[This post was first published on The Health Care Blog on 4/16/13, where they titled it “An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week.” It has generated many interesting comments. I post it here with its more modest original title. This post is about recruiting and retaining doctors to work in primary care for medically complex elders.]
A
few weeks ago, The Health Care Blog published a truly outstanding commentary by
Jeff Goldsmith, on why practice
redesign isn’t going to solve the primary care shortage. In the post,
Goldsmith explains why a proposed model of high-volume primary care practice —
having docs see even more patients per day, and grouping them in pods — is
unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer
patients. He points out that we are replacing a generation of workaholic boomer
PCPs with “Gen Y physicians with a revealed preference for 35-hour
work weeks.” (Guilty as charged.) Goldsmith ends by predicting a
“horrendous shortfall” of front-line clinicians in the next decade.
few weeks ago, The Health Care Blog published a truly outstanding commentary by
Jeff Goldsmith, on why practice
redesign isn’t going to solve the primary care shortage. In the post,
Goldsmith explains why a proposed model of high-volume primary care practice —
having docs see even more patients per day, and grouping them in pods — is
unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer
patients. He points out that we are replacing a generation of workaholic boomer
PCPs with “Gen Y physicians with a revealed preference for 35-hour
work weeks.” (Guilty as charged.) Goldsmith ends by predicting a
“horrendous shortfall” of front-line clinicians in the next decade.
Now,
not everyone believes that a shortfall of PCPs is a serious problem.
not everyone believes that a shortfall of PCPs is a serious problem.
However,
if you believe, as I do, that the most pressing health services problems to
solve pertain to Medicare, then a shortfall of PCPs is a very serious problem
indeed.
if you believe, as I do, that the most pressing health services problems to
solve pertain to Medicare, then a shortfall of PCPs is a very serious problem
indeed.
So
serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with
a 35 hour work week.
serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with
a 35 hour work week.
I
can already hear all clinicians and readers older than myself harrumphing, but
bear with me and let’s see if I can make a persuasive case for this.
can already hear all clinicians and readers older than myself harrumphing, but
bear with me and let’s see if I can make a persuasive case for this.
The crisis we face
First,
consider the situation:
consider the situation:
The most
pressing and urgent health services research problem society must solve is how
to restructure healthcare such that we can provide compassionate, effective
healthcare to an expanding Medicare population, at a cost the nation can
sustain.
pressing and urgent health services research problem society must solve is how
to restructure healthcare such that we can provide compassionate, effective
healthcare to an expanding Medicare population, at a cost the nation can
sustain.
This
is a problem with very high human stakes at hand. As we know, most older adults
end up undergoing considerable health-related suffering at some point, with
family caregivers often being affected as well. Much of this is due to the
tolls of advancing chronic diseases, such as diabetes, heart disease, COPD,
arthritis, dementia. (See this handy CMS
chartbook for the latest stats on chronic disease burden in the Medicare
population.) And a fair part of the suffering is inflicted by the
healthcare system itself, which remains ironically ill-suited to provide
patient-centered care to those medically complex older adults – and their
caregivers — who use the system the most.
is a problem with very high human stakes at hand. As we know, most older adults
end up undergoing considerable health-related suffering at some point, with
family caregivers often being affected as well. Much of this is due to the
tolls of advancing chronic diseases, such as diabetes, heart disease, COPD,
arthritis, dementia. (See this handy CMS
chartbook for the latest stats on chronic disease burden in the Medicare
population.) And a fair part of the suffering is inflicted by the
healthcare system itself, which remains ironically ill-suited to provide
patient-centered care to those medically complex older adults – and their
caregivers — who use the system the most.
Needless
to say, the financial stakes are high as well, with projected Medicare
expenditures usually cited as the number one budget buster threatening the
nation’s financial stability over the next 50 years.
to say, the financial stakes are high as well, with projected Medicare
expenditures usually cited as the number one budget buster threatening the
nation’s financial stability over the next 50 years.
A necessary part of the solution
Next,
consider an essential component to compassionately and effectively meeting the
healthcare needs of the Medicare population:
consider an essential component to compassionately and effectively meeting the
healthcare needs of the Medicare population:
Medicare
beneficiaries – and their family caregivers – must be partnered with good PCPs
who can focus on person-centered
care, and can collaborate with them as they navigate the many health
challenges of late life.
beneficiaries – and their family caregivers – must be partnered with good PCPs
who can focus on person-centered
care, and can collaborate with them as they navigate the many health
challenges of late life.
Especially
once they are suffering from multiple chronic illnesses and/or disability,
seniors – and their families — need a stable relationship with a clinician who
can fulfill the role of trusted consultant and advisor as they go through their
extended medical journey. Healthcare for older adults almost always becomes
complex and stressful for seniors and their families. Even educated and
activated patients who are willing and able to direct their own care will need
a generalist who can maintain a longitudinal health dialogue with them, and who
can help them sort through complicated medical situations as they arise.
once they are suffering from multiple chronic illnesses and/or disability,
seniors – and their families — need a stable relationship with a clinician who
can fulfill the role of trusted consultant and advisor as they go through their
extended medical journey. Healthcare for older adults almost always becomes
complex and stressful for seniors and their families. Even educated and
activated patients who are willing and able to direct their own care will need
a generalist who can maintain a longitudinal health dialogue with them, and who
can help them sort through complicated medical situations as they arise.
Now,
much as been made of teams in primary care, and the importance of moving past
our historic model of PCP as the person who knows it all, and does it all. This
change is long-overdue, and I’m thrilled to see it coming. When properly
implemented, I’m quite sure that team-based care will help older adults obtain
the comprehensive primary care services they need and want.
much as been made of teams in primary care, and the importance of moving past
our historic model of PCP as the person who knows it all, and does it all. This
change is long-overdue, and I’m thrilled to see it coming. When properly
implemented, I’m quite sure that team-based care will help older adults obtain
the comprehensive primary care services they need and want.
But
even with excellent team-based care, I believe most older adults will want and
need a PCP to function as their high-level medical strategy consultant and
collaborator.
even with excellent team-based care, I believe most older adults will want and
need a PCP to function as their high-level medical strategy consultant and
collaborator.
Common challenges for PCPs of older
adults
For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:
- Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.
- Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.
- Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.
- Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)
- Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.
- Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15+ items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)
- Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.
- Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.
- Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.
- Weighing in on family conflicts. I’ve often watched patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)
I
must say that I love doing the work above. It’s deeply satisfying to help
patients make sense of all that is medically happening to them, and to support
them as they cope with their health challenges. But it’s also, as you can
imagine, difficult work that is cognitively and emotionally demanding. The
pressure of 15-20 minute visits makes things harder than they should be, but
even if we went to 30-45 minute visits, the work will remain fundamentally
intense and somewhat taxing for the provider.
must say that I love doing the work above. It’s deeply satisfying to help
patients make sense of all that is medically happening to them, and to support
them as they cope with their health challenges. But it’s also, as you can
imagine, difficult work that is cognitively and emotionally demanding. The
pressure of 15-20 minute visits makes things harder than they should be, but
even if we went to 30-45 minute visits, the work will remain fundamentally
intense and somewhat taxing for the provider.
Can
anyone seriously argue that we won’t need PCPs to do the work above for
Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage
dementia, falls, and all the other geriatric problems too.)
anyone seriously argue that we won’t need PCPs to do the work above for
Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage
dementia, falls, and all the other geriatric problems too.)
Ok.
Then if we agree that the work above is essential to the wellbeing of millions
of older adults, and is a crucial component to providing overall cost-effective
healthcare to the Medicare population, we must get serious about how we can
recruit and keep clinicians as Medicare PCPs.
Then if we agree that the work above is essential to the wellbeing of millions
of older adults, and is a crucial component to providing overall cost-effective
healthcare to the Medicare population, we must get serious about how we can
recruit and keep clinicians as Medicare PCPs.
The benefits of a 35 hour work week
If
the work of Medicare PCP could be
organized so that it fit into a 35 hour work week, we’d see the following
benefits:
the work of Medicare PCP could be
organized so that it fit into a 35 hour work week, we’d see the following
benefits:
- More
clinicians would be willing to do, or stay, in the job. Let’s face
it, we have ample evidence that work-life balance is important to the
younger generation of physicians, especially those with young children. As
much as this dismays the older generation of physicians, this trend seems
to be here to stay, so perhaps we should learn to work with it. Debt relief
– the usual hope for attracting people to primary care – is never going to
be enough on its own.
- PCPs would
do the job much better. Providing compassionate,
comprehensive person-centered care to medically complex patients demands
cognitive and emotional energy. The work of Daniel Kahneman and others has
shown that people
do get cognitively depleted by work which requires complex decision-making.
(Once depleted, they begin seriously avoiding cognitive and emotional
challenges.)
Given
that we are asking PCPs to actively engage with patients and families, embrace
shared-decision making, adapt to technological changes, and make a whole host
of behavior
changes, making sure that clinicians in this role aren’t burnt out by long
working hours just makes sense.
that we are asking PCPs to actively engage with patients and families, embrace
shared-decision making, adapt to technological changes, and make a whole host
of behavior
changes, making sure that clinicians in this role aren’t burnt out by long
working hours just makes sense.
Summing it up
The
impending shortage of PCPs constitutes a national emergency. In order to
provide the growing Medicare population with compassionate, effective
healthcare at a sustainable cost, seniors will need stable relationships with
PCPs who can function as their strategic medical consultants, collaborate in
helping to meet healthcare goals, and provide emotional support.
impending shortage of PCPs constitutes a national emergency. In order to
provide the growing Medicare population with compassionate, effective
healthcare at a sustainable cost, seniors will need stable relationships with
PCPs who can function as their strategic medical consultants, collaborate in
helping to meet healthcare goals, and provide emotional support.
Doing
this type of PCP work can be extremely rewarding, but it’s also cognitively and
emotionally demanding.
this type of PCP work can be extremely rewarding, but it’s also cognitively and
emotionally demanding.
Structuring
the job of Medicare PCPs into a 35 hour work week would probably attract more
clinicians to the job, including those with young children. It would also help PCPs maintain the cognitive and
emotional resources needed to do the job consistently well, and could reduce
burnout in this group of key clinicians.
the job of Medicare PCPs into a 35 hour work week would probably attract more
clinicians to the job, including those with young children. It would also help PCPs maintain the cognitive and
emotional resources needed to do the job consistently well, and could reduce
burnout in this group of key clinicians.
