A veteran physician recounts the current challenges of primary care, and how the field could evolve.
Dr Simon Murray sat down with MD Magazine to recount the current challenges of primary care practice, and how he expects the field to evolve in the future.
What are the biggest challenges for modern primary care physicians?
We face a lot of challenges. There are more patients than they can handle generally. Costs of doing business are rising faster than they're getting paid - so economics, the economics are difficult. Morale is low. Primary care doctors see their colleagues as, right or wrong, making a lot of money and they themselves are not. They feel that they tend to be dumped on by other doctors, by the specialists.
The patients are demanding and there's a lot of patients that you have to see during the day to get by. It's difficult, it really is difficult, and I think something is going to break unless things change in the United States. I think the primary care system is really overwhelmed.
In most countries in the world, 70% of the doctors are primary care and 30% are specialists, in our country it's the reverse - 70% specialists, 30% primary care, and I don't think the government gets it, that they pay a lot of lip service to primary care and trying to improve things but they don't, nothing has changed. In fact, the work we have to do has even increased. Preauthorizations for medicines, preapprovals for X-rays, things like that. We never used to have to do that but now we have to do it more and more and more. People have to hire staff just to get preapprovals for medicines. It's onerous.
When I sit in the room with a patient, I imagine the government, Uncle Sam is there, the malpractice lawyer is there, the pharmaceutical company is there trying to persuade me, over here is a hospital trying to get me to do something and here is Medicare with the rules and regulations trying to get me, and here's the medical board here, they're all in the room together with me, all looking over my shoulder. And you feel the pressure from all of that, you know, when you're just trying to do your job and everybody else is trying to regulate your life.
Where do you see primary care in the next decade?
I see more doctors retiring early. I see less American students who want to go into primary care. I think you'll see that by the matches - the matches don't fill. The ROAD to success is radiology, orthopedics, anesthesia and dermatology - the ROAD to success. Primary care is not on that road. So primary care, pediatrics, general surgery and psychiatry are underfilled for a variety of reasons - a lot of extra work, low pay and all that.
I see that the pool of candidates who pick internal medicine may decline. The best students are not gonna take that residency - they're gonna go for the higher paying specialties, better lifestyle specialties.
That's a challenge. So the quality of internal medicine and primary care may decline. That void is going to be filled by nurse practitioners and by PAs. Frankly I don't think PAs have the ability to practice primary care medicine like a doctor can. I'm sorry to say it. They can do a lot of things, but they just can't. They don't have the training or the background to do it. But that's how they intend to fill it.
There's a general lack of respect for all professions - politicians especially, lawyers - but for a long time doctors held out. We were not really included, but we're seeing more and more of this disrespect toward us. Part of that is earned, part of it is earned. The patients are perceiving that they're not getting what they're paying for, they see their costs going way up, but the doctors are not getting it, not all of it, it's going elsewhere.
What has to change, in my opinion, to save primary care is that if patients paid a certain fee a year extra, and then used their insurance for their visits, the doctors could see far fewer patients, could take interest, and could handle a lot of things that they are referring out now. Since 85% of my income comes directly from the patients, it's definitely in my best interest to be on my best behavior, and to do what's necessary and right. I mean, I would try to do that anyway. If I don't do the right thing, they're gonna fire me.
Right now you go to the average doctor and if you're gonna leave, he probably wouldn't even notice, cause he's got so many patients. I think it's woefully inadequate to spend 6, 7 minutes with a 70 year old woman with 85 problems, but that's what they're forced to do.
What areas do physicians always seem to overlook?
I think as doctors, we tend to think we can get away with being rude to people and not have any repercussions about it. I mean, I've heard so many stories and I've probably been guilty of it myself - of doctors who are in such a rush that they ignore what the patients are asking. They interrupt them before they finish their story, they're in a hurry to get through the interview, that they don't really hear what the patients have to say.
If you could give your younger self advice, what would it be?
Keep your mouth shut and just listen more. Listen more and speak less. It might also be to not make up things. Only say things that you know are right. And don't be afraid to say you don't know. Sometimes doctors don't know what the answer is so they'll just make up some story. Just say what it is. If you don't know, you don't know, but the proper answer is, "I don't know, but I think I know someone who can help you with that." It can't just end with, "I don’t know," it has to always be followed with "I will try to find someone who does, or we can find someone who does, or I'll read about it or I'll find a way to figure it out."
What are your thoughts on the current state of American health care?
The fee for service system has to go, and number 2, private insurances, I'm sorry to say, have to go. They're a big problem. Everybody, I think, should be on one system. We should have a government-sponsored health plan that everybody is on.
People say, "Look at Canada, look at England, look at how bad their system is." I think they should build into those systems the right for people to opt out and have private health insurance if they want to. If you wanna drive a Ford, you can drive a Ford. If you wanna drive a Mercedes, and you have the money, you can buy a Mercedes. I think health care should be the same. Have the government sponsored plan for everybody. No private health insurance companies except if you want to pay yourself out of your pocket.
What's the most important thing physicians should always keep in mind?
The best a doctor can do is to keep well informed, to read a variety of sources, keep his mind or her mind open, that there may be other answers. An answer may exist, you may not know what it is, but it's out there maybe, and it may not be found in the New England Journal, it may be found somewhere else.
The other thing I think about medicine that doctors should know is that we're all going to be patients some day, so treat people like you would want to be treated. I don't want to be rushed by doctors, I don't want to be scolded, and I don't want to be berated for what I'm not doing right, so I try not to do that with other people.
We're all patients at some time, so I think if you remember that it goes a long way in helping you get along with people.