Non-Clinical Burdens In Primary Care

In the June 7 issue of Annals of Internal Medicine Dr. D.W. Dowdy discussed the challenges facing primary care physicians. Among many things he emphasized wwere th34toll that non-clinical burdens take on physians. Here is my response which I had sent to the Annals via their rapid response system ()which by the way is a great way to comment on an article appeaing in the Journal.


Annals of Internal Medicine [rapid response to “Trained to avoid primary care by Dowdy DW in June 7 issue v. 154]

The author’s comments regarding the “nonclinical burdens faced by every primary care provider in the country” cannot be emphasized enough. They often consume more time than the actual medical care given to patients. Worse, they have relentlessly increased as cost- control and information-gathering agencies have gained more control over doctors. And board-re-certification with its unrealistic expectations adds to the burdens of primary care physicians.

Although the medical home has been proposed as an antidote to these burdens, I don’t see it as promising a solution as others do. Already most primary care offices are viewed as dumping areas for all the administrative work that other members of the health team prefer not to do. The medical home proposes to use midlevel providers to take care of the administrative work and the “routine” illness now done by generalists, freeing them up to take care of the seriously ill. But most primary care doctors use the “routine” illnesses as opportunities to cement their relationship with their patients and to learn about their social and psychological backgrounds, both of which are absolutely necessary to be good primary care doctors.

Just focusing on serious illnesses is incompatible with the philosophy of primary care. Shouldn’t the specialists be the ones focusing on the more serious illnesses?
The idea of generalism in medicine has never taken root in the minds of our leaders in medical education. They have not shown strong unified public support. So, American medicine remains, as it has been for over a hundred years, research-based not practice-based.

As important as research is, it may be better if it were limited to designated research sites where researchers collaborate and coordinate their efforts. I say that because after looking at the journals on the shelves on my hospital library filled with esoteric reports, I wonder how much of today’s research is truly useful or just the result of publish or perish. The beneficial result may be that specialists may be doing some of what primary care doctors are doing today, assimilating some of their “non-clinical burdens”. They may also get to know their patients better.
Perhaps the solution lies in how the primary care doctors of the future will be trained. They may be hybrids. Part nurse-practitioner, part traditional physician, with a customized and shortened training period; say two years of medical school and three of residency training in a community health center.

Besides adding a long-needed change to the culture of medicine, this approach will get more primary care physicians into the workforce quicker with more of them available to share the total work load a large part of which is administrative.