The Troubling Feedback Loop of Primary Care

Est. Reading Time: 4 Minutes

Editor’s note: Shawn Morris retired as CEO on June 30, 2023, but remains on the company’s Board of Directors.

There are two things we know for certain about primary care: it’s effective, however, it’s under tremendous pressure as fewer doctors choose primary care as their profession — and those who do face challenges acquiring and adjusting to the tools needed to thrive.
Study after study demonstrates the immense value of primary care, with some going so far as to outright show how “more primary care physicians leads to longer life spans.” Primary care is pivotal in driving the volume-to-value transition. For every dollar spent on primary care, $13 are saved. By preventing emergency visits, primary care providers can save the healthcare system $32 billion each year. The list goes on.

But there is trouble looming on the horizon. Primary care specialties — internal and family medicine, pediatrics, and OB-GYN — have withered in recent years. The American Association of Medical Colleges (AAMC) predicts there will be a shortage of up to 55,200 primary care providers by 2032. Exacerbating this trend is a shift of primary care physicians to hospitalist roles, according to MedPAC.

In order to reverse this trend, we need to understand the overlooked cause of this problem.

The Problem of the Feedback Loop

In 2016, the Milbank Quarterly published a piece titled, “Where Have All the Primary Care Doctors Gone?” In 1992, the New England Journal of Medicine ran a piece titled, “Where Have All the Primary Care Applicants Gone?” These articles show us that this dwindling of primary care is nothing new and that it begins in medical school and residency. In essence, applicants for residency aren’t interested in primary care.
Here’s why:

  • Lower pay. According to Kaiser Health, primary care physicians earn, on average, $231,000 a year, or, put differently, a little more than half of what orthopedic physicians earn.
  • Higher burnout. 79 percent of primary care physicians report symptoms of burnout compared to 57 percent of specialists.
  • Changing practice. Primary care is traditionally regarded for the strong patient-provider relationships and interactions. However, new data from the Annals of Internal Medicine shows primary care providers spend twice as much time on desk work or electronic health records (EHRs) than with patients — and that doesn’t even count off-the-clock, after-hours clerical work.

Without new entrants, any system will gradually shrink until it’s gone. Without residents in primary care, the field is jeopardized. But, at the end of the day, it’s not fair to blame students for not wanting to go into primary care given the current state of affairs. As Richard Joseph, MD, and Sohan Japa, MD, wrote in a humbling, confessional article, primary care’s “long hours and increasing demands,” combined with “four years of drowning in medical school debt and three years barely keeping afloat on a resident’s salary, the preference for becoming a specialist is entirely rational.”

Students’ reluctance to enter the field is where things become worrisome. This situation could lead to a feedback loop in which changes in one part of a system enhance or amplify changes in another part of the system that create increasing instability. Here’s an example of a feedback loop commonly used by climate scientists: Polar ice caps melt due to rising temperatures. As the ice caps disappear, they reflect less sunlight and heat back into the atmosphere. This excess light and heat further melt the ice caps, which perpetuates the vicious cycle.
What is frightening is that as the applicant pool diminishes, the duties expected of primary care physicians will become even greater, making the job even less appealing to would-be applicants. Drs. Japa and Joseph recognize this trend when they went on to write: “Our experiences belie a deeper existential crisis in primary care. The pressure on primary care is mounting: to coordinate care for an aging population beset by chronic disease, to improve the overall wellness of the population, and to control costs and eliminate waste, all the while ensuring a satisfying patient (and supposedly clinician) experience.”

How Can We Fix This

Breaking the cycle requires a multifaceted solution. Here are some ways to combat the problem before it becomes a crisis:

  • Modernize and optimize finances. Primary care providers stand to thrive as value-based care advances. Their ability to reduce waste and unnecessary utilization while improving health outcomes should be recognized and rewarded for its preventive capabilities. As adoption of value-based care payment models increases, providers can fine-tune their documentation and lower expenses.
  • Address burnout. Though burnout has many causes, one of the primary ones is a lack of representation. Primary care providers are tasked with not only healing their patients, but the healthcare system as a whole. Joining an organization that elevates providers’ voices and includes them in developing solutions to pervasive issues helps foster a sense of community and engagement.
  • Reduce administrative tasks. Primary care providers are saddled with more documentation, billing, and coding than other specialities. Finding an organization that is focused on a transformational platform that incorporates talent, tools, and technology with an EHR that automates repetitive tasks helps free up time for providers to do more meaningful work with patients. Additional technologies such as virtual scribes can further wick away work from providers’ busy schedules.

The sooner these changes happen the better. Feedback loops become stronger over time. The longer we delay action, the harder this problem will be to solve. We cannot afford — both financially and medically — to live in a world where primary care is not a priority.

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