In an ongoing email exchange I wrote:

… opined that the answer for primary care would not exist within "fee for service(FFS)". If we follow Deep Throat's admonition and "follow the money", we can understand why residents eschew primary care.

I believe we should look carefully at how primary care physicians are currently paid. All attempts at fixing the FFS system seem to make it worse. RBRVS was touted as a big advance for non-procedural physicians – obviously that was wrong.

The answer to attracting students and residents is to make the job attractive to those already doing it. We need to better understand the optimum panel size for an internist – likely a bit hire in a PCMH – and then figure out a payment structure that makes the size doable.

Hospital medicine works because everyone knows that 15-17 patients represents the optimal number of patients each day. Hospitalists have successfully negotiated for this optimum. Primary care internists (different from family physicians) should develop the same understanding.

Why is this so important? I believe the big problem is providing internists enough time to enjoy doing a complex job well. We discourage residents from primary care because their role models do not enjoy seeing too many patients each session. The suits make internists overschedule because of the FFS system. The system is broken, and likely cannot be fixed. We need a new system.

My good friend, Yul Ejnes, a private practice internist who becomes the Chair-Elect of the ACP Board of Regents in April, writes:

I’m in private practice, which is the source of 95% of my income – in other words, I work on commission. Bob Centor’s comments resonate – my schedule can accommodate 24-25 patients in a day, but I usually see 21-22 due to my blocking slots to account for patients who I know will take longer (I hate running late), how much non-face-to-face work I have piling up, and how stressed I am. I do so at a cost, since my income is derived from how many patients I see and that volume (which amounts to 85-90 patients in a week) is enough to pay the overhead and allow me to pay myself enough to pay my bills and keep a roof over my head (let’s just say that I’m in the lower quartile for GIM income). The  difference between seeing the 25 and the 21-22 amounts to tens of thousands of dollars per year, which, by the way, is almost all profit, since the incremental cost of seeing those patients is minute. Having said that, I need to feel comfortable about the time that I spend with my patients (we still undress patients in my office), I enjoy the time I spend with them (many of them are in their 20th year with me), and I can’t get home at 7:30-8 every night, so I suck up the loss and do it the way I do it. (As an aside, one thing that EMR implementation has NOT done is shorten my work day. In fact, I would argue that it is still ½-1 hour longer than it was pre-EMR, and I’ve been using one for over three years.)
 
Even the 21-22 a day pace is not easy. If the schedule is booked, I’m going room to room from 8:30 to 11:45 or noon nonstop, then again from 1:00 to 4:30 or 5:00, with most of lunch hour spent documenting, dealing with phone calls, and putting out fires, and another 1 ½ to 2 hours after the last afternoon patient doing the same. Somewhere in the middle of all of that there are labs/x-ray reports, forms, consultant letters to review, etc.. I usually walk out of the office exhausted and have little desire to do anything of substance when I get home – I reheat dinner and settle down, as opposed to what “normal” people do after work.
 
I’ve said this to friends and colleagues many times – when the schedule is lighter, which might be the result of weather, scheduling goof ups, or chance, I feel very different at the end of the day – less stressed, happier with what I’m doing, able to think more clearly. 16-17 patients seems to be a number that works for me based on my experience. On those days, I don’t necessarily spend more time on visits, but I have time between visits to collect my thoughts, can handle non face-to-face matters in real time, and can actually take a break during noon hour. I also get out the door a little earlier; instead of an eleven hour day, it’s a 9 ½ to 10 hour day. Unfortunately, I cannot adjust my schedule accordingly under the current system – were I to do so, in order to stay in business I’d have to cut my own pay such that I’d be better off working as an assistant principal in the local middle school.
 
I can easily understand how this type of professional life would not attract a recent graduate. Sometimes I question why I’m still doing it. The “hook” in my case is the 20 years of taking care of the same group of patients, including three generations of some families (don’t let the FP’s make you think that they’re the only ones who get to do this), which helps me to manage the complex problems but is also very personally rewarding. The early stage physician doesn’t have the benefits of the long-term relationships to offset the negatives of volume and pace of the work (and as I already noted, that may not be enough of an offset), so it’s hard to sell this career option. A system that did not require throughput in order to stay afloat would go a long way to reversing the decline of primary care. Not to mention the issue of overall compensation relative to other specialties, which none of the above addresses.
 
Yul

The problem with primary care internal medicine is not the job I did in the 1980s, but rather what the job has become.  Fix the job and you can fix the profession.

Patients need great internists, therefore we must advocate for improving the job.

Related posts:

1. Primary care payment – is win-win possible?
2. Dazed and Confused – Levels of primary care?
3. Duty hours, patient safety and resident education
4. How should we pay for primary care?
5. Pulling primary care out of insurance

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