dissatisfaction ratings that seem to be rising despite having one of the most technologically advanced health systems in the world. Simply put, our system is an epic fail.  

'Tis against my inclination to bitch and moan, but 'tis simply a reality check.


Doctor Blondie said...

Interesting. Primary care is the most important care there is! Some of the world's best functioning health care systems have good primary care in place.
Of course, I'm biased, at the moment General Practice is my first choice. I will earn more than enough as a GP in the UK or in Holland to pay back my loan (1/5 of that of the average American graduate).

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