What happened to primary care?

March 3, 2020

How the crumbling of the physician-patient relationship lies behind the problems facing primary care delivery

Primary care is in a bad place. Physicians feel undervalued. Cumbersome technology, administrative burdens and payer hassles mean physicians are unable to spend the time they want with their patients.

At the same time, patients have never had more choices for where to get primary care. Hospital systems and private equity are gobbling up practices. Drug store chains are opening clinics, where patients can see a non-physician provider for basic care.

Does this mean the traditional physician-patient relationship is dead?

Timothy Hoff, Ph.D., professor of management, healthcare systems and health policy at the D’Amore-McKim School of Business at Northeastern University, argues that both physicians and patients still want a long-term relationship, but modern healthcare, with all its complexity and focus on value is preventing both parties from forging the caring relationships they would prefer.

This is the case that Hoff makes in his book, Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health, published in 2018 by Oxford University Press.

Hoff sat down with Medical Economics to discuss the state of the physician-patient relationship and what can be done to fix it. This interview has been edited for length and clarity.

Medical Economics: There is this ideal of the doctor-patient relationship that physicians and patients hold on to. Has it ever really existed?

Hoff
: That’s a fair question. It’s something that we’ve romanticized over time. But I think it’s real, it’s been real, and you can see evidence for it in our own healthcare history, as well as even some of the trends that you see going on right now.

There was a time where we had these doctors called general practitioners, the forerunners of family doctors, when we did have much more relational medicine. That was in part because we didn’t have as much technology to rely on and we didn’t have so many specialists. Back then, many people did have long-standing ongoing relationships with a single doctor, particularly in the primary care area. Those doctors tended to practice in the same communities, they stayed fairly stable over time within a practice.

So those relationships were definitely there. I think it’s definitely been real. I think we do romanticize it for a reason because there’s elements of it that are very real that many people have experienced over time and feel very strongly about.

ME: How has being a primary care physician changed over the years?Hoff: Primary care has changed an awful lot. I would focus, and the book talks about this, on three major reasons. One is the continued specialization in American medicine, this idea that no one doctor can do it all. And so, increasingly, primary care physicians have had their scope of practice whittled down. For example, they stopped doing hospital care, and were replaced by hospitalists. They stopped delivering babies. So one of the ways it’s changed is the scope of practice continues to get more and more narrow.

Another way it’s changed, and my book really takes aim at this, is primary care is the first brand of medicine that’s really been fully corporatized, and corporatized with this idea I call “metric fever,” which is what I call trying to standardize medicine as much as possible, which has the effect of making it more transactional. That makes it less focused on the squishy or relational elements like the doctor getting credit for talking to the patient. You can’t measure that precisely, so increasingly those things aren’t being valued.

And finally, as healthcare is being consolidated, more primary care doctors now work for large entities with hospitals at the center of them. And hospitals think about primary care very differently than the traditional primary care practice used to. So I think that those are the major ways primary care has changed: narrow scope of practice, standardization and cook-booking of primary care, and doctors who are largely employees of large systems.

ME: One of the things we hear about a lot is the consumerization of healthcare, that patients are looking at healthcare more like they’re looking at other things that they purchase and consume in their lives. Do you think it’s true patients are looking at healthcare this way?Hoff: Most doctors will tell you that most of their patients still desire the same things from their care and from their interactions with the system as they did 20 or 30 or 40 years ago. Patients want someone who’s an expert, who’s going to listen to them. They want someone who’s going to help them solve the problems they have, they don’t want to feel blown off and they want someone who shows a degree of empathy towards them.

I think a lot of consumerization is being concocted by an industry that’s not being controlled by doctors right now. For big organizations that want to streamline care, the view of the patient as consumer is really the best view to take.

Do patients want more consumer convenience? That’s true. They don’t want to wait three months to see a doctor. They don’t want to have to be put through tons of inconvenience for a primary care visit.

But the expectations of patients are being taken advantage of. This consumer rhetoric comes along that says, ‘Oh, I know your needs are not being met, and we can meet them, and here’s how we’re going to do it.’ But, you know, a lot of that, in my opinion, is snake oil.

ME: What are your thoughts on the emergence of quick convenient care settings?

Hoff
: There’s a real concerted effort among big healthcare companies and even non-healthcare companies like Amazon, Apple, and Google, to turn the primary care part of healthcare into a cheaper, more transactional form of care delivery-a fast food kind of model. Fast food with the use of technology: that’s the way I would put it. I think it’s a tsunami threatening to disrupt all primary care. There’s government acceptance of this new way of looking at it, there is venture capital acceptance of this new way of looking at it. But I don’t think patient acceptance is there. I think we’re being led to believe it is, but it’s not. But I do worry that, if something doesn’t change soon, you’re going to see a primary care system that looks extraordinarily different from the one we had even 10 years ago, a sort of pop-up franchise, drive-thru kind of system, aided by the use of technology.

ME: What is the impact of these trends on actual patient outcomes? Are these changes leading to improvement in outcomes for, say, patients with chronic conditions?

Hoff
: The data is underwhelming, let’s put it that way. We’ve invested a ton of money in the use of metrics and the use of measurements, the use of EHRs to document and collect data on patients. And yet the studies that are out there show the quality gains are negligible, particularly given the amount of investment. In other words, we haven’t had this dramatic improvement in outcomes. So, from a quality perspective, none of these new ways of looking at primary care have done the job, and from a cost perspective, the jury’s still out.

ME: For primary care physicians who feel the deck is stacked against them, what should they do? How can they fight back against these trends?Hoff: When it comes to primary care, it’s important to stress the relational side of medicine, the interpersonal connections that really make the difference. And so we have to pay for that. Doctors have been saying this for years, and I agree with them, that you’ve got to value those aspects more. And we’ve got to acknowledge the fact that to many policymakers and payers, that sort of care looks inefficient. So we do need to invest more in this relational care.

The medical profession itself is going to need to come to a decision about how much primary care doctors matter. I think doctors of all kinds now need to think about new forms of collective mobilization. I don’t use the term unions. They’ve got to find ways to band together-not in the way that they are banding together now. It’s very reactive now. They need to come together to assert their economic power and to advocate for specific things that are going to bring more value to the work that they do.

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