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Time To Think Seriously About PCPs (Or the Lack of Them)

October 27, 2008
by Mark Hagland
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As if hospitals and the healthcare system didn’t already have enough concerns ahead, a study published last month in the Journal of the American Medical Association revealed that only two percent of graduating medical students plan to work in primary care in internal medicine, a backbone of the primary care-based healthcare system. Among nearly 1,200 fourth-year medical students that JAMA surveyed, only two percent say they’ll go into internal medicine, a steep plunge from the nine percent who had made such plans as fourth-year students back in 1990.
Why so few? Some medical students cite paperwork and the challenges of dealing with chronically ill patients. "I didn't want to fight the insurance companies," Dr. Jason Shipman, 36, a radiology resident at VanderbiltUniversityMedicalCenter in Nashville, Tenn., who is carrying $150,000 in student debt, told the Washington Post.
But more than the chronic care issue, a fundamental reason is the salary gap, and the fact that many medical students these days simply can’t see any way of paying off their medical school loans long before retirement on the $186,000 average internist pay, when orthopedic surgeons, for example, earn an average of $436,000.

There are clear clinician workflow, staffing, and efficiency issues here. Hospitals and health systems depend heavily on internists (and at academic medical centers, which generally do not have family practitioners, internists really are the core primary care attendings), and if so few medical students who are graduating soon are going into internal medicine, the healthcare system will have to find new ways to become more efficient and to handle such shortages over the long term.

It seems obvious to me that, while automation can never completely solve such profound staffing problems, IT will be called on as never before to address what looks to become a very long-term situation. All clinicians—primary care physicians, physician assistants, specialists, nurses, pharmacists, techs, and the like—will have to learn to work more efficiently and to optimize the previous resource of time even better than they can do so now. And as a result, clinical documentation, clinical decision support, medication ordering, electronic medication administration, PACS, and other clinical information systems, will all need to be optimized as fully as possible.

And CIOs, in concert with clinician leaders and with other members of the c-suites in their organizations, will need to look at clinician staffing more intensely than ever before, in order to prepare for coming shortages across numerous medical specialties. There really isn’t an alternative, if the patient care delivery system as we know it is to continue to function.

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Comments

Thank you very much, Joe Bormel! In terms of hospitalists, their use/optimization is not addressed in my second book, but it's a topic I've become increasingly interested in. I would certainly welcome your thoughts and input going forward. I do believe that hospitalists will become even more important than they presently are, to the efficient and clinically effective operation of all but the smallest hospitals, as the healthcare system evolves forward. Thank you again for your thoughts!

Wow, you are prolific!

"Paradox" in the title of your first book, and the recommendation of a CIO friend led me to reading it.   "Paradoxes are the basis for all deep truths" was the first line of my blog post, here.   Paradoxes seem to be fundamental to management and humility.  From your book, I came understand that paradoxes are also a deep part of healthcare economics.

I'm looking forward to reading your second book.  The examples in your first book, along with the framework are very focused and rich.

Is your comment


... hospitalist use must both increase and be much more fully optimized. The models that have emerged so far for hospitalist use in hospitals have not been optimized to the extent they could be.

developed in your latest book, or do I need to wait for your third?


Mark,
The data we are seeing, mostly unpublished and never will be, is that hospitalist perform better than alternatives, in cost and quality measures. Often much better. Focus and rhythm are becoming increasingly important in our world.

The careflow, teamwork and learning that HCIT can enable will require hospitalists to evolve to the optimization levels you describe and have been established in other knowledge-work industries. Whether operating with 45% of admissions handled by hospitalists or a much higher percentage is an unanswered question. Logically, it's assumed that the number and penetration needs to be maximized. As you allude to, the practicality, staffing and other issues for smaller hospitals and increasingly complex hospital courses leaves this a work in progress.

Your words resonated for me; specifically:


It seems obvious to me that, while automation can never completely solve such profound staffing problems, IT will be called on as never before to address what looks to become a very long-term situation. All clinicians—primary care physicians, physician assistants, specialists, nurses, pharmacists, techs, and the like—will have to learn to work more efficiently and to optimize the previous resource of time even better than they can do so now. And as a result, clinical documentation, clinical decision support, medication ordering, electronic medication administration, PACS, and other clinical information systems, will all need to be optimized as fully as possible.

I agree.  So then the discussion leads to, what exactly does that look like.  It brought to mind some work of the author Thomas Davenport, and the following framework from "Thinking for a Living."


Specific examples of each of these is elaborated by Davenport, with concrete examples of several 'ways to improve hospitalist knowledge work' from Partner's Healthcare.  Some of this has been covered by HealthCare Informatics, by you and others in detail.  John Glaser and Tonya Hongsermeier have explicitly addressed how Partner's has translated these KM basics to address clinical documentation, clinical decision support, medication ordering, electronic medication administration, PACS, and other clinical information systems, in public forums.

Underlying most if not all of the 10 points above is standardizing in appropriate places in the knowledge work of practitioners.  Hospitalists play an important role in this optimization work.  Although the artifacts are flowsheet definitions, order sets, rules, documentation templates, care planning and execution engines, etc, the focus on clinician workflow as informed by knowledge management is a key framework to manage and lead the efforts you describe.

I wish the ambulatory world was seemingly as straightforward, bringing the PCPs into the brighter future being experienced by some hospitalists !


I'd love to see some readers comment on that statement, or anything else in this thread!

Joe,
Thank you so much for the wonderful comment! And yes, I think that any strategy to increase the output of graduating medical students going into primary care will require at least two prongs, including both bumping up PCP pay, and improving efficiency and delivery of care improvements. The improvements to workflow, etc., would not only make PCPs' worklives more pleasant, they would also allow office-based PCPs to improve their patient-visit volume, etc. For many, that could make the difference economically in the future. I also believe that hospitalist use must both increase and be much more fully optimized. The models that have emerged so far for hospitalist use in hospitals have not been optimized to the extent they could be. And again, IT will play a role there strategically. Thank you again for your comment, and for having read my first book! (My second, Transformative Quality: The Emerging Revolution in Health Care Performance, has just been published, and extends some of the same themes as the first book, while digging more deeply on the quality side of health care, and bringing forward more case studies from pioneering organizations). Thank you again!

Joe,
Thank you so much for your excellent thoughts here, as well as bringing in the excellent thoughts of Thomas Davenport. Would anyone else like to comment on this thread? Joe has done a wonderful job in framing this set of issues broadly, using insights from his clinical and professional background. Thank you again, Joe!
Mark

Mark,
In your book, Paradox and Imperatives in Health Care, you offered 2 policy prescriptions. The first was to preserve providers' revenue. Do you foresee a combination of bumping up PCP's pay with efficiency (and delivery model) improvements as part of the solution to the problem you outlined? This would seem most concordant with themes in your wonderful book.
-Joe

Mark Hagland

Editor-In-Chief

Mark Hagland

@hci_markhagland

www.healthcare-informatics.com/blog/mark-hagland

Mark Hagland became Editor-in-Chief of Healthcare Informatics in January 2010. Prior to that, he...