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Sunday, May 2, 2010

Primary Care....What is THE Problem?


Now that health care reform has been passed, attention is being given to the shortage of 'primary care'.  What is the problem?

1. The new "politically  correct term 'Primary Care' Provider,rather than family physician, or general practitioner. This lumps MDs in with NPs. PAs, MedicalCorpsmen, and who knows what else.  (would you go through 4 years of college, 4 years of medical school, and 3 or 4 years of serfdom as a resident to be 'lumped in '

2. The enormous amount of non clinically related administrative tasks and secretarial work to be done each day. A recent article by Richard Baron MD in the NEJM chronicles the day in the life of an internist.  This publication is a MUST READ for anyone in pre-med.  It gives an accurate appraisal of what to expect if one selects to become a general internist or family physician.

In addition to the daily acts of diagnosis, treatments, and minor procedures, these generalist internists did the followng:

  • Made 24 telephone calls
  • Refilled 12 prescriptions (a vast underestimate of the daily refills, since a) the number reported in the study doesn't count refills done during an office visit, and b) the study counted the act of refilling 10 meds for a single patient as one refill)
  • Wrote 17 e-mails to patients
  • Looked at 11 imaging reports, and
  • Reviewed 14 consultation reports.
  • Beyond what happens during the 18 patient visits, the docs perform nearly 80 acts of data exchange and review each day. After Rich’s practice analyzed this workflow, they re-defined a “full-time physician” as one with 24 scheduled visit-hours per week, embedded in a 50 hour work-week. In other words, docs in Rich’s practice can expect to spend half their time on office visits with patients, and the remaining half on non-visit paper/computer/telephone work.


I would say that the number of patients these physicians see is very very conservative.  From my experience it is much more like 25-30 patient encounters a day.

Now I am NOT saying this is a bad thing.  Many young aspiring students go into medicine for this vision of their careers.  In fact most go into medical school, either undecided, or want to become a family physician either because of a personal experience with their own family's physicians or a personal life experience from an illness or that of a family member.


3. The fatal flaw of the CPT procedural coding system aligned with performing procedures rather than the extent of complexity and cognitive work for the event.  This results in an enormous disparity of income for generalists and specialistss.



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