Imagine this scenario: You’re waiting in the examination room, nervous. You’re feeling vulnerable because you’re sick, you have a problem that’s embarrassing to talk about, or maybe just because you’re only wearing a paper gown and your underwear. The doctor walks into the examination room and … it’s someone you’ve never met before. You try to explain what’s going on, but you’re frustrated because your information is supposed to be recorded in the computer somewhere—isn’t that what all the other doctors were doing when they stared at the screen during your last three appointments?
Most people like seeing the same primary care provider (PCP); in the medical literature this is known as continuity. (This article will use the term “PCP” to refer to clinicians who see patients in a primary care setting since nurse practitioners, physician assistants, and doctors who have done a residency in internal medicine, family medicine, or pediatrics can all be primary care providers.) A relationship with your medical providers not only saves you time—you generally don’t have to re-tell your story—but the trust that’s built over time allows you to share more and perhaps delve deeper into the issues that affect your health. From a doctor’s perspective, those relationships and trust often translate into better communication and more willingness to go along with care plans. Sometimes knowing a patient’s story over time can help clinch a difficult diagnosis or prevent other doctors from doing something that won’t work.
A good PCP can go a long way. The fragmentation of our health care system practically requires that anyone who’s seeing more than one specialist have a PCP who can coordinate information between different doctors and hospitalists. A PCP who knows their patients well can sometimes squeeze them in for appointments or deal with issues over the phone that would otherwise confound a different doctor. PCPs can also help prevent a hospital admission—or help patients figure out what happened when they were admitted to the hospital and keep them from having to go back.
A recent study in the British Journal of General Practice backs up this common sense with hard evidence: Having the same primary care provider for many years reduces the risk of death or admission to the hospital. The risk of dying decreases by 10 percent after about two years with the same primary care provider and 25 percent after 15 or more years. That’s a huge effect—just as powerful as billion-dollar “blockbuster” statin drugs like Lipitor (atorvastatin). As the authors of the study put it, “Over the years, [PCPs] may become specialists on their individual patients, rather than on their diseases.”
Many people want a relationship like this with a doctor, and some doctors have capitalized on this desire. Direct Primary Care practices are becoming more popular, where patients pay fees directly to their PCP without getting insurance involved. (Similarly, what’s called “concierge” medicine does the same thing, except that the PCP also bills your insurance in addition to the fees.) There is hope that Direct Primary Care might help reduce the overall costs of health care, but it’s a movement still in its infancy and unlikely to break the stronghold that hospital-owned practices and big chains have on primary care.
So patients want continuity, doctors like it, and it’s got clear health benefits …why is it so hard to find? As with many other things, America’s fragmented and confusing system of health insurance plays a big role. A job change, your employer choosing a different health insurance company, or a breakdown in negotiations between insurers and clinics can all result in your PCP leaving your insurer’s network. Cuts to Medicaid also result in people losing their insurance altogether, which makes continuity even more difficult. And an inevitable challenge is that resident physicians learning how to be good primary care doctors only have three years of residency before they graduate, meaning that the relationships they develop with patients will often end when they find their first job.
Turnover among doctors is also high, meaning that doctors will frequently change jobs and start all over with a new panel of patients—or they just quit medicine altogether. Lack of job satisfaction is frequently cited as a reason for doctors leaving their jobs, including the ever-growing demands of working with electronic medical records and the pressure to see too many patients. Patients, on the other hand, complain about waiting too long to see their PCPs and will sometimes take an available appointment with a different clinician if that’s the only appointment available. Patients also suffer when doctors are overworked and don’t feel a sense of connection when their doctors spend more time during a visit staring at a screen than talking face-to-face.
There are a few possible solutions. The first is simply to start researching and talking about improving continuity. The benefits are clear—if the decrease in mortality that continuity brings was a new drug being marketed, we’d demand that insurers and the government pay for it. Yet it’s not a health policy priority, and neither insurers nor the government seem to be taking it very seriously. Testing and researching different programs to improve continuity should be a research priority in primary health care.
The second is to ease the burden on PCPs in general. Training more PCPs would probably help, and the easiest way to do this is to increase the number of primary care residency slots. We could also train more mid-level providers (such as physician assistants or nurse practitioners) to help meet this need. Increasing the supply of doctors and shifting more primary care work onto mid-level providers would probably decrease doctor salaries, which is usually not a popular proposition since salaries for primary care doctors are already lower than specialists. But as a physician myself, I’ll go ahead and say that all doctor salaries should probably be a little lower than they are anyway, and I don’t think anyone will suffer too much if specialists make 10 percent less than their average $368,000 per year and primary care doctors take a 5 percent cut on their $260,000 per year. We’ll live.
More frankly, it’s a waste of time and money to make doctors who went to four years of medical school and at least three years of residency responsible for simple preventive care like ordering colonoscopies or giving vaccines. A more radical idea would be to shift some of this preventive care burden and even the management of conditions like uncomplicated hypertension and diabetes to community health workers with associate’s degree-level training; they would follow evidence-based algorithms for otherwise healthy patients and refer upwards for more complicated conditions. This would free up primary care doctors for the real work that they’ve been trained to do: managing complex patients with multiple conditions. I’ve written in more detail about what a “tiered” health care system that devolves less complicated tasks to lower cadres of health workers looks like.
Other possibilities that ought to be investigated include things like gradually increasing payments from health insurance for visits after some years of continuity, since financial incentives always get clinics and hospitals to pay attention. Shrinking the size of primary care practices might be difficult, but in the big Norwegian study mentioned above, most practices studied were made up of three to six physicians each. This almost certainly allowed the most complicated and sick patients to have continuity with multiple doctors in a practice—meaning that whoever’s available or on call has a relationship with the patient in question whenever they have a problem. Bigger health care management groups that own multiple hospitals and clinics ought to work on developing internal systems for maximizing continuity.
Increasing continuity in patient-PCP relationships should be a priority for health care organizations and policymakers, and we should be researching what kinds of changes would make it easier for patients to form long-term relationships with the people caring for them. One of my favorite parts about being a primary care physician is getting to know my patients’ lives and accompanying them through the ups and downs of their illness. Becoming a specialist in individuals, not diseases, is a crucial part of working in primary care. Health policy should back this up and make it easier for the relationships that facilitate healing to flourish.
