First Posted at The Health Care Blog on 4/16/2013
A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with ”Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.
Now, not everyone believes that a shortfall of PCPs is a serious problem.
However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.
So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.
I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.
The crisis we face
First, consider the situation:
The most pressing and urgent health services research problem society must solve is how to restructure healthcare such that we can provide compassionate, effective healthcare to an expanding Medicare population, at a cost the nation can sustain.
This is a problem with very high human stakes at hand. As we know, most older adults end up undergoing considerable health-related suffering at some point, with family caregivers often being affected as well. Much of this is due to the tolls of advancing chronic diseases, such as diabetes, heart disease, COPD, arthritis, dementia. (See this handy CMS chartbook for the latest stats on chronic disease burden in the Medicare population.) And a fair part of the suffering is inflicted by the healthcare system itself, which remains ironically ill-suited to provide patient-centered care to those medically complex older adults – and their caregivers — who use the system the most.
Needless to say, the financial stakes are high as well, with projected Medicare expenditures usually cited as the number one budget buster threatening the nation’s financial stability over the next 50 years.
A necessary part of the solution
Next, consider an essential component to compassionately and effectively meeting the healthcare needs of the Medicare population:
Medicare beneficiaries – and their family caregivers – must be partnered with good PCPs who can focus on person-centered care, and can collaborate with them as they navigate the many health challenges of late life.
Especially once they are suffering from multiple chronic illnesses and/or disability, seniors – and their families — need a stable relationship with a clinician who can fulfill the role of trusted consultant and advisor as they go through their extended medical journey. Healthcare for older adults almost always becomes complex and stressful for seniors and their families. Even educated and activated patients who are willing and able to direct their own care will need a generalist who can maintain a longitudinal health dialogue with them, and who can help them sort through complicated medical situations as they arise.
Now, much as been made of teams in primary care, and the importance of moving past our historic model of PCP as the person who knows it all, and does it all. This change is long-overdue, and I’m thrilled to see it coming. When properly implemented, I’m quite sure that team-based care will help older adults obtain the comprehensive primary care services they need and want.
But even with excellent team-based care, I believe most older adults will want and need a PCP to function as their high-level medical strategy consultant and collaborator.
Common challenges for PCPs of older adults
For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:
- Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.
- Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.
- Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.
- Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)
- Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.
- Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15 items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)
- Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.
- Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.
- Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.
- Weighing in on family conflicts. I’ve had to watch patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)
I must say that I love doing the work above. It’s deeply satisfying to help patients make sense of all that is medically happening to them, and to support them as they cope with their health challenges. But it’s also, as you can imagine, difficult work that is cognitively and emotionally demanding. The pressure of 15-20 minute visits makes things harder than they should be, but even if we went to 30-45 minute visits, the work will remain fundamentally intense and somewhat taxing for the provider.
Can anyone seriously argue that we won’t need PCPs to do the work above for Medicare beneficiaries over the next 20 years? (Plus we’ll need them to manage dementia, falls, and all the other geriatric problems too.)
Ok. Then if we agree that the work above is essential to the wellbeing of millions of older adults, and is a crucial component to providing overall cost-effective healthcare to the Medicare population, we must get serious about how we can recruit and keep clinicians as Medicare PCPs.
The benefits of a 35 hour work week
If the work of a Medicare PCP could be organized so that it fit into a 35 hour work week, we’d see the following benefits:
- More clinicians would be willing to do, or stay, in the job. Let’s face it, we have ample evidence that work-life balance is important to the younger generation of physicians, especially those with young children. As much as this dismays the older generation of physicians, this trend seems to be here to stay, so perhaps we should learn to work with it. Debt relief – the usual hope for attracting people to primary care – is never going to be enough on its own.
- PCPs would do the job much better. Providing compassionate, comprehensive person-centered care to medically complex patients demands cognitive and emotional energy. The work of Daniel Kahneman and others has shown that people do get cognitively depleted by work which requires complex decision-making. (Once depleted, they begin seriously avoiding cognitive and emotional challenges.)
Given that we are asking PCPs to actively engage with patients and families, embrace shared-decision making, adapt to technological changes, and make a whole host of behavior changes, making sure that clinicians in this role aren’t burnt out by long working hours just makes sense.
Summing it up
The impending shortage of PCPs constitutes a national emergency. In order to provide the growing Medicare population with compassionate, effective healthcare at a sustainable cost, seniors will need stable relationships with PCPs who can function as their strategic medical consultants, collaborate in helping to meet healthcare goals, and provide emotional support.
Doing this type of PCP work can be extremely rewarding, but it’s also cognitively and emotionally demanding.
Structuring the job of Medicare PCPs into a 35 hour work week would probably attract more clinicians to the job. It would also help PCPs maintain the cognitive and emotional resources needed to do the job consistently well, and could reduce burnout in this group of key clinicians.