The Unfair Blame On Primary Care Physicians


 
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By Sheetal Khedkar Rao, MD

When plastic surgeon Dr. Robert Pearl published his op-ed, “How Doctor Culture Sinks U.S. Healthcare,” a polemic essay critical of primary care physicians like me, he set off a firestorm. While he made some valid points, Dr. Pearl also blamed many of the preventative health failures in the U.S. squarely on the shoulders of primary care physicians without acknowledging that our health care system and our American way of life have created and exacerbated many of these exact problems.

My physician colleagues and I try to steer our patients toward health, but too often we are left feeling like Sysiphus. Getting blamed for the U.S. health care mess, as Dr. Pearl does in the article, does not help Americans nor does it do primary care doctors justice.

I agree with Dr. Pearl that American health care suffers from systemic, bureaucratic challenges. My list is even longer than his, but similarly, includes the grinding tasks of EMR charting, prior authorizations, and ever-expanding lists of quality metrics. Most primary care physicians spend hours outside of the office charting, answering calls and emails, and engaging family members in discussions to provide the best possible patient care, even though this time is neither compensated for by salary nor FTE hours. Ask any primary care physician working during COVID, and you will learn these emails and calls have only multiplied as questions about COVID symptoms, treatments, and quarantines have become the norm.

Dr. Pearl is also correct that several Americans who died from COVID had chronic, preventable diseases which contributed to their demise. He is correct that preventing disease is undervalued in current fee-for-service health care models. However, Dr. Pearl is sorely mistaken in saying that American physicians are an “equally large part of the problem” because they did not dedicate enough “time and effort to preventing and … managing these types of chronic diseases.” He is wrong in insinuating that the majority of American physicians don’t value preventative medicine because we don’t prioritize it or see it as “heroic” enough to spend time on. It’s impossible to address chronic care, acute care, and preventive care in the standard 15 to 20-minute visit, including talking to a patient, doing an exam, refilling medication, charting, and completing a checklist of insurance company-mandated requirements. I might find 5 to 10 minutes to counsel them on diet, sleep and exercise routines, but then I might get penalized for this by running behind in clinic, which leads to patient complaints and negative Press Ganey reviews.

Dr. Pearl unfairly blamed “tens of thousands” of hospitalizations on primary care physicians, many of whom were on the front lines from the early days of the pandemic, practicing through challenges such as inadequate PPE and significant pay cuts in exchange for risking and all too often losing their lives. I won’t even bother delving into the shortcomings of our federal pandemic response and the concurrent scourge of disinformation that contributed to significant acute loss of life. I will, however, assert that Dr. Pearl has gravely underestimated the importance of the role our society and government play in chronic illness.

Are internists to blame for the high cost of life-saving medication like insulin that patients often can’t afford? Are family physicians at fault when our government subsidizes artery-clogging red meat, rendering it more affordable than organic produce? Are inner-city pediatricians responsible when their patients breathe polluted air that exacerbates their asthma? Are obstetrician-gynecologists to blame for maternal health disparities brought on by poverty? Is it the physicians’ fault that many Americans are chronically stressed, have inadequate childcare, or have to work multiple jobs to support themselves and are therefore unable to find time to exercise, cook healthy meals, or get enough sleep? Dr. Pearl needs to take a hard look at American public health metrics and social determinants of health. More than a buzzword, these social determinants of health should be available to all Americans since primary care physicians are often left fighting an uphill battle without them.

I also could not help but ask, “Et tu, Brute?” Dr. Pearl could have made his point without kicking his colleagues while they were down, overworked, and burned out. He did not have to contribute to anti-physician media bias. Are all primary care doctors perfect? Of course not — the heartbreaking story Dr. Pearl shares of a friend who passed from ovarian cancer is just one example — and we all know there are others. We have room to grow. But we also face enormous challenges: Health care has become a service industry while many doctors still see themselves as scientists. Scientific facts have become politicized, and expertise of all types has become devalued with the advent of Google. Our jobs are constantly encroached upon by physician extenders with less training as we gradually lose our autonomy to profit-driven executives. Yet primary care physicians still, despite all of the above, love to take care of people. In fact, we in primary care go into hundreds of thousands of dollars of debt to make modest salaries so we can answer a calling to heal and help.

Should physicians have better training in palliative care and how to communicate with patients? Yes. Should academic medical centers admit more primary care residency spots? Yes — yesterday! Should all physicians treat their patients just as they would their own families? Yes. So many of them already do. Let’s be fair and honest about what needs to change and improve. Let’s also call on elected officials to reduce barriers to healthful living. Our health care system is suffering, and so are patients and physicians. COVID has shown us what has been behind the curtain all along. Physicians need to work together to preserve our profession as one we would want our children to pursue. The future of health and health care is at stake. Dr. Pearl made some good points. He did not need to attack and unfairly blame his colleagues to make them.

Sheetal Khedkar Rao is an internal medicine physician.

 
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