The Chasm Between Intention and Achievement in Primary Care

Reuben put it well: “Primary care is on death row.”¹ A total of 21% of general internists are leaving that practice sometime in the first 10 years after completing training,² and only 6.7% of all 2007 US medical school graduates are choosing family medicine or ambulatory internal medicine.³ The net loss is worrisome because robust primary care seems to be an important component of high-performing health systems.⁴ Enhancing primary care through such models as the patient-centered medical home has been proposed as an important if incomplete part of US health system redesign.⁵ Explanations offered in both professional⁶ and popular⁷ media for the disappearance of primary care physicians have focused on salary or income differentials between primary care physicians and their specialty colleagues, differentials that in some markets have reached a factor of 3. While higher primary care incomes would be helpful, at least as large a problem affecting primary care is the lack of capacity to perform successfully the work of a generalist.

Pellegrino and Thomasma⁸ define medicine as “a meeting of at least 2 personal intentions, one seeking help and the other offering it.” Individuals who enter the profession of medicine do so largely to offer help, and career satisfaction in clinical medicine may be most closely related to how successfully physicians are able to realize their medical intention. Increasingly, the practice of primary care physicians in the United States is characterized by ongoing frustration in the quest to meet patients' and personal expectations. Perhaps the greatest difference between specialty practice and primary care practice in the United States today is in the capacity to do a good job. This mismatch between intention and achievement is a function both of the mental models of primary care and of the funding available to support that care. Both will need to change for primary care workforce issues to be successfully addressed.⁹ However, they influence each other: lack of payment impoverishes the mental model, and an insufficiently value-driven mental model limits available payment.

By its very nature, primary care has a broad conception of meeting patients' needs because patients present with undifferentiated problems, many of them not especially “medical” in the traditional sense.¹⁰ As the initial point of contact between patients and a complex delivery system, primary care physicians confront issues of cost and access daily, whereas patients confront a dizzyingly complex delivery system in which determining what they need and how they obtain it is a massive challenge. Advocating for and supporting patients are often seen as hassle-factor activities to physicians, even as success or failure is consequential for patients' health and, thus, the realization of medical intention. Yet the mental model, adopted as a matter of personal survival, requires the physician to remove responsibility for advocacy and supporting these kinds of patient needs from the primary care “job description” because they simply cannot be accomplished reliably and consistently with the available resources.

This same mental model affects physicians' approach to the team with which they work. Primary care training often takes place with minimal support staff. Despite some notable exceptions—such as the Accreditation Council for Graduate Medical Education internal medicine Educational Innovation Project¹¹ —models of primary care success offered to trainees are typically exemplified by individuals making heroic personal efforts to compensate for the absence of systems and support. This approach is dysfunctional in practice, where the volume and complexity of the task requires an activated team. The primary care physician trying to function alone is on a burnout trajectory. Once again, the mental model fails: the focus in training is on the physician role in patient care without emphasizing the essential need to delegate, to work in teams, and to build and improve systems that engage others.

The American Board of Internal Medicine convened a project on the Comprehensive Care Internist,¹² seeking input from multiple stakeholders—including specialists, other primary care team members, insurers, employers, and patients with chronic illness—on what might be expected and needed from someone who could fulfill their needs in the sphere of primary care. A remarkably consistent and coherent picture emerged across all stakeholder groups, defining Comprehensive Care Internal Medicine as “the personal, longitudinal and coordinated care—including prevention and wellness care—for a defined population of patients with undifferentiated, acute and/or chronic problems.”¹² Eight core attributes of a physician who could perform in this manner were identified: an expert diagnostician and clinician; a patient advocate; an effective communicator; a team leader and an effective teammate; a systems manager; an effective user of health information technology and health data; an effective change agent; and a practitioner accountable for efficient, accessible care. The group also agreed that this combination is neither widely available to patients nor the target for current primary care training. Primary care physicians need new training and a new job description to realize fully their medical intention in a medical world that has become unmanageably complex.

There is a striking mismatch between the activities primary care physicians perform to contribute value to patient care and what they are paid to do. Population health and patient advocacy activities, for example, contribute value to populations of patients and could contribute to making care less costly, yet they are unreimbursed. Owning an electronic health record (EHR), which is an essential part of the infrastructure for team-based care, does not produce a direct financial return on investment; owning a DEXA (dual energy x-ray absorptiometry) scanner, even if there are already more scanners than the community needs, immediately generates revenue. It should not be surprising that primary care physicians choosing to make investments in their practices may be more likely to purchase DEXA scanners—or their revenue-generating equivalent—than they are EHRs. A payment structure must be developed to support investments in the infrastructure primary care physicians need to deliver reliably and effectively value-added services.

Perhaps a model to emulate is that of the technical or facility fee available to others in the delivery system. When a gastroenterologist performs a colonoscopy, 2 recognizably separate fees are generated: one is the professional fee, designed to cover the physicians' time and expertise to perform the procedure. But insurers also recognize that, to perform the procedure, the gastroenterologist needs a colonoscope, monitoring equipment, space, and staff, and a second facility fee covers those elements. The result is that the gastroenterologist aspiring to meet the patient's medical need is provided direct financial support to acquire the requisite infrastructure. The bulk of revenue in a primary care practice, however, comes in the form of professional fees, with the facility fee wrapped into the single fee paid for primary care (comprising both professional and facility components). Making the facility fee component invisible is both a cash flow/reimbursement issue and a form of categorizing payment that reinforces the sense that “it's all about the doctor,” even as it profoundly limits how primary care physicians are supported by training and practice institutions. As policy makers contemplate directing additional resources to support primary care, there is not much evidence about what it actually takes to meet patients' needs reliably and by design.

Critical resources must include comprehensively adopted EHRs as well as additional support staff to use effectively the information the EHR can generate and disseminate. Successful EHR adoption is more complex than simply buying hardware and software. Physicians relying on paper charts provide care to 1 physically present patient at a time, and documentation is used primarily to support billing. Even as physicians adopt information technology, it is primarily used for word processing, and incomplete adoptions appear to be the rule rather than the exception.¹³ Primary care teams need to go beyond using word processing to higher-value information technology applications such as ensuring that data are usefully structured.¹⁴ Comprehensively adopted EHRs with structured data create major opportunities for health improvement in nonvisit-based care (telephone calls, outreach, e-mail), activities that should not usually be performed by physicians but by new and differently trained staff or automated by technology.

The patient-centered medical home has many definitions and is attracting increased funding in pilot projects around the country. A useful definition views the patient-centered medical home as a “political construct.”¹⁵ The core value proposition is that enhanced support for primary care will lead to increased quality, improved access, and decreased total health system costs. This may or may not be true, and evidence is clearly incomplete. But those who would be partners in advancing this effort should understand that the creature they seek does not naturally exist in the health care ecosystem created by the current reimbursement model and that the imagination and creativity of physicians to create it have been heavily selected against by that ecosystem. The medical intention is there in many hopeful medical students and idealistic practitioners, but real-world models for achieving comprehensive primary care have been limited by a hostile environment. Conceptualizing the problem as being about income differentials can only lead to ruinous disagreements among specialty groups. Thinking of it as a project to unlock the idealism and core professionalism of those who are trying, in a very complex and challenging environment, to meet their patients' needs comprehensively and realize their medical intention, could lead to productive and creative partnerships between those who seek to deliver this care and those who seek to receive it.