Opinion | What If…?

Over this past long Thanksgiving holiday weekend, in addition to eating way too much turkey and stuffing, and being thankful for family, friends, my health, and so many other bounties in my life, I was able to reflect on how blessed I am to be able to be a primary care physician, how much I love doing what I do, even with the world and the practice of medicine as chaotic as they are. I got to thinking even more than usual about how to get from where we are to where we need to be.

The Most Amazing Nurse

Many years ago, there was an incredible nurse at our practice who always did whatever needed to be done for our patients. Nothing seemed too much for her to do. She was always the first one to arrive in the morning and the last one to leave at night, and she spent endless hours talking to patients — guiding them, educating them, and listening to them.

When a patient would call feeling ill, she was always the first to reach out and check on them, run through what they were feeling, and offer up some sage advice, and usually by the time the doctors got to these messages there was nothing much left for us to do. She had amazing common sense, and wonderful clinical judgment. She knew when people were sick, when they needed to come in, when we should all be worried, and when they could safely handle things at home.

In the days before endless bureaucratic rules and documentation, she would often go ahead and do things that needed to be done even without a written order, knowing that we would back her up and make sure everything was dutifully documented down the line.

But in the modern world of healthcare, people have become so siloed in their jobs that the concept of supportive team care seems to have fallen away. Everyone is following their own little rule books, with strict limits on what they can and cannot do.

Sure, a lot of this is done for safety’s sake, making sure we pass all our site visits, accreditations, audits, and inspections. But it has eroded the delivery of healthcare and the sense of collegiality that we all had while working together to take care of patients.

As I’ve written about so many times before, the field of primary care feels threatened and at risk of further erosion, and much needs to happen to get us all to a better place. Patients complain endlessly about not being able to reach us, their portal messages not being answered fast enough, their refills and forms not being completed in time, not being able to get an appointment when they’re sick or need an urgent preoperative visit, or when they just want to schedule a routine annual physical. Or just have someone answer the phone.

Enticing the Next Generation of Primary Care Doctors

Tensions and pressures are building up from every direction, creating a toxic environment that makes it hard to entice medical students, residents, and junior faculty to want to enter the field of primary care. Finding modern solutions to getting all of the stuff done seems to be one of the best options for enhancing the life of primary care physicians and attracting trainees to enter these fields.

It does seem unlikely that we’re going to find a lot of new people who have the dedication, the willingness, and the skills to do what that nurse once did for all of our patients. So perhaps we need to look in other places. We need to make sure that as artificial intelligence and smart systems and new technology come online in healthcare, we can focus these new technologies at the things that are leading pain points for those practicing today.

I am hopeful that we can work with the people who design these systems to create virtual assistants and smart tools within the electronic medical record to alleviate the burdens that are weighing so heavily on the shoulders of primary care doctors, nurses, social workers, and everyone else involved in healthcare. As I’ve said before, why should anyone need to get involved in the process or use any amount of mental energy to order a routine annual mammogram for a patient who is due for one? Even better, why involve the medical office and personnel at all? Just make it happen.

Sure, there have to be limits. We don’t want patients just calling up and saying, “I had a headache this morning; I want an MRI of my brain,” and have some bot order one for them. And we need to make sure patients are coming in so that we can see them, evaluate them, and build a strong relationship with each of them, so we can know what they need for their healthcare and to help move them to a healthier place.

Making It Automatic

When someone calls up and requests a refill for medication that requires in-person monitoring, such as blood tests or a physical examination, and they haven’t seen us in 2 or 3 years, things should click into place automatically. “To continue safely receiving this medication at our practice, you will need to be seen so we can check your blood pressure and perform a physical examination and blood tests, and then ongoing refills can be made available for you.” Perhaps remote patient monitoring with home blood pressure machines or continuous glucose monitors can check on compliance and feed into an algorithm that can escalate or alter medications to get people to goal.

But if someone wants the flu shot, or their overdue colonoscopy, or to see a dermatologist about a concerning growing lesion, we should be able to build smarter systems that can make this stuff happen without a lot of expenditure of medical mental energy. Free up the physicians to do actual doctoring work, and let a computer fill out a form. At the same time, we should make sure that we’re not missing anything. Let an AI system review labs and keep us focused, checking for trends and noticing patterns that we might miss.

In these modern, budget-constrained times, we’re never going to be able to hire dozens of nurses like the one who used to work at our practice, or enough social workers, mental health providers, community health workers, medical technicians, registrars, or people answering the phone to really get the job done. So please listen to us when we say that these things have to happen, and if no one is willing to spend on more human resources, then work with us to find solutions that can make everyone want to become a primary care doctor, like in the days we all remember.

Let’s be thankful for what we’ve got, but also know that we can get to a better place.

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