The Future of Primary Care

I’m both excited and depressed about the future of primary care. I know that many family medicine doctors will increasingly take on the gatekeeper role for health insurance companies. But many will also embrace the preventative role which was overshadowed by all the hype of western medicine.

The Current State of Primary Care

Okay, no news here. We have terribly long wait times and as a family medicine physician, I no longer care. I’m burnt out and don’t feel that my interventions are that effective.

I worry about lawsuits and my patients know that I’m worried about them complaining. It’s a battle and not I nor the patient can win.

I order the same useless tests on patients. I get conflicting information from ACOG, ADA, and USPSTF. This forces me to come up with my own untested decisions which are hard to justify to patients.

As for prevention – I can’t recall the last time I convinced a single patient to lose weight, change their diet, much less take their medications as prescribed.

Finally, I don’t see an outcome. I have practiced for 15 years and I see my patients aging, obesity increasing, insulin requirements going up – it’s as if my interventions are meaningless.

The Future of Primary Care

I am hopeful that the future of primary care will involve a real patient-doctor relationship based on disease prevention. A relationship that’s not contractual but desired and consented to by both parties.

I definitely don’t want to do this alone – I’ve done that for far too long. I don’t want to collect all the patient data and sit there and figure out who is at risk for what. I want technology.

We’ll get into tech in a minute in this article. It definitely hasn’t delivered as promised and the EHR has only drained more and more of my time. Other than a few blurbs in it, I rarely reference the actual progress note in the EHR.

I should be able to compare one group of my patients to another. Meaning, I should be able to run non-IRB-approved experiments constantly in my patient population. How can I when I can’t collect any data?

In this idyllic future of primary care, I would communicate with the patient any way I want – in-person, online, asynchronously, or via small voice mail blurbs.

Undelivered Promise

Western medicine told us that if we measure the A1C and LDL and treat the aberrancies we’d be saving patient lives. Wrong. No, not just wrong, but these were lies.

We were told that there is a medication to lower the patient’s weight. Then came surgeries. None worked – the weight was regained by the patient because we never addressed the underlying issue.

We were told that metformin would keep the DM2 at bay. Then came the new medications – basically, anything to prevent us from using insulin. And yet everyone eventually ends up on insulin. And that’s when this disease really takes off.

We were told that screening patients in this or that way would prevent morbidity and mortality. That we should tell them to avoid fatty foods. So much crap

Patient Selection

I don’t want some random Joe sent to me. I have a particular personality type which likely won’t match with everyone. This helps me build much closer bonds with some patients and likely not be a good fit for others.

This is a big problem in the insurance model. They own the patients and the doctors. They send whomever to some random MD or DO. No logic behind the selection. It’s a machine meant to extract as much money from the system as possible. Really sick.

I’m a healthy, active 40s MD. I should see patients in my own age group. I get them – I know what they are going through. I don’t have much to offer someone much older. But I can also connect with many parents and their children.

The humanity the system wants to remove is exactly what we need for the future of primary care to have any potential. Relationships are important even though they aren’t always easy.

Technology Assisted Care

We have so much patient data – live data. Why is it that I have to make a decision each and every time for each and every patient? You’re telling me that based on the obvious information about the patient in the EHR my EHR can’t recommend the right antibiotic for this uncomplicated UTI?

That my EHR can’t recommend a fasting insulin level or a CGM for a patient who is still at high risk for DM2 despite normal A1Cs?

Obviously, I am harping on data here. I love data – useful data that is properly digested for a primary care doctor. The psychiatrist needs to know the details of the PHQ9 questionnaire. As an FP, I just need to know how the patient’s score is changing.

A single BP reading in the clinic is often useless. If in 2022 we aren’t using 24-hr averaged BP readings, god help us!

Healthcare Cooperative

I like being a solo doctor because medicine is already confusing, I don’t want to deal with another doctor’s style. 2 family medicine doctors can’t agree on the same thing.

But the future of primary care will have doctors who meet regularly to discuss point of contention. Informative sessions, education, and learning is really important for doctors to feel connected and to improve their skills.

In this model of primary care, I want to work side by side with another family medicine doctor and we manage a group of patients together. If I miss something they’ll catch it. If they have a knowledge gap then I’ll fill it.

Continuous Monitoring

In the current model of primary care medicine, we get to interact for such a short time with so many patients that it’s like reading a book by opening a random page and grabbing 3 adjacent words at a time.

I need ongoing relationships with my patients. Often the first few months are the most important. And I need the patient data to be continuous. Again, this is a place for technology.

Which direction is your weight headed? What’s your blood sugar doing over many months? Are there any drops in oxygen levels at night? What’s the trend of the apoprotein b?

Patient Support

As a family medicine doctor, I’m much more than a medical license. Try to convince the insurance companies and the patients of that.

I want to be a community resource for patients. If someone needs help with transportation, financial support, or a group to connect to I want to be the hub of that.

I should know which resources are available in my community and whom I can plug into where. Are there interesting research studies into which I should enroll a patient?

I never want to tell a patient that I can’t do something for them because their insurance doesn’t cover it. What do I care if an insurance company doesn’t want to do something?! I am resourceful and can suggest a community clinic or hospital or an imaging center which the patient might be able to afford for further testing or treatment.

Virtual Care

Because of the advent of really good technology in healthcare, we are able to virtualize a lot of the routine visits between a family medicine doctor and a patient. I believe this is a move in the right direction.

Not all visits can be virtual and patients will have their own unique preferences. I just want the option to work remotely and serve those patients who don’t want to tackle traffic to come to my office.

But I can’t do virtual care if I’m relegated to a handful of apps. Open it up and let me deal with HIPAA once the patient data is compromised.

Data is moving online and there is no reason for the patient’s clinical data to not be accessible by the handful of doctors who practice in the US. Interoperability isn’t a luxury. Those who are the most disadvantaged have the most interrupted care and need access to their info.

Less Litigation

None of this can happen unless we lift the litigation and legislation which is hindering the patient-doctor relationship. I don’t see that as the future, actually. I think the reality is it’s going to get much worse.

Some patients will waive their right to sue doctors or file online complaints. This will be a step in the right direction. It’s a 2-way trust which we’ll have to rebuild slowly with primary care and the patient.

Government Support

I used to think that the government had a vested interest in the health of its citizens. I don’t believe that any longer. It’s as much a financial decision for them as are taxes.

However, for those few government agencies which are looking to provide primary care doctors with support and want to see more access in primary care, they will need to support the individual primary care doctor.

What we are seeing now is some shifting of resources – from specialty care to primary care. But this means nothing for large medical groups which own both. They are given more funds for primary care. Fine. They’ll take it and use it for another department.

The individual primary care doctor will need the support to start a private practice, whether in-person or online. An FP should be able to start a physical practice for less than $25k and a virtual one for less than $5k.

Make that happen and you’ll improve access. You’ll demonetize the practice of medicine and shift the focus on the sustainability of practicing medicine.