Primary Care Experience

“In theory there is no difference between theory and practice—in practice there is”—Yogi Berra

In the late 1960s and 1970s, leaders in medicine rediscovered the importance of a strong cadre of generalist physicians who could serve as “quarterbacks” of the health care team. The resulting new specialty of family medicine was followed by establishment of divisions of general medicine and general pediatrics, federal and foundation support for primary care training programs, and the creation of academic generalism. The values and competencies that were articulated during that period have shaped a generation of primary care clinicians. Consistent with the general ethos of physician-patient relationships at the time, there was little direct consultation with patients about these changes.

At the dawn of a new century, health care professionals confront the challenges of caring for an aging and increasingly diverse population, a patient population with more chronic illnesses and more treatment options, and significantly increased access to current scientific evidence. In theory, these challenges should reinforce the importance of primary care values and competencies. In practice, however, the daily experience of many primary care clinicians doesn't quite suggest a golden age. Both physicians and patients report frustration with encounters, effective care coordination remains an elusive construct, and the “hassle factor” of chaotic practice environments is accepted as routine.

In this issue, Montgomery et al. present findings of older patients’ primary care experience.¹ Using a well-validated instrument, they surveyed a cohort of Medicare patients seen in fee-for-service and managed care settings in 1998 and 2000, deliberately sampling patients in states with mature managed care markets. Significant declines in three measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams) were observed and were apparently unrelated to the type of system. However, elderly patients reported no changes in their perception that their doctors knew them or in their level of trust of their doctors.

These findings are striking in several respects. First, these findings reinforce the importance of the patient's experience as an essential dimension of primary care. Second, it is likely that these perceptions reflect the experience of far too many primary care physicians today. Rather than “shock and awe,” these perceptions may unmask suppressed frustration among physicians. Based on our own experiences as patients and/or advocates for friends or family members, these findings are disturbing but will not surprise most general internists. A common conversation at annual meetings of the Society of General Internal Medicine (SGIM) in recent years concerns the dysfunctional practice environment at [insert your institution here] and reminds us that at the end of the day our patients continue to inspire us and motivate our aspirations to improve care.

In fairness, the experience of patients in primary care likely reflects dysfunction at the larger health care system level. Given the dominance of primary care as the major source of visits in the United States, we may simply be the “canary in the coal mine” for health care. At a time when patients want and demand more from their providers, they perceive that we are actually providing less of the kind of care that meets their needs. and because the elderly tend to be far less skeptical of medical care than their younger colleagues, this study may only be revealing the tip of the iceberg for the patient population at large.

While these data would suggest that we are not meeting patients’ expectations, it is interesting that these findings on patient-physician communication do not reflect the amount of time we spend with our patients. While we may not have reduced the time we actually spend with patients, those few precious minutes may now be consumed in search of radiology reports and checking health plan formularies. The lack of time and energy to engage our patients—to hear their pain and heal their physical and emotional suffering—may be eroding.

But change is hard. Primary care and general internal medicine needs careful growth and development. The results of a thoughtful process led by an SGIM task force to articulate the challenges confronting general internal medicine as well as possible strategies to address those challenges were recently summarized by Larson.² His article argues that the current health system chaos should spur innovation in practice management, reimbursement, information technology, teaching, and research. It also emphasizes that the core values of general internal medicine must include effective communication and sharing knowledge with our patients.

However, there are reasons for optimism. A return to the golden age of primary care could be hastened by greater attention to the microsystem changes that our practices desperately need. Health information technology and health information exchange across providers and settings of care could help to automate some of the more frustrating and time-consuming tasks that clutter up our current visits. If we didn't waste time locating a chart or a needed radiology report, we could focus on the more human aspects of the doctor-patient relationship that need nurturing. We need to embrace the concept of team-based care and work with other clinicians who can help meet some of our patients’ needs. If we accept that we cannot do it all, we can use the power of our relationship to catalyze healthy behaviors and chronic illness management.

Finally, while the evidence presented by Montgomery et al. raises serious concerns about continued erosion in the primary care relationship, it may provide us with the information we need to redesign the relationships at the heart of primary care. It is time for primary care and general internal medicine to move toward “sustained partnerships” with patients. The era of the “informed patient” has arrived and will continue to move our relationship with patients toward a more sustained partnership. In this new vision, we would define our relationship with patients as a shared enterprise in which patients’ experience is not just a metric for study, but also a core value. What should or could guide our efforts to close the theory-experience gap, then, is reliance on regular reports from our patients. Primary care can lead in this regard—the public is clearly ready—are we?