Primary care outpatient general internal medicine is dead. After a long decline through years of languishing, it finally succumbed to terminal undervaluation and budgetary neglect. We will never see things like this again. As with most good things taken for granted, they will not be missed until it is too late and extinction is complete.
Our current health care system has devolved into a bloated bureaucracy that has lost sight of what matters and who matters, blinded by self-serving fiscal dictates, rooted in corporate greed and wedded to governmental incompetence. Professional ethics and common sense have been replaced by unreasonable expectations, amorality and complete disregard for key stakeholders in the health service. This metastatic cancer, left to spread for years without treatment, eventually killed its host.
When I began clinical practice in the late 1980s, collegiality and collaboration between primary care physicians and specialists was the norm. Patient management in both inpatient and outpatient settings has enabled constant continuity of care and skill growth while better understanding your patient's illness and progress. Meaningful relationships were strengthened and access to care was significantly easier. Communication between the medical providers involved was facilitated. Primary care had not yet become the garbage disposal for problematic, socially complex, and unwanted patients, with all their baggage and time-consuming hassles that specialists wash their hands of. General internists were physicians who were still valued and making a difference in the clinical arena, not yet relegated to the ranks of unglorified triage nurses and secretarial data entry technicians whose talents were wasted. Medical records were simple and the information you wanted was easy to find before copy-pasted notes made EMR notes inaccurate and irrelevant. Documentation requirements did not intrude on after-hours life, and “pajama time” was not a concept. Rigid and absurd EMR limitations with endless clicks and check boxes that do not advance patient well-being were inconceivable. Common sense and true fulfillment existed. There was very little “moral damage”, a vital element of today’s “burn-out”.
Many primary care physicians had the autonomy and flexibility to adapt to their patients' needs and circumstances. The ethical boundaries were clearer. Tests were only ordered when legitimate clinical indications and adequate benefit justified their performance. Today, corporate pressures encourage unnecessary and inappropriate testing or referrals to specialties in order to generate a loss and increase revenue, often to the detriment of patients and their loved ones. More time was allocated to education and creating management plans that improved patient compliance and understanding. The desired favorable clinical outcomes were more reliable and durable, an interesting dichotomy of today, where, despite the high cost of bureaucratic supervisors, readmissions, emergency department visits, and clinical failures are at an unprecedented level. Patients appear much less informed about their medical history and needs, which correlates with the split care of seeing multiple specialists (or, more typically, their APRNs or PAs) and the perfunctory, superficial involvement of their physician treating.
There is no more “captain of the ship”. Patients and their families must fight for themselves in a system that does not take into account their humanity and their needs. Incompetent and dangerous polypharmacy is an epidemic in the United States, particularly among middle-aged and geriatric populations with chronic illnesses. Endless mandates divert valuable time, attention, and effort away from what the patient actually needs: someone to actually manage their chronic conditions 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 (with no means to improve them), and that they turn to specialists to provide care. which was formerly managed by primary care physicians.
Physician assistants (APRNs and PAs) now make up the bulk of primary care providers, but unfortunately, they increasingly have inadequate supervision to appropriately manage complex chronic illnesses due to the rapid decline in numbers of doctors. Our society has accepted that these non-physicians are equal in education and experience with less than half the education and training. Why take years, costs, and more difficult effort to become a doctor? Corporate health systems enjoy the substantial savings they get from these discounted employees. This perverse system may work well for worried people, but is a disaster for those who suffer from multiple comorbid chronic illnesses or need geriatric care.
The creation of hospitalists in the early 1990s, while conceptually interesting and effective, began the inevitable decline of ambulatory care into the nightmare we see today. Patients, doctors, and physician assistants have never been so isolated in silos drifting directionlessly in a sea of inaccessibility, corruption, futile apathy, and greed. Critical supply and shortages of medicines appear to be constantly increasing. Inequalities in monetary reimbursement of services are numerous. Hospitals, outpatient clinics and primary care physicians are withering and dying under the influence of a perverse economy that underestimates the essential role they play in this country. Rural healthcare is experiencing this first, but if left unchanged and unaddressed, it will inevitably emerge throughout our healthcare system. All the wonderful knowledge gained from the truly remarkable technological and pharmacological advances that have taken place over the past two decades is meaningless when access to it is restricted. Diseases that are diagnosed and treated much more effectively and quickly in the hospital setting are delayed by arbitrary hospital length of stay determinations that prematurely discharge patients to their PCP, who then cannot get those patients to seek care. specialists to complete the assessment or begin their treatment for months. This is a particularly perverse and perverse form of intentional rationing of care, the ultimate cost of which falls on the patient. Prior authorization requirements serve a similar purpose, further aggravating the daily moral harm suffered by physicians. Why bother being a doctor when a non-clinical, uneducated bureaucrat, immune to his decision, decides what care your patient will or will not receive?
Proponents of direct primary care will propose their path as a solution, and perhaps for a lucky few, their practice's location and patient demographics may make it a viable option. However, for more than 95 percent of patients and doctors in this country, this cannot be the reality. No amount of life or career coaching, mindfulness and yoga can erase the daily madness encountered in the trenches. Doctors are driven, brilliant people and can (and should) find more fulfilling ways to exist in this world.
And so here I am at the premature end of my career, giving an exit interview to no one who wants to hear or acknowledge our reality, leaving a once noble and respected profession that has become an unrecognizable monster ravaging every aspect of our culture. and society, insatiably devouring our resources, our dignity and our humanity. Like me, many of my colleagues across the country are retiring early, no longer able to exist within a system that demands so much and cares so little. Our expertise and wisdom cannot be easily replaced. The current workforce is insufficient in number and training. The frightening projection of a severe doctor shortage is looming. I mourn the death of what was once meaningful, functional, and generally improved patient well-being. I look to the future with sadness and pessimism and see the inevitable collapse of our current health care system at a time when our country's needs will be at their greatest. Unfortunately, we are past the point where we can avoid this disaster. Nero fiddles while Rome burns.
Ross L. Fisher is an internal medicine doctor.