April 27, 2023: Imagine yourself sitting in your local hairdresser and, while you wait your turn, get medical attention on the spot.
It is already happening to some extent. And the COVID-19 pandemic helped further unleash the primary care visit to the doctor’s office, allowing patients to demand access to their doctors via video or other virtual means. Experts have noticed and say they will need to focus more on reaching patients where they are.
As the primary care landscape evolves, patients can expect a team approach to their care, aided in large part by artificial intelligence (AI), electronic patient records, and often their own devices. What patients cannot count on in the near future is the ability to see a primary care physician at a time of their choosing.
Experts say the technology and team approach will continue to break ground in treating patients and identifying patients who need primary care treatment. (The barbershop experiment, in which pharmacists successfully treated hypertension in an underserved patient population, is one example.) The biggest challenge facing healthcare professionals is the alarming shortage of primary care physicians and the lack of incentives to produce more.
“The pipeline is problematic,” said Barbra G. Rabson, president and CEO of Massachusetts Health Quality Partners, a nonprofit group of health care stakeholders trying to improve the quality of health care in the state. of the Bay. “It’s pretty sad.”
In 2021, the Association of American Medical Colleges projected that the US will face a shortage of between 17,800 and 48,000 primary care physicians by 2034. By that time, the US population 65 and older, a demographic group that will rely more on these providers, will grow by 42, 4 %.
Meanwhile, the existing supply of doctors is turning grey. Rabson said a third of Massachusetts primary care physicians are 60 or older. The Association of American Medical Colleges predicts that within the next decade, two-fifths of active physicians across the country will be at least 65 years old and looking for the exit.
The warning comes as no surprise to doctors and patients, who have witnessed a surge in physician retirements in the COVID era. Sang-ick Chang, MD, a clinical professor of medicine specializing in primary care and population health at Stanford Medical School, has seen it develop in his neighborhood.
“People who have moved to the area looking for a [primary care doctor] they struggle and are on a long waiting list,” he said. “I feel terrible that there are no doctors available.”
Replenishing the supplier pool will not be easy, experts said.
“We can’t produce all these doctors tomorrow,” said Atul Grover, MD, PhD, executive director of the Institute for Action Research at the Association of American Medical Colleges. Many of the best medical schools in the country do not have homestay residency training programs. “They don’t even try to train primary care physicians,” Rabson said.
Money plays a big role in medical students’ career choices, experts say. Primary care is “the lowest-paid and least-busy specialty in the entire field of medicine,” Chang said.
Although a primary care physician’s salary of about $250,000 a year is enough for most people, medical students, especially low-income ones, see that a career in orthopedics or dermatology can earn two to three times as much.
“There are people who want to do primary medicine,” Grover said, but “income expectations make the difference.”
“I went into primary care because I like the patients,” said Kirsti Weng Elder, MD, section chief of primary care at the Stanford School of Medicine. She wanted to earn a good but not necessarily “fabulous” salary for her work. But she sees people coming out of medical school today $500,000 in debt, five times what she left, and “you have to pay that debt off.”
There are also 10 times as many medical specialties as there were in the 1960s, Grover said, and the reimbursement payment system favors procedures over generalists.
“We underestimated primary care and that is reflected in reimbursement,” Abraham Verghese, MD, a professor of internal medicine at Stanford, said in an email. “In American health care, we place great importance on getting things done to people instead of doing things for people. … It is much more difficult to find primary care for an aging parent than it is to find a specialist willing to replace your heart valve.”
The decline in private primary care practices, also made worse by the pandemic, extends to hospitals, Rabson said. The advent of hospitalists means that primary care physicians are less likely to spend time in a hospital consulting on their patients, further disrupting the continuity of care that physicians would prefer.
“Private practice is kind of dead,” said Baldeep Singh, MD, professor of primary care and population health, also at Stanford.
In its place is a system based on equipment owned by hospitals or private companies like Optum (owners of Harvard Vanguard), CVS (which runs Minute Clinics), Amazon (which bought One Medical in February), and virtual providers like Teladoc. Health. Even Meta, Facebook’s parent company, is accessing virtual care through the “metaverse.”
These companies, which offer same-day appointments, attract potential patients who don’t have the patience to wait 3 months to see a doctor.
“You go to Amazon because you can find something you want to buy and have it delivered tomorrow,” Lee Schwamm, MD, chief digital officer for Yale New Haven Health, at a recent Massachusetts Medical Society conference addressing healthcare challenges. “We’re going to see a lot of companies that haven’t traditionally been in healthcare want to play that role because they know how to do those kinds of things very well.”
The proliferation of social media platforms has also reached primary care, especially for younger patients. “People really want instant access all the time and are not used to making appointments,” Weng Elder said. “My kids don’t know what that means.”
Patients got a glimpse of the future of the primary care visit when pandemic lockdowns, like Toto in The Wizard of Oz, opened the curtain on televisit in a system that was not yet ready. Weng Elder said that she was one of the first doctors to use telehealth several years before COVID. “We were excited to try it out, and it was very, very poorly adopted,” she recalled. “People thought it was weird.” But before they knew it, doctors were forced to do it and “suddenly people realized it was a good thing.”
“The video invites you to your patient’s house,” he continued. “You can see if they have a messy house or a tidy house. You can ask them to open their fridge, to show me their medications, to let me walk.” Family members can also be invited into the conversation.
Video visits, which doctors say now account for 20-30% of primary care visits, also save patients the time and expense of traveling to the hospital or office, a boon for patients with limited mobility or who live far from their provider.
Doctors go by the rule of thumb that 80% of a diagnosis comes from the patient’s history, aided largely by algorithms and artificial intelligence, while the rest comes from a physical exam. “Chest pain requires an EKG,” Chang said. “We can’t do that on a video visit.”
Patients without a GP lose out, and Grover sees a growing problem. “Patients are getting older, they have multiple medical conditions, and what we’re seeing is patients in the hospital getting sicker.”
A condition that could have been managed with the help of a primary care physician becomes one that is treated in urgent care.
The doctors said that electronic health records, which allow them to see how a patient was treated in an emergency room on the other side of the country, have improved to the point where different record-keeping systems now communicate better with each other. . But another approach, they said, is one of a primary care team, sometimes bypassing the doctor unless necessary.
“It’s a much better team sport,” Singh said. “I have a pharmacy team that helps me. I have a social worker who helps me with patients who are depressed.” Also part of the team are nurse practitioners, case managers and physician assistants.
In such an environment, in a few years, “I can see primary care physicians as people managers,” said Wang Elder. “They end up seeing people having critical conversations that need to be had.”
Yale’s Schwamm described it as reaching people who shop at Walmart and Bloomingdale’s. Conditions like diabetes and atherosclerosis are not “infectiously contagious,” he said, but “socially contagious” and need to be addressed as soon as possible.
The salon study said that an expanded program reaching 941,000 black men to help control blood pressure would prevent 8,600 major (and costly) cardiovascular events. And the program didn’t even use primary care doctors at first.
“The pharmacists are incredibly well trained and talented,” Grover said. “They understand what is left out of their experience.”
The trick is to convince insurers to buy these programs. “Payers need to be more creative and flexible in how they reimburse for the kind of care we expect.”
The digital divide threatens to widen. Doctors hope that in the coming years, more and more patients will be able to upload information from their phones, Fitbits, and blood pressure and glucose monitors.
Niteesh K. Choudhry, MD, PhD, professor of health policy management at the Harvard TH Chan School of Public Health, told the Massachusetts conference that the devices give patients more control over their own care and require less work. of the providers.
“Self-management led to better blood pressure control than primary care management,” he said. “We need to imagine that there’s a lot of healthcare that we take responsibility for, where patients could be better at.”
They give doctors a better view of how patients are doing “where they are, not with us in our offices.”
Rabson said such devices are much more likely to be used if a patient has a primary care physician. And Weng Elder added: “If you have money, you can get a Bluetooth blood pressure monitor. If you’re poor, you don’t. That will be a disparity.”
Grover said the devices will help people in rural areas only if there is decent broadband. But disparities also occur in urban areas, where life expectancy can vary by many years, depending on where in that urban area one lives.
Primary care physicians see an average of 1,500 patients a year and are spending more and more time responding to electronic patient inquiries.
“The labor crisis means you’re much more likely to be offered a nurse practitioner or nursing assistant than a doctor because there won’t be a doctor,” Chang said.
“The alternative solution is good, maybe we don’t need doctors in primary care. Maybe we just give up.”
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