I was honored to give the keynote address at the LSU Family Medicine Residency in Alexandria, LA last night. I was program director there from 2005-2013. ~~~
I want to thank the graduating class for asking me to speak at their graduation tonight. You guys have worked hard for the past 3 years and you have really contributed in many ways to making the residency better…even if you gave some of us a few more gray hairs in the process. Each graduating class always has a certain personality, and yours has been particularly creative and energetic. And as far as giving this keynote, I’ve listened to a few of them over the years, and I can tell you it’s not easy to make a great speech. My impression is that what you really want is a little bit of inspiration in a short enough package not to keep you too long from what you really came here for tonight, so that’s what I’m going to try to deliver.
What I want to talk about is our healthcare system and where we fit into it. Let’s face the fact that our health care system today is struggling to redefine itself. Americans are proud of their healthcare system and by and large sneer at other systems around the world, yet we all know it is so dysfunctional in so many ways that things simply have to change. I think the reasons so many Americans love our system is because of advances in certain fields, and the rapid access to life-saving care from some of our biggest killers: like intensive care of the sick and very premature newborn, advances in cancer care, the way cardiac catheterization has revolutionized treatment of heart attacks, and advances in trauma care. And another huge area that doesn’t get enough recognition is immunizations. Each of those areas has seen such advances in the last 20-30 years that they have probably each individually helped to increase the lifespan of Americans. But these areas are really islands in a stream that is confusing if not downright impossible for the average American to navigate and the fact that, in spite of all those advances in care, many Americans have difficulty finding (or affording) reliable access to quality primary care, where many of those emergency types of problems can be prevented. So this graduating class is entering a field where they are desperately needed, and you are joining the workforce on the side of the equation that most needs improvement.
So what are the problems with our primary care delivery system, and how is our system going to fix itself? Without wading into any hard data, I’m going to touch on broad aspects of these questions from two perspectives: the needs of patients, and the needs of the primary care physicians themselves. In many ways for many years, these two sets of needs have often competed with each another, with one or the other sets of needs sometimes winning out over the other, but with the two seldom being well balanced.
• Patients need access to their physician and they need care that is timely, competent, efficient, and cost-effective. Good communication is essential, and empathy and compassion facilitate the trust that is needed for the relationship. But when patients’ needs are considered to the exclusion of the needs of physicians, without solving any other problems that make our system dysfunctional, you end up with physicians who are stressed out, overworked, and burned out.
• So on the other side of this equation, physicians need decent hours, they need enough sleep, they need a reasonable amount of financial reward for their labors, and they need to be able to manage their stress. They need time with their families and they need some healthy recreation. But when physicians’ needs outweigh the patients’ needs, you end up with a system of care that is organized around the physician, and you end up with limited hours of access, long wait times to get appointments, slow communication, and so on.
I think in the older-school style of practice, the needs of the patient were paramount and the needs of the physician were considered virtually not at all. The problem is that many of these physicians really spent very little time with their families. You have a lot of kids who resented their parents’ medical practices. I think the current generation of physicians really has rejected the older model; they value time with their families and they are trying to find ways to limit the intrusion of their medical practice into that time. But I think in many ways the pendulum has swung too far that way, and for a sustainable solution we have to find ways to balance the two needs so that both are met.
So what do patients tend to experience today in their encounters with primary care?
• Before they ever choose a PCP, it’s hard for patients to tell who really provides the best care. They mainly go by reputation in the community, but the larger the community, the harder that may be.
• It may be hard to find a PCP who is accepting new patients.
• Once they get in, it may be hard to get appointments when they need them.
• Patients often find it hard to afford their visits, insured or not.
• Patients may not be able to afford their medications, or to navigate insurance requirements for them.
• Anytime the patient gets referred to any other provider they stand the chance of their care getting more fragmented and difficult to manage.
From the PCP’s standpoint, their problems look like this:
• Flat or decreased insurance reimbursement
• High costs and inefficiencies associated with using an EMR
• Pressure to see more and more patients resulting in less time spent with each patient
• Ever-increasing paperwork required for prior authorizations
• More and more time spent appealing insurance denials, not to mention time spent trying to keep up with the constant stream of new medical knowledge, changes in reimbursement rules and new CPT codes every year (and all of this with the move to ICD-10 looming somewhere in the future).
Our system is undergoing such rapid change due to so many pressures that the practice of medicine today hardly resembles anything our forefathers would recognize. Hippocrates would shudder at the distraction created by the computer screen in our visits. The computerization of medicine, like it or not, is one of the hallmarks of modern clinical practice. Has it been a good thing, or a bad thing? All emotional reactions aside, I think we can say there have been some harmful effects, and many of the supposed benefits haven’t been realized. In many cases we spend our time entering the data into a computer, never to see it return in any useful form. But the government has forced us to do it, and like it or not, we can’t change it.
Or can we? Pressures like this one are increasingly causing physicians to look for alternative practice models that will enable them to restore control of their practices and lives. One thing is clear: many doctors are not happy in the current environment and are trying to find ways to become happy in their practices again.
Now I don’t have to tell this audience why primary care is still a wonderfully rewarding profession. (Or maybe I do after talking about all those problems! I’ll remind you as we wrap up in a few minutes.) But with system pressures like those, is it any wonder that PCP’s are seeking alternative practice models? That stream of new models started with a trend toward outpatient only care and leaving inpatient care to hospitalists, and has continued on from there.
• Many more physicians are now seeking employed positions versus owning and operating their own businesses. This gives the promise of being free from administrative headaches, to “just focus on practicing medicine,” (leaving the business aspects to others). This works out pretty good for a lot of people, but the problem is the loss of control, and many physicians find the pressure to see more patients really increases. From what I’ve seen, the larger the system the physician is employed by, the more loss of control the physician tends to experience, and the more pressure to see volumes of patients.
• Another approach would be to eliminate third-party payors altogether and instead take money only directly from patients. This is the so-called “direct care model.” Some physicians sought to charge very high retainer fees leading to the moniker “concierge medicine,” but the more “blue-collar variety” with more affordable fees has helped many physicians break free from the bureaucracies of Medicare and insurance companies, reduce their patient loads, and become more accessible to their patients. What’s not to love about that? Although this model is still fairly young, some direct care practices have been around for more than 10 years, so it may have some sticking power. (Many of these practices advocate to their patients to buy very high-deductible, catastrophic type of insurance policies and to only use them in cases of real emergencies, and they point out that this is more akin to how we use other types of insurance, such as homeowner’s insurance and car insurance. We don’t use those types of insurance for regular maintenance and minor repairs on our homes or cars, nor should we use health insurance for common, predictable needs.)
• But it isn’t only physicians and patients who are frustrated with the insurance system. Employers are looking for creative ways to manage the healthcare costs of their employees. Although it’s easy to imagine that some employers might want to try to short-change their employees and shift more of the costs of health care their direction, many smart companies are figuring out that the healthier their employees are, the happier and more productive they will be. So this is a case where making good health care more accessible and less expensive for their employees can really help with the morale and productivity of the workforce. One of the products of this thinking is a new model that doesn’t really have a name yet, and for now I’ll call it Employer-Based Primary Care. Here the employer directly pays for and manages the primary care delivery to its employees. This is a very new model that a few of us are trying out, and although the early results look pretty good, we’ll have to stay tuned for a few years to see how this one turns out.
• But in spite of all these (and other) varieties of practices that have proliferated, I’m happy to tell you that traditional primary care is still intact. Just yesterday I talked with one of our graduates, Dr. Lynda Odom–who is here tonight–who is settled in a traditional practice at a small hospital, seeing patients in her office, taking call in the emergency room, seeing her inpatients, and caring for patients at the nursing home. She’s happy as a clam! So there are many models out there, from old to new, that can work well for you as doctors and for your patients.
Primary care is absolutely essential and what I want to encourage this graduating class about is that it is still possible to find highly satisfying and rewarding ways to deliver primary care, and that there are new models out there that may help to strike a better balance between the needs of the patients and their physicians than was possible in the past. There may be other, better ways yet to be discovered that you all will play a part in creating.
And there are some aspects of high quality primary care that will never change, so as I close tonight I’m going to remind you of something I told this graduating class as they began residency. Probably the most important skill of the primary care physician is that of being an empathetic listener. Listening to your patients both helps you to understand your patient in the ways that you need to, and helps establish the connection between you that leads to mutual trust. When patients talk about a bad experience with a doctor, they often say “she didn’t really listen to me” or “he just really didn’t care.” Also, 90% of your diagnosis comes from the history and physical examination, and most of that comes from just the history itself. I have a patient whom I have only seen once so far, who came in as a new patient after a hospitalization for a series of problems. I listened carefully to her symptoms and reviewed her hospital records and realized there was an abnormal finding on a CT scan that correlated with her symptoms, but hadn’t yet been explained. Ultimately that led to the patient being diagnosed with stage IV colon cancer. I still haven’t seen that patient back in the office again, but I’ve talked with her on the phone a few times and she’s grateful for the part I played which really only involved listening and a little attention to detail.
However else our models of care change, the basic skills of a good PCP will always remain essential. You all have learned them well. You are ready to jump in and begin changing what will be many thousands of lives across your careers. I know you may not feel very ready right now, but you are more prepared than you realize. Whatever other challenges come, remember the basic lessons you learned as a resident, and listen carefully to your patients. I am proud of each one of you, of who you are, of what you have accomplished, and of what you’re going to do in the world. Thank you for inviting me back to share with you tonight, and God bless you.