Primary care vs. PRIMARY care

What has been your experience with primary care? Do you come away from your primary care visits with a complete understanding of the answers to your questions and the plan of care? Do you feel that you have a great relationship with your physician? Do you see your same physician every visit? Does your primary care provider approach your health concerns in a manner that is aligned with your preferences? Do you feel that you have enough time at each visit with your provider and are able to get in touch with your primary care physician when you need them? Or, has your experience been rushed primary care visits, sometimes with different providers, and minimal discussion about your preferences for treatment? Does the primary care experience feel void of personal connection? Do you feel that your primary care provider only has time to briefly discuss medication and referrals to specialists?  More and more, medicine continues to be siloed into specialties and subspecialties, and, at the same time, the primary care experience is becoming less personable, more rushed, and, frankly, less effective. 

We are incredibly fortunate in this country to have medical subspecialists. If you have a very rare condition or you have a complex traumatic injury, you will need these providers, and I am just as grateful as anyone else for what they offer. However, the current healthcare system is set up in a way where your primary care physician is becoming less and less primary. How many issues does your primary care provider address head on with full ownership of the management plan? How many times does your primary care provider spend the time to fully understand your concerns? I don’t know of many primary care physicians who feel they even have the time to do this anymore. Do we need a specialist to remove the mole on your back, perform a joint injection, or perform a well woman exam? More importantly, what specialty in the current healthcare system is there for patients to help educate and empower them on their health journey? True primary care is capable of handling all of this and more. 

My personal experience has been that I commonly interact with a large percentage of patients who are seeing multiple specialists at a time. These providers may or may not communicate to each other. They may or may not be aware of the others’ evaluations, labs, medications, or management plans. Far too many times I have seen a patient get the same labs two to three times in a single month just because each specialist they saw ordered what they typically order without knowing that the patient just had the same lab done a few weeks earlier in a different location. I have also seen serious medication interactions occur from similar situations where there is an absence of communication between specialists. At best, this is extremely inconvenient for the patient. At worst, this is life threatening. And, I don’t blame the providers. They are experts in their field focused on the referred condition for which they are seeing the patient. They know what they need to do to provide the patient with a plan for the condition within their scope of care. But, is this siloed approach an ideal framework for addressing human health and complex medical conditions? 

The vision for direct primary care (DPC) is to empower primary care providers by giving the provider time again to provide great medical care, freeing the provider from insurance-driven constraints, and allowing the provider to establish a meaningful relationship with the patient.

Empowerment for the patient starts with empowering our primary care providers. Throughout medical school, residency, and time as a staff family physician, I have seen for far too long how well meaning, extremely intelligent and caring primary care providers are hindered and restrained by the twenty minute office visit. This produces less effective patient care and an ever growing population of primary care physicians who feel unsatisfied and burnt out. 

We need to set the record straight: giving a primary care provider twenty minutes for an annual visit is not sufficient. This is where the line needs to be drawn. A primary care provider will frequently face upwards of three patient concerns at a twenty minute visit, while the specialist who will see them for one of these concerns could have close to thirty to sixty minutes at an initial evaluation. This represents the opposite of ideal primary care.  However, the way that most health systems function today sheds light on why the system has become dysfunctional. 

In a traditional health system, the hospital, clinic, etc. will be able to bill more from insurance if a specialist sees a patient. Primary care services are typically reimbursed at a lower rate compared to most specialist evaluations. Therefore, a health system has incentive to see as many referrals to specialists (within the preferred network) as possible to maximize billing and income. Seen this way, it makes total sense why we have relegated primary care physicians to short visits with limited evaluation and management for patients’ conditions and concerns. If these same patients can be seen by multiple different specialty providers in the network, even if unnecessary, the health system profits more.

Here is where I see the greatest strength of restoring true primary care: when sufficient time is available to really understand the patient, their concerns, unique personal and family history, family and social life, occupation, and preferences for treatment, primary care providers can address so much more in a holistic manner. This approach takes time. In fact, much more time, and this time is simply not available in the current model of care with thousands of patients empaneled to each physician.

Primary care physicians are in a unique position to address health in a holistic manner. It is the very essence of why most providers choose this path. By transitioning to the DPC model, these physicians are once again free to treat in a whole-person centered approach. The focus can be on understanding patient preferences, helping the patient navigate health decisions, spending more time dedicated to optimizing patient nutrition, exercise, sleep, and stress management. Direct care removes unnecessary burdens from the provider-patient relationship, creating an open and transparent exchange that makes sense and works for both provider and patient. This is true PRIMARY care.