Change the schedule and improve primary care

January 9, 2020

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

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.

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.