Blog | Tuesday, February 21, 2017

Is direct primary care the answer or the problem?


Long time readers know of my fascination with the affect heuristic. Simple stated, we overvalue the benefits of a concept that we like, and underestimate the problems or vice versa.

This article about direct primary care induces conflicting analyses, “Here is the PCP crisis solution and it's simple.”

I like the idea based on this reasoning. Primary care in 2017 has several problems. Both physicians and patients have dissatisfaction with direct face time. Primary care physicians suffer high levels of burnout because the financial model requires them to see patients to quickly to do their job properly. These quick visits likely induce physicians to order more tests and consultations than they would if they could spend more time on history and physical examination.

Direct primary care allows physicians to spend more time with patients, because they decrease their “panel size” from greater than 2,000 to 800 or less. These physicians have more time to communicate with their patients using telephone and email.

But the panel size decrease waves a red flag for opponents of this movement. They always ask, “Who will care for the patients?”

When primary care physicians burnout they often totally leave their practice, often becoming hospitalists or urgent care physicians or subspecialists or retirees. If direct primary care keeps them practicing, even with fewer patients, at least they are providing important primary care.

Currently, medical students and residents often find primary care unappealing because of the work conditions. I often argue that direct primary care may induce students and residents to choose primary care and work with a reasonable number of patients.

This debate has no solution. My arguments are not based on data, but rather on anecdotal observation. I worry about primary care, because the current model often leads to more expensive substandard care. You cannot rush visits and provide the highest quality primary care. You must take shortcuts to shrink your visit times.

This debate is philosophically interesting and, in my opinion, a great example of that affect heuristic. We cannot resolve this question with data, because the factors are multiple and too often you really do not understand the underlying motivations for doing primary care, or leaving primary care or moving to direct primary care. So we will likely continue debating this issue to no clear conclusion.

But of course, I am correct.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.