American Primary Care is a Big Waste of Time (When…) – The Health Care Blog


Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.

Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?

The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.

Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.

Primary care here is wasting time in many ways:

When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.

When we are forced to act as if we only see our patients once – ever, instead of over several visits year in and year out. We can’t see you quickly for your sore throat or UTI, because a visit without the required screenings hurts our quality ratings. Having non-physicians do the screening (the point I am making above) is not necessarily the solution because my medical assistant can’t keep me humming and at the same time do all the screening duties on even patients with the simplest of clinical problems.

When we keep thinking that the only time and place for us to interact with our patients is in the office visit. All other “businesses” are figuring out how to engage their “customers” via emails, podcasts, events and so on. Very few medical practices are doing the same. We typically only make money when patients are seen in the office, but if we could have staff interact with patients in whichever way is most appropriate between visits, the time patients spend in the office would be shorter and more effective and clinic productivity would improve – as would quality. Right now, so many of our visits are a real scramble to get through.

When we use the telephone in such inefficient ways. In an era when people generally have their personal cell phone on them, we act as if we are calling them at the phone booth on the corner of their block. They leave a message saying “please call me back”. You do and they don’t answer. You leave a message saying “please call me back”, and so it goes. A personal cell phone is as private these days as an email or a secure patient portal. I think we can leave general messages with patient permission – your tests came back normal, please double up on your new prescription and come back in two weeks, things like that.

When our administrators are too preoccupied with well-meaning but stilted and bureaucratic top-down mandates. Just like providers often can’t be as helpful as they would like to their patients because of our mandates, there is little room for innovation on the administrative side because of the regulatory burden.

We have become a terribly rigid and stuffy “industry” during my 40 years as a physician. We are not like a flea market or Saville Row (London’s bespoke tailor street) like yesterday’s private practice. We are like the postal service or the US immigration service. There will be disruptions if we don’t start moving with the times, and with our patients. They will move away from us whenever they can, to Concierge Medicine, Direct Primary Care, freestanding clinics, varyingly alternative practices or even non-medical caregivers, leaving only the most utterly sick and complex patients with us. Is that what the Fed, Medicare, Medicaid and the insurance companies want for us? And is that what is best for most patients?

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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