We gratefully acknowledge the sponsorship of the Valley Consortium for Medical Eduction (Modesto. California) for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:
This presentation follows: 22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 3, Smith)
Kevin Haughton, MD, Providence Health Systems, Olympia, Washington [Dr Haughton is a Fellow of the Coastal Research Group]: I’m Kevin Haughton. I work at Providence Health and Services, which historically is a network of 27 hospitals from Alaska to Southern California.
Providence has been quite successful as a hospital system. But in the last two or three years, Providence has seen PPACA enacted and has realized that they have to develop accountable care organizations. Therfore, Providence has decided to become an integrated delivery system.
The organization has started hiring physicians and developing an integrated network.
That’s where my job has changed. I’ve hired a lot of physicians over the last couple of years. Most of the market of physicians available for hiring consists of young people fresh out of residency or on their first job change out of residency. Therfore, I wanted to reflect a bit on that population of physicians and how they’ll fit into the way medicine is going to be organized in the future.
I’ve divided my talk into what it looks like for the people who are going to do primary care and for those who are going out of residency into practice. As you know, there are both economic considerations and lifestyle considerations to figure in. We’ve talked about those considerations a little bit in this conference. I’ll touch on those briefly.
Residency Graduate Indebtedness
But I’d like to focus a bit more on what their strengths are what challenges are facing them in terms of the ability to do a good job. How much do they appreciate the longitudal relationships that we have, how well do they understand the “big picture”? Do they see themselves, as primary care physicians, as part of the solution to where medicine in general needs to go?
Dr. Freeman spoke to the issue of medical student indebtedness. This graph only goes up to 2003, but it’s gone up significantly since then.
The last I heard the average debt of somebody coming out of medical school is $150,000, so that fact clearly is figuring into what their choice of specialty is and this is just another indication that primary care is a little underpaid.
These numbers are a bit old, and it’s only gotten worse since then.
The chart below is from the Medical Group Management Association’s Physician Compensation and Production Survey (1998 and 2005):
I think you can appreciate the slope of these curves. The green there is primary care, and other specialties are mostly above that. With medical school graduates having on average, $150,000 in debt; they are facing choices of what specialty they want to go into. This chart indicates the kinds of remuneration that they can expect from whichever specialty they choose.
Lifestyle Issues: Hours Worked
And the context of all this is lifestyle. We heard recently that the ER docs and the ICU docs have some of the fewest hours worked of any specialty. In addition to that, people going into primary care notice that the hospitalist (most training programs now have a hospitalist system) usually have a schedule that alternates a week on and a week off, plus the same amount of vacation that you get in primary care.
All of these lifestyle issues are coming to light in the context of the number of hours that everyone works. I think we have focused on this since we started calculating resident duty hours.
I’d say – looking through this room – that most of the physicians here did not have duty hour restrictions when they were residents. It has been interesting to see what has happened to the culture of residents in the era of duty hours. Pretty much everybody that I’m now interviewing to work with us in primary care has been in the soup of duty hours during their training, which, as you know, involves a whole lot of tracking and attention to little details on the part of program directors.
Here are the new duty hours rules that are starting in July of 2011. What are the unintended consequences of having these duty hours? I think the residents feel more overworked now than they did before we had duty hours.
In the old days, you know, when you became a resident, you realized that you’re going to be working all the time. Now residents feel that since they are up to around 75 hours, and are near their absolute max, that they are really working too hard.
Their misery level about how hard they’re working has actually gone up, even though the number of hours that they work has gone down. That was not an intended consequence of setting maximum resident duty hours.
I think, when people graduate from residency programs now and they go out and get a job, there is a common frustration with that first job. “Wow, this job is a lot of hard work! No one’s looking out for me and how hard I’m having to work now!”
That’s another adjustment that we have to deal with that plays out in a lot of ways in newly practicing primary care physicians.
I’m not saying that I think maximum allowable duty hours for residents aren’t worthwhile, but it’s not clear that it’s been all good. I don’t think there’s been much documented improvement in patient safety, which was really what they were looking for when these rules were established.
Consequently, physicians coming out of residency now frequently are looking for a job that has a lot of structure and has real limitations on what they’re going to do in their practice. Some of the first questions they ask me are what are the hours, how many hours am I supposed to be available to see patients, and what’s the vacation like?
I did a graph of the residency program once, charting the total number of hours missed at the residency program for sick leave. It was just a straight line that went up each year, because more hours of sick leave are being used each year. If you went back 30 years, you would probably find that the average doctor would hardly ever miss a day of work because of illness. Now it’s a really common for physicians.
What New Physicians Want
I believe that physicians are now looking for pay that’s based on salaries, in which they still get paid when they get sick and when they go on vacation.
They also are accustomed to working in their training programs with a very good hospitalist system with lots of subspecialists. They see nurse triage systems helping out with their quality of life, so they look for that. They’d like to practice somewhere where they have that same kind of backup.
The Electronic Medical Record
I think electronic medical records are more or less essential now for hiring doctors. I’m convinced that we’re graduating primary care doctors – who, when they see a picture of a doctor holding a paper chart feel the same way I feel when I see a picture of a doctor smoking a Camel. “Oh, that was a long time ago! Boy, that’s really quaint!”
You can no more hire a primary care residency graduate without an electronic medical system than you can a urologist without a Da Vinci robot in your hospital, because no newly trained urologist wants to work in a hospital without one.
The Practice Organized as a Medical Home
I think that primary care doctors beginning a new career are looking for the advantages of a medical home. Primary care physicians want to be able to do a good job, but in some ways the job is very hard to do well. So we really need to change the way we do it so that the physician can do a good job and can feel good about what has been done at the end of the day.
I still see physicians valuing longitudinal relationships with their patients. I think that’s really what sets primary care apart from other specialties. I’m glad to see that, despite their concern about not working too many hours, they still highly value the relationships with patients over time.
The Lack of Appeal of RVU Reimbursement Schemes
They also recognize one of the reasons they prefer to have a salary, is that they recognize the value for taking care of poor and elderly patients, and understand that their care has a different rhythm.
As an example, if somebody in this room sprains their ankle and comes to see me in the office, that’s a very quick visit. We get right to the point, and take care of things!
But if a poor, vulnerable, elderly patient comes in, it may take a long time to take care of them. You may need to get the translator to come in. They may be hard of hearing. By the way, they may have four chronic diseases. You have to make sure that in the meantime that you haven’t messed up something on one of those conditions.
So the rhythm of that person’s care is much slower. But, when reimbursement is based on RVUs, you can end up getting paid about the same amount of money as treating the sprained ankle.
Even if they’re being paid on their RVUs independent of the payer type, physicians whose reimbursement is based on a per-procedure basis still prefer not to see the poor and elderly because they cannot crank through the patients as quickly.
Deciding on a Primary Care Physician Career
Those are some of the economic considerations and I think some of these things are more important to the physicians whom we are recruiting – the ability to do a good job, longitudinal relationships, and desire to be part of the solution of the health care system’s problems.
We’ll start with the idea of being part of the solution. The graph to the left summarizes Dr Barbara Starfield’s data on the relationship between primary care providers and health care quality.
When you do a better job of primary care, quality goes up and cost goes down. This, of course, has been repeated in other countries, and it’s been repeated in the United States if you measure the data by states. So this has been pretty compelling.
Starfield’s research has been so widely accepted, that I can have this conversation at the hospital and with all various kinds of specialists in the room.
I think that Starfield’s research does attract people into primary care and that is totally appropriate.
I think specialists understand that the health care system – when conceptualized in the diagram at the right – has tipped too much to the MRIs and transplant side and that we need to bring the system back to a proper emphasis on the public health and primary care side.
That’s part of what we’re trying to do – to get back towards emphasizing the left side of that arrow, because that’s really where the overall population health improvements have been in the past.
The salaried physician and primary health care
Why does primary care help more? The emphasis on prevention is clear in primary care compared to other parts of the system. The value of the relationship between physician and patient in itself has a healing value that has been studied and that attracts physicians to longitudinal care.
Applicants have a general sense that primary care is the less costly way to approach health care. Applicants are looking for alternative ways of providing that access - in this case, access is more than just the visit in the office – even though there’s no payment for that right now.
That’s one of the reasons that new physicians are looking for salaries.
The Incentive for Promoting Coordination of Care
Coordination of care is a tough nut to crack, but clearly that’s going to be important for us to manage health care costs. As the graph to the left displays, there are a whole bunch of people who don’t cost any money and there are a few people who cost lots of money, so we’re trying to keep people on the left side of the graph as much as possible.
To do that, we’ll need care coordination and case management for people on the right side of that graph. Primary care is playing a huge role in that.
I think this is one of the barriers to hiring good people to do primary care is an intuitive sense that there is not enough time in the day to do what needs to be done.
As an example, one researcher calculated that if you followed all the current clinical guidelines, you’d have to work 22 hours a day, not counting the administrative duties of making sure your electronic medical records are up to date and all the other stuff you have to do to be a practicing doctor.
So basically it’s impossible to do a good job as a primary care doctor with the number of patients that we’re currently expected to take care of, using the current system that we have to take care of patients.
According to the statistics that I’ve heard, we do about 50% of what we’re supposed to do in chronic disease. If we all agreed on some guidelines on what to do to manage diabetes and heart failure, we probably would meet those guidelines about 50% of the time.
It’s probably the same with prevention. If we could all agree on, say, who should get a colonoscopy and thow often, that we probably would get that right about 50% of the time.
Not everything is bad though, I think we do pretty well at diagnosing appendicitis and having the appendicitis removed. In the case of a heart attack, we do pretty well in getting the patient into the cath lab and getting coronary arteries reopened again. There are other very acute things that happen that involve a lot of heroic medicine and that frequently are quite expensive that we do well.
Not everything about U. S. healthcare system is horrible, but there are certainly some areas to improve.
The Current Primary Care Physician
So what does an average PCP do? This is about a year ago a general internist published a study in which four general internists measured everything that they did all day long. Interestingly, the only thing that they are getting paid for are the visits that generate the EM codes.
Not only are new physicians seeking salaried jobs, this is also pushing current orunar care care physicians towards salaried jobs as opposed to just being paid based on RVUs. I think it also speaks to fact that they like to have alternative strategies for communicating with patients besides the visits.
The Role of Registries
Currently, we have registries for preventive care, with registries for various chronic diagnoses. I can pull these up on all my patients to see who needs the hemoglobin A1C, who’s a target, who needs to be contacted. When someone comes in with diabetes we’ll use a dashboard, and we can enter the data right at the time.
That automatically updates the registry so we can track the patients and where they’re at with their chronic diseases. Similarly with their health maintenance we can watch you know, who needs the colonoscopy, who needs a tetanus booster.
I just did want to mention there is some reason for optimism about the future of primary care physicians. You’ll notice that these curves displaying offered and filled positions in famly medicine are increasing all the way out to the right so as time goes by.
We are having a better fill rate and the number of slots is increasing.
I’m in the University of Washington Network and we are definitely increasing the number of physicians that go into primary care from there. Most of the University of Washington primary care residency programs are actually expanding the number of slots that they have and there are new residency programs being established in the state of Washington.
Lead Question, Ana Eastman, Whittier Presbyterian Hospital, Whittier, California [Dr Eastman is a Senior Fellow of the Coastal Research Group.]: Kevin, you talked about some of the unintended consequences of some of the things we have to deal with like duty hours, for example, residency programs are struggling to prepare our graduates for working in the real world.
How do you propose that teaching programs incorporate or redesign expectations in context of limited elective time, the increased duty hours which also limits the amount of time that we can have them in a group, and all the curricular requirements that we have to incorporate in their education?
Dr Haughton: I think that’s a real struggle. One of the things we’ve done to address duty hours is that we’ve developed night float systems. As most the people in this room know as soon as you develop a night float system the time has to come from somewhere and you still have the same requirements. It’s pretty hard to do that.
One of the things that works well for us is they have to do rural rotations so they go out and work with real live rural docs for a month at a time and see what their call schedule is, how many patients they see and what their life is like. Real life experiences with the kind of doctors that they want to be I believe is helpful.
Dr Eastman: Ah, mentors.
Dr Haughton: It’s a good idea.
Dr Ross (moderator): Thank you very much. Thank you Kevin, for an erudite presentation.
This presentation is followed by: Proceedings of the 22nd National Conference: How Will it Work? A New Era for the Teaching Health Center (Part 1, McKennett).