Once a pillar, now in ruins: the state of primary care


Primary care outpatient general internal medicine is dead. Following a lengthy decline over years of languishing, it finally succumbed to terminal underappreciation and fiscal neglect. We shall never see the likes of it again. As with most good things taken for granted, it won’t be missed until it is far too late and the extinction is complete.

Our current health care system has morphed into a bloated bureaucracy that has lost sight of what and who matters, blinded by self-serving fiscal dictates trenched in corporate greed and married to governmental incompetence. Professional ethics and common sense have been replaced by unreasonable expectations, amorality, and total disregard for the primary stakeholders of health care services. This metastatic cancer, allowed for years to spread untreated, has finally killed the host.

When I first began clinical practice in the latter 1980s, collegiality and collaboration among primary care physicians and specialists was the norm. Managing patients in both the hospital and outpatient clinic settings allowed a steady continuity of care and growth of skills while better understanding your patient’s illness and course. Meaningful relationships were strengthened, and access to care was significantly easier. Communication between involved medical providers was facilitated. Primary care had not yet become the garbage disposal for problematic, socially complex, unwanted patients with all their baggage and time-consuming hassles that specialists wash their hands clean of. General internists were physicians who were still valued and made a difference in the clinical realm, not yet relegated to being unglorified triage nurses and secretarial data entry technicians upon whose talents were wasted. Medical records were simple and desired information was easy to find before copy-and-paste note bloat made EMR notes inaccurate and irrelevant. Documentation requirements did not intrude on life after work hours, and “pajama time” wasn’t a concept. Rigid nonsensical EMR limitations with endless clicking and box checking that does not advance the well-being of the patient were inconceivable. Common sense and genuine fulfillment existed. There was very little “moral injury,” the lifeblood of today’s “burnout.”

Many primary care physicians had the autonomy and flexibility to adapt to their patient’s needs and circumstances. Ethical boundaries were clearer. Tests were ordered only when legitimate clinical indications and adequate benefit justified doing them. Today, corporate pressures encourage unnecessary and inappropriate tests or specialty referrals to churn and increase revenue, often to the detriment of the patient and their loved ones. There was more time allotted to educate and create management plans that improved patient compliance and understanding. Desired favorable clinical outcomes were more reliable and durable, an interesting dichotomy from today, where despite the high cost of bureaucratic overseers, readmissions, ER visits, and clinical failures are at an all-time high. Patients seem far more uneducated about their health history and needs, correlating with the fractionated care of seeing multiple specialists (or, more typically, their APRNs or PAs) and cursory superficial involvement by their PCP.

There is no “captain of the ship” anymore. Patients and families are left to fight for themselves in a system that disregards their humanity and needs. Incompetent and dangerous polypharmacy is an epidemic within the United States, especially in middle-aged and geriatric populations with chronic diseases. Endless mandates divert precious time, attention, and effort away from what the patient truly needs – someone to actually manage their chronic diseases and improve their health and outcomes. It seems that primary care providers now only exist to document in the EMR that all preventative care and screenings are up to date, that their social determinants of health are documented (without any means to improve these), and refer out to specialists to provide care that was formerly managed by primary care physicians.

Physician extenders (APRNs and PAs) now comprise the bulk of primary care providers, but unfortunately, they increasingly have inadequate supervision to appropriately manage complex chronic diseases due to the rapidly dwindling numbers of physicians. Our society has accepted that these non-physicians are equals in training and experience with less than half the education and training. Why bother taking the years, cost, and more difficult effort to become a physician anymore? Corporate health care systems relish the substantial cost savings they realize from these discounted employees. This perverse system may work for the worried well but is a disaster for those with multiple comorbid chronic diseases or geriatric care needs.

The creation of hospitalists in the early 1990s, while conceptually of some value and efficiency, began the inevitable decay of outpatient care into the nightmare we see today. Patients, physicians, and physician extenders have never been more isolated in silos drifting unguided in an ocean of inaccessibility, corruption, futile apathy, and greed. Critical supply and drug shortages seem ever-expanding. Inequities in monetary reimbursement for services abound. Hospitals, outpatient clinics, and primary care physicians are atrophying and dying under a perverse economics that undervalues the essential role they provide in this country. Rural health care first experiences this but left unchanged and untreated, it will inevitably emerge throughout our entire health care system. All the wonderful knowledge gained with truly remarkable technological and pharmacological advancements that have occurred over the past couple of decades is meaningless when access to them is restricted. Diseases that are far more efficiently and quickly diagnosed and treated in an inpatient setting are delayed by arbitrary hospital lengths of stay determinations that prematurely punt patients back to their PCP, who then can’t get these patients in to see specialists to finish the workup or start their treatment for months. It is a particularly wicked and perverse form of intentional rationing of care, with the patient paying the ultimate cost. Prior authorization requirements serve a similar purpose, further exacerbating the daily moral injury for physicians. Why bother being a physician when an uneducated non-clinical bureaucrat with immunity from their decision decides what care your patient will or will not receive?

Proponents of direct primary care will offer their way as the solution, and perhaps for a fortunate few, their practice location and patient demographics may make this a viable option. However, for more than 95 percent of patients and physicians in this country, this cannot be their reality. No amount of life or career “coaching,” or mindfulness and yoga, will wash away the daily insanity encountered within the trenches. Physicians are motivated, bright people and can (and should) find more fulfilling ways to exist in this world.

And so here I find myself at the premature end of my career, giving an exit interview to no one who wishes to hear or acknowledge our reality, leaving a once noble and respected profession that has become an unrecognizable monster rampaging through every aspect of our culture and society, insatiably devouring our resources, dignity, and humanity. Like me, many of my colleagues across this country are retiring early, no longer able to exist within a system that demands so much and cares so little. Our expertise and wisdom can’t be easily replaced. The current workforce is insufficient in numbers and training. The frightful projection of severe physician shortages is imminent. I mourn the death of what once made sense, was functional, and usually achieved the betterment of patients. I grimly and pessimistically look at the future and see the inevitable collapse of our current health care system at a time when our country’s needs will be at their greatest. Tragically, we are past the point to avert this disaster. Nero fiddles while Rome burns.

Ross L. Fisher is an internal medicine physician.


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