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November 7th, 2013

Is the Overwhelming “Primary Care To-Do List” Driving Talented Residents Away?

Paul Bergl, M.D.

Is there really another guideline-based preventive measure to discuss today?

In my 3 years of residency, the nearly universal resident response to outpatient continuity clinic was a disturbing, guttural groan. I recognize that many aspects of primary care drag down even the most enduring physicians. But I have also found primary care — particularly with a panel of high-risk and complex patients — to be a welcome challenge. I recently spoke with one of my institution’s main advocates for academic primary care, who I know has wrestled with this standard resident reaction.

And we had a shared epiphany about the one of the main deterrent driving promising residents away from primary care: inadequate training in prioritizing outpatient problems.

It’s easy to see how primary care quickly overwhelms the inexperienced provider. An astonishing number of recommendations, guidelines, screenings, and vaccinations must compete with the patient’s own concerns and questions. This competition creates an immense internal tension for the resident who knows the patient’s needs — cardiovascular risk reduction, cancer screenings, etc. – but is faced with addressing competing problems.

At my institution, the resident continuity clinic also houses a generally sicker subset of patients. Take these complex patients and put them in the room with a thoughtful resident that suffers from a hyper-responsibility syndrome, and you get the perfect mix of frustration and exhaustion.

There are diverse external pressures that also conspire to make the trainee feel like he should do it all: the attending physician’s judgment, government-measured quality metrics, and expert-written guidelines for care.

In this environment of intense internal and external pressures, how can we give residents appropriate perspective in a primary care clinic?

I would argue that residency training needs to include explicit instruction on how to prioritize competing needs. Maybe residents intuitively prioritize health problems already, but I’ve witnessed enough of my residents’ frustrations with primary care and preventive health. Let’s face it: there is probably a lot more value in a colonoscopy than an updated Tdap, but we don’t always emphasize this teaching point.

At times, perceptions of relative value can be skewed. “Every woman must get an annual mammogram” is a message hammered into the minds of health professionals and lay people. Yet counseling on tobacco abuse might give the provider and patient a lot more bang for the buck. Our medical education systems do not emphasize this concept very well. Knowing statistics like the number needed to treat (NNT) might be a rough guide for the overwhelmed internist, but the NNT does take into account the time invested in clinic to arrange for preventive care or the cost of the intervention.

Worse yet, there are simply too many recommendations and guidelines these days. Sure these guidelines are often graded or scored. But as Allan Brett recently pointed out in Journal Watch, many guidelines conflict with other societies’ recommendations or have inappropriately strong recommendations. Residents and experienced but busy PCPs alike are in no position to sift through this mess.

Our experts in evidence-based medicine need to guide us toward the most relevant and pressing needs, guidelines about guidelines, so to speak. We need our educational and policy leaders to help reign in the proliferation of practice guidelines rather than continuing to disseminate them.

Physicians in training have their eyes toward the potential prospects of pay-for-performance reimbursements and public reporting of physicians’ quality scores. No one wants to enter a career in which primary care providers are held accountable for an impossibly large swath of “guideline-based” practices.

So how might we empower our next generation of physicians to feel OK with simply leaving some guidelines unfollowed? In my experience, our clinician-educators contribute to the problem with suggestions like, “You know, there are guidelines recommending screening for OSA in all diabetics.” Campaigns like “Choosing Wisely” represent new forays into educating physicians on how to demonstrate restraint, but they do not help physicians put problems in perspective. Our payors don’t seem to have any mechanism to reward restraint or prioritization and can, in fact, skew our priorities further.

I hope that teaching relative value and the art of prioritizing problems will be a first and critical step toward getting the next generation of physicians excited about primary care.

7 Responses to “Is the Overwhelming “Primary Care To-Do List” Driving Talented Residents Away?”

  1. Elizabeth says:

    Bravo! I would also advocate that the residents shouldn’t be spending their valuable clinic time on things like ordering mammograms and vaccines when a trained nurse coordinator can do so.

  2. Carol Vassar, MD says:

    This essay touches on many of the shortcomings in health care today. Perhaps the most serious is the overwhelming quantity of information available and the lack of reliably impartial experts to help wade through and parse out the important points. We certainly don’t have the time or expertise to evaluate all of the research or even the guidelines by ourselves individually. On the other hand, our reliance on experts encourages industry to stack the deck in favor of their products by producing research and guidelines to support their products. We already have several books written on the subject, two by former editor’s in chief of the NEJM, Marcia Angel, The Truth About Drug Companies and Why You Need to Know, about just what the title says, and Jerome Kassirer, MD, On the Take, about the complicity of the physician community. Jerry Avorn, MD at Harvard and John —–, MD also from Harvard, have also written books on the subject as well as having testified before Congress about the seriousness of the problem. NIH has had to adopt a new conflict of interest policy due to the excess influence of industry in the cholesterol guidelines. As reassuring as the part of the new policy published in the NEJM back years ago was when it came out, the part of the policy which was not published in the NEJM but was on the NIH website was far less reassuring. The director, in the latter part of the policy, given free reign to make exceptions if he deemed it appropriate.
    We need to know how to judge research and talk among ourselves about the shortcomings of the available guidelines. We also need to demand more money for independent research which will only be possible if we can restore the truly independent status of NIH, CDC, IOM and all other health related agencies.

  3. Jeoffry B. Gordon, MD says:

    As a primary care doc with 40 year’s experience one reason I recently retired was the extraordinary push rewarding attention to preventive activities and parameters while avoiding the core of medical care of the truly sick..
    There is no doubt that primary preventive medicine is very important and the more that is done the better. Nonetheless it is very disheartening when reward systems are set up to raise my pay for mammograms and colonoscopies and flu shots and not for extra hours spent trying to save an alcoholic, attending a terminal cancer patient, curing heart failure in a patient with diabetes, hypertension, hyperlipidemia, and coronary artery disease, or attending a mother whose daughter just died. These are recorded as bland common visit encvounter codes. In fact the suits and computers can count mammograms, etc easily and thus magnify their import but the EHR and the insurance industry are oblivious to those activities which are the core of compassionate medical care. Your residents are more likely to be frustrated by this distortion in medical practice.

  4. Dr. Ebad Ansari says:

    There is no doubt the new primary care physician is burdened a lot with so many guidelines, and health insurance required a massive in put of details of medical records. On top of it he is stressed out because he is still in the learning phase, with patient informed of so many guidelines and ready with several questions he is burdened with more time and looking in to guidelines and answering the questions. In the end he is stressed of his main responsibility to treat their illness especially when his work starts a new.

  5. Jonathan Rapp, M.D. says:

    As a teaching family medicine doctor I couldn’t agree more with your main thesis. But in making your point you reveal an internist’s bias: yes, colonoscopy may be more of value to the older patient, but her Tdap may be more important to the infant grandchildren she looks after! Vaccinations are so easy to accomplish and deserving of out support that we should look for other, more burdensome and less well validated interventions to put lower on our priority agenda.

  6. Saumil says:

    “Let’s face it: there is probably a lot more value in a colonoscopy than an updated Tdap, but we don’t always emphasize this teaching point.”

    I agree with the overall premise of the article, but I was a little surprised at this sweeping statement. I’m not sure exactly what the data shows, but colonoscopies are done much too often and are expensive. I would surmise that if a patient without a family history of colon cancer is living with someone who is pregnant or an infant, Tdap is more important, cost-effective, and acceptable to the patient. Perhaps FOBT +/- sigmoidoscopy instead of the more expensive colonoscopy in that case for screening?

  7. Paul D Simmons, MD says:

    An excellent article that reveals the tip of a big, exhausting, burnout-inducing iceberg. Eleven years into practice, I’m finally learning to give up perfectionism, prioritize and say “I cannot cover that today” to patients.

    But I agree with previous comments: if medicine could provide one service to humanity to save the most lives for the lowest cost, vaccination hands down would be that service.

    Nevertheless, the thesis stands and needed to be emphasized.

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