Joseph E. Scherger, MD, MPH

A core problem with primary care today is a schedule that does not allow the physician to be effective. The primary care physician lacks the time to heal.
	
	The work of primary care became expansive starting in the 1970s when chronic illness management, preventive medicine and the biopsychosocial model were developed. Before the 1970s, in general, people only when to the doctor when they were sick. The physician had one problem to deal with. Now the work is much more complicated but no one changed the schedule! The number of patients a primary care physician is expected to manage stayed largely the same.
	
	Physicians are the only professionals in society that try to do complex work during brief visits. Lawyers, accountants, psychologists, interior decorators, landscape architects-no one else does. Without the necessary time, primary care physicians are not fulfilled and frequently burn out.
	
	I started as a semi-rural physician out of residency in 1978. I had a 10-minute appointment schedule and saw about 30 patients a day. My patients convinced me to take longer with them so I went to 15 minutes appointments. I would often drive home reflecting on the patients who really needed me that day that I wish I had more time for but I was too busy servicing the needs of the rest.
	
	Fast forward to 1996, when I went to a university practice. The clinic was so dysfunctional at the front desk that they could only schedule me for 8 patients a half day clinic. I complained to no avail. So I just went with it and took more time with the patients I saw. Magic started to happen. I knew my patients narrative. They told me I learned things they never told another doctor. They loved me in a much different way. I was more effective.
	
	I now practice in hybrid direct primary care model with 30 and 60 minute appointments. My group has had the highest patient satisfaction in our entire health system every quarter for the past 10 years. We now have 12,000 patients, 18 physicians and a handful of PAs/NPs in the practice. No one has ever burned out.
	
	The secret to great patient care is time. Changing the schedule to give primary care physicians enough time with patients to do a good job is the fundamental system change.
	
	About 15 years ago, I was a consultant to what was then Group Health Cooperative of Puget Sound in Seattle. We established their first medical home practice and reduced the panel sizes for the primary care physicians to about 1800. The teams were expanded to include a nurse practitioner or physician assistant working with the physician. The number of patients seen daily by the physicians was 12 and up to two hours daily was spent on “desktop medicine” communicating and managing patients online. One happy physician told me she felt guilty for her friends and colleagues in other practices still running on the hamster wheel.
	
	The economics of reduced panel sizes and fewer visits work by reducing healthcare costs when primary care is improved. Unfortunately, fee-for-service medicine still dominates and health systems bring in revenue from high revenue healthcare. We need to transition to a health industry from a wealth industry. Only then will we be able to re-engineer primary care to be attractive and effective. 

Joseph E Scherger, MD, MPH, is a Primary Care 365 Physicians and core faculty in the family medicine residency program at Eisenhower Health in La Quinta, Calif. He is also a member of the Medical Economics Editorial Advisory Board.

Articles

Physicians are the only professionals in society that try to do complex work during brief visits.

Fixing the problems with primary care

The problems with primary care in America today are deep and complex. Lower pay, tedious schedules, lack of joy in work, and lower esteem lead the list. Sometimes complex problems can be greatly improved using a simple intervention. A core problem with primary care today is a schedule that does not allow the physician to be effective. The primary care physician lacks the time to heal.

The work of primary care became expansive starting in the 1970s when chronic illness management, preventive medicine and the biopsychosocial model were developed. Before the 1970s, in general, people only when to the doctor when they were sick.  The physician had one problem to deal with.  Usually that could be addressed quickly.  Now the work is much more complicated but no one changed the schedule!  The number of patients a primary care physician is expected to manage stayed largely the same, 2000-3000 members of a community.

Physicians are the only professionals in society that try to do complex work during brief visits.  Lawyers, accountants, psychologists, interior decorators, landscape architects, no one else does.  Not even health system administrators have brief appointments!  Are primary care patients less complicated that an employee?  Without the necessary time, primary care physicians are not fulfilled and frequently burn out.

I started as a semi-rural physician out of residency in 1978. I had a 10 minute appointment schedule and saw about 30 patients a day. My patients convinced me to take longer with them so I went to 15 minutes appointments. I would often drive home reflecting on the patients who really needed me that day that I wish I had more time for but I was too busy servicing the needs of the rest. 

Fast forward to 1996 when I went to a university practice.  The clinic was so dysfunctional at the front desk that they could only schedule me for 8 patients a half day clinic. I complained to no avail. So I just went with it and took more time with the patients I saw.  Magic started to happen. I knew my patients narrative. They told me I learned things they never told another doctor. They loved me in a much different way.  I was more effective.

I now practice in hybrid direct primary care model with 30 and 60 minute appointments. My group has had the highest patient satisfaction in our entire health system every quarter for the past 10 years. We now have 12,000 patients, 18 physicians and a handful of PAs/NPs in the practice. No one has ever burned out. Quadruple aim accomplished.

The secret to great patient care is time. This is best articulated by Kenneth Ludmerer in Time to Heal. Changing the schedule to give primary care physicians enough time with patients to do a good job is the fundamental system change.  About 12 visits a day is still very busy but a much more rewarding work day. Communicate online between visits. 

About 15 years ago I was a consultant to what was then Group Health Cooperative of Puget Sound in Seattle. We established their first medical home practice and reduced the panel sizes for the primary care physicians to about 1800. The teams were expanded to include a nurse practitioner or physician assistant working with the physician. The number of patients seen daily by the physicians was 12 and up to two hours daily was spent on “desktop medicine” communicating and managing patients online. One happy physician told me that she felt guilty for her friends and colleagues in other practices still running the on the hamster wheel.   

The economics of reduced panel sizes and fewer visits work by reducing health care costs when primary care is improved. Unfortunately, fee-for-service medicine still dominates and health systems bring in revenue from high revenue health care. We need to transition to a health industry from a wealth industry. Only then will we be able to reengineer primary care to be attractive and effective.

How to re-engineer primary care to be attractive and effective.

Change the schedule and improve primary care

When I entered medical practice in 1978, a hospital administrator earned about what I did as a family physician. Administrators did not earn what surgeons or other procedural specialists did.  All that has changed. Hospital administrators are now called CEOS and a “C suite” of other executives has grown to manage health systems. As Marni Jameson Carey pointed out in her April 25, 2019 First Take article, CEO compensation has grown much faster than that of physicians, now to the level of five times more than an orthopedic surgeon.

Here I define a “talker” as someone who does not care for patients, but rather spends their days talking about healthcare.  A “doer” is someone who cares for patients, including physicians, nurses, physician assistants, nurse practitioners, pharmacists, and various therapists.  The $3.7 trillion healthcare industry comes from caring for patients. Only the doers generate that revenue. The doers generate the money that supports the talkers. Yet the talkers seem to have all the power to set their income levels and that of the doers.

During my 40 years of medical practice, the number of talkers in healthcare has exploded. In addition to any health system loaded with various administrators, there is the complex industry of health insurance plans, consultants, pharma, and medical devices. A whole new industry of talkers has recently been developed, the coders making sure the documentation for billing is correct to collect the money. Elizabeth Rosenthal, MD, calls all these high cost activities “an American sickness” in her book by the same name.

Twenty years ago I was part of a not-for-profit health system that started to lose money.  Managed care had flushed out a lot of “waste” in the health industry and cut revenues to a bare bones level. The health system responded by laying off a large number of talkers. The doers were considered essential and were kept. Many of the talkers slowly returned as the system became profitable again. There seems to be more talkers today than ever before.

Less than a year ago I gave up administration and went from being a half time talker and half time doer to being a full time doer.  My base income went down 30%.  As a full time doer I am working harder and am clearly doing more good for patient care. My professional satisfaction is way up.

As a veteran doer providing primary care to a group of patients, often frustrated by the talkers getting in the way, I long for a time of reckoning when we realize we cannot afford a multi-trillion-dollar healthcare industry. My hope is that we will get back to the basics of good patient care. Eric Topol, MD, sees that potential happening in his new book, Deep Medicine. In Topol’s vision, computers with intelligence will replace many of the talkers and will support the doers to focus on deep relationships with patients. Short of climate Armageddon, we will not go back in time to a simpler age. Rather optimistically, healthcare like other industries benefitting from new technology, may become much more efficient and user friendly for patients and their caregiving doers.

When I meet college students looking for a career in healthcare, I encourage them to become doers rather than talkers. That is not to say that healthcare administration is a bad thing, just that the United States is flush with such talkers and job security is not guaranteed. Caring for patients has its deep rewards and will always be necessary, no matter what happens to the economy and society at large.

In the end, the doers will earn more than the talkers-and I’m not just talking about money.

Joseph E. Scherger, MD, MPH, is a family physician with Primary Care 365 at the Eisenhower Health Center in La Quinta, Calif. He is also a core faculty member with the Eisenhower Health Family Medicine Residency Program.

Physicians are the doers of healthcare, and its time for them to take back control of medicine

In healthcare, why do talkers earn more than doers

Welcome to Medical Economics' blog section

 which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / 

The work of primary care has changed. What was once mostly minor acute care with patients only going to their doctor when they were sick with one problem has become much more complex. Today, primary care physicians are expected to provide comprehensive preventive services, manage a variety of chronic diseases and provide counseling for patients suffering from stress at home or at work. On top of that, the coding and documentation of patient visits now takes up half the time of a busy physician’s schedule.

The problem is that nobody changed the schedule! Primary care doctors are still expected to do their work in brief visits and care for the same large panel of patients as yesteryear. No wonder the burnout rate among primary care physicians is approaching 50 percent, according to various studies, and U.S. medical students are avoiding primary care specialties. 

The fable of the boiling frog is widely known. The premise is that if you put a frog into boiling water it will jump out. If you put a frog in water and you slowly turn up the heat it will just sit there and boil. Most primary care physicians today are boiling frogs. Some commit suicide, many retire early, and brave ones go into new models such as direct primary care.

Primary care is vitally important to any rational healthcare system. Primary care physicians 

manage 75 to 85 percent or more of the reasons a person should see a doctor

. When primary care is used, populations are healthier and have lower overall healthcare costs. For that, in the U.S., 

primary care physicians receive about 8 percent of the healthcare insurance premium dollar

.) Primary care has been in great trouble for some time and needs to change.

There must be a national effort to rethink how primary care is practiced. Quality primary care takes time with patients to do the complex work, even with teams providing the effort, and the panel sizes per physician needs to match the work required. There are new models of primary care emerging such as concierge medicine, direct primary care, and franchise models such as Iora Health. These all provide insights into what works well.

It is time for a revolution throughout primary care voicing the words of Howard Beale played by Peter Finch in the 1976 film 

, “I’m mad as hell and I’m not going to take it anymore.” 

The healthcare system would grind to a halt of primary care physicians stopped and demanded proper working conditions, with appropriate payment from health plans and health systems. Let’s do that before we boil away.

Joseph E. Scherger, MD, MPH, is vice president for primary care and Marie E. Pinizzotto, MD, Chair of Academic Affairs at Eisenhower Medical Center in Rancho Mirage, Calif. He is also a member of the 

Quality primary care takes time with patients, so it’s time for physicians to press for the time needed to truly make needed change.

Author | Joseph E. Scherger, MD, MPH

Articles

Fixing the problems with primary care

Change the schedule and improve primary care

In healthcare, why do talkers earn more than doers

How physicians can avoid becoming a boiled frog