Ryan Neuhofel, DO, who is a colleague and a friend of mine, wrote an incredible piece for the AAFP online site. In a very calculated and logical way he smashes the quality and metric people and then goes on to say this:
However, does a bit more — or less — money significantly change the behavior of individual physicians on a day-to-day basis? Particularly at the primary care level?
He’s right. And all the “incentives” that were supposedly carrots they were offering were actually sticks made up of more bureaucratic tasks. It is these sticks that are still killing us. As Neuhofel puts it:
The list of things that hamstring PCPs from doing their best is long, but let’s start with some simple math. The average full-time PCP is now responsible for a panel of 1,200 to 3,000 patients. (There is some debate on how to calculate this number in a traditional fee-for-service clinic.) Physicians are often rushed through 15 to 30 office visits per day that last 15 to 20 minutes at most. Given the complexities of modern health care and the growing prevalence of chronic illness, this is insane.
In addition to sheer patient volume, physicians are increasingly distracted by a mountain of clerical and other nonclinical tasks. We can always strive for efficiency and delegation of tasks (teamwork) when appropriate, but there is no substitute for a doctor’s time. It’s no wonder family physicians are often inaccessible to patients’ acute needs and feeling burned out.
He is spot on. It is a no-win situation or is it?
Rather than apply more external pressure, we must recognize that intrinsic factors are what matter most to a PCP. We need an environment that fosters a sense of autonomy, mastery and purpose to fulfill our potential. The only way to create this culture is to allow PCPs the following opportunities:
- the opportunity to sit and truly listen to each patient to understand his or her story;
- the opportunity to educate patients and allow them to ask questions;
- the opportunity to develop long-term, trusting relationships with patients and staff;
- the opportunity to utilize (not just collect) relevant and coherent patient data;
- the opportunity to learn and grow in our knowledge and skills; and
- the opportunity to stay sane and happy while doing all of the above.
Now, what kind of job, at least in primary care, would allow this to happen? What kind of environment would foster “a sense of autonomy, mastery and purpose to fulfill our potential”? Hmmmm, I wonder? I spend 30-60 minutes with my patients now. I read between patients or at home because I am not exhausted. I email patients articles I find interesting as it relates to their issues. My wife, and office manager, babysits some patients’ kids and hangs out with them when the Mom is in the exam room. This is the video above and a very typical day in my practice.
I am not some great doctor. I think after 20+ years I am pretty good. I am, however, much better in an environment that Neuhofel describes above. Life was not always like this for me. I was brutalized in the system for 15 years working for two different hospital systems. I put in my time in and I got burned out. I was ready to quit medicine altogether. It was then I decided to make a jump and do my own thing. Has it worked out? Yes. Was it easy? No, but is anything worth doing easy?
I now make more than I used to make in the system. I have only 600 patients on my panel. With more time and less patients, I am the doctor I dreamed of being as a kid. This is ONLY because I opened my own direct primary care practice, which proves Neuhofel’s “environment” theory is right. Some may respond, “Well, that’s easy for you but not for me.” I would again respond that it wasn’t easy for me but because of the early adopters of DPC we are making it easier for others. DPC is gaining more and more traction from primary care doctors daily. The DPC Alliance is the only organization truly dedicated 100% to DPC doctors unlike some associations (AAFP) who brush us off by putting non-doctors in charge of “helping” us.
If you want the opportunity Ryan talks about above, then you need to take the jump. If you want to Do Better then you need an environment to Do Better. I know it may take time for you to get there but until then, I’ll leave the office light on for you (because I will be home by 5 PM).