Guest Post: A Letter To The Healthcare System — By Dr. Frank Cacace
By Dr. Frank Cacace, MD FACP
Find him on Twitter @GIMaPreceptor
(Published with permission)
From: All primary care docs (community, employed in large network, academic medical centers) To: The healthcare system writ large, administrators/financial lever pullers
Primary care docs are in a precariously fatigued way. We deliver longitudinal relational care, which is foundational to the whole person rewarding work we need to be professionally happy, and to the revenue and reputational growth you need to maintain community markets.
The data is clear that patients have greater quality of care and longevity with a primary care doctor. That said, we primary care doctors feel taken advantage of at your hands. You think we’re too busy with incessant pace and volume to notice, but here’s what we know:
1) We are not valued; we are paid less by payers for all levels of service. Every hour of patient facing time produces two hours of documentation and administrative work — that is done on our own time and invades our lives. You don’t acknowledge this.
2) We have no hand in patient visit times (always less), flexibility to adjust for complexity (no), panel size (limitless), metrics that matter (chosen for us from CMS/ACO menus), EHRs (billing instruments with rapid workarounds for new metric choices, but not for doctor-saving interoperability), productivity targets baked into contracts (commodity squeeze), presence or absence of scribes (almost never, told we don’t make enough to pay for them), support staff ratios (many docs/MOA, little EHR task help, stretched RN/secretary support).
3) You don’t acknowledge our skill or our agency.
4) You make us feel like commoditized cogs, not valued autonomous adults ever included
in a discussion re business model choices made for us. Why treat us in such a financially unfriendly way? Why an RVU? Why dehumanized visit times? Why clawbacks on salary? Why such high FTE contracts for starting physicians?
We need to discuss how many patients we can cognitively, physically, or safely see before there is perpetual exhaustion. If we say we are spread way too thin already, refrain from percentile talk, faulty data and insistence on national averages. Data hunts shouldn’t keep pleas at bay.
Trust us if we say our current panel size keeps us working in an uncompensated, overwhelmed, family-denying way, including nights and weekends, causing delays in call backs and discharge follow ups. The more patients we see past reasonable, the more dissatisfied patients are, and the more they see others for sick calls, preoperative assessments, and other unexpected needs.
We must advise current EHR upgrades, so that they become patient and physician serving platforms that don’t make repeat clicks always necessary, failing to link dashboards with events without our extra work. Some of us teach medical students, residents, and fellows, build curricula, do community work, do non-funded research and mentor extensively, do diversity, equity, and inclusion (DEI) or wellness committee work. All of this becomes uncompensated “pajama time” work, and while good for your portfolio, prestige and teaching income, too often feels like a tax on our good will and care for learners and teams and the community.
And what of our burnout? Our occasional depression? What of our earlier retirements? What of the cost to you to replace a lost primary care doc in a timely way so as not to lose the patients in their panel? Don’t YOU want a less compressed primary care doctor w time to listen? Don’t YOUR parents deserve the same? YOUR kids? We want to enter the exam room brimming with energy and love for our work
The facts: Short term ledger thinking will never make primary care practices or divisions look great revenue wise. By definition, our success is realized incrementally over the long term primary care docs have unfair and inappropriate financial expectations put upon their practices. It is the cause of hour to hour unhappiness. This is bleeding into the patient-physician space, which is chronically under resourced. We are losing primary care docs especially on the heels of COVID, an ongoing travesty through which our financial pressures, productivity targets and mission based work never abated. Trainees just aren’t sure they can proceed with a career in primary care as it is valued now.
This is a tremendous disservice to communities and society. Primary care calls for foundational investment that is not obsessed with the short term ledger. Embedded behavioral health, social work, pharmacy, proper MD/MOA ratio, standard RN/MD ratio, scribes should not be subject of never ending funding fights for us. It is exhausting and almost always the stuff of never improving patient and physician experience. A constantly overwhelmed “chicken without a head” environment is no way to achieve quality, safety, or joy.
The author of this ‘letter’ on behalf of we primary care docs is dangerously close to walking away and that really would be a crying shame. But staying in a system where the right minded art and social importance of this work is not supported accordingly may not be sustainable — I feel plaque buildup and dysplasia of cells happening each day. I won’t truncate my time — and I think all my colleagues agree.
I am begging all those with influence — start looking at and treating primary care differently. Think about the long game, never short.
Original twitter thread:
