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Cracks in the Armor of Primary Care Medicine

Primary care medicine and the physician’s and providers that provide it are at the breaking point. I’ve provided some of the key points identified in a survey of primary care physicians completed March 1, 2022.

  • 46% of physicians said that primary care is crumbling.
  • 41% said they are mentally and financially fragile.
  • 33% said they have been denied or are over-due serious payment from insurers and health plans.
  • Only 21% of primary care offices are fully staffed.
  • 60% of patient visits take longer due to worsening health of population and exacerbated concerns with delay on access to care during the pandemic.
  • 25% of doctors plan to leave primary care in the next 3 years.
  • 28% of doctors had to limit use of telehealth due to insufficient payment. 
  • Computer literacy is a significant obstacle for 20% of the patients trying to use telehealth.
  • Broadband speed is a significant issue for 20% of patients trying to use telehealth.
  • 36% of physicians state that their burnout is at an all-time high.
  • 53% say that their ability to bounce back and recover from this adversity and burden is severely limited.

“Primary care continues to face a policy emergency regardless of when the COVID-19 public health emergency is rescinded. The findings above continue the ongoing narrative captured in over 35,000 responses to this survey since March 2020. ”

Policymakers, health plans, hospitals and patients alike must respond or watch primary care collapse on their watch.

Why Haven’t You Called Me About My Labs Yet?

The pipes in Rome were slowly killing the people.  No one knew lead in the pipes was actually poisonous.

Today, it’s quite easy to scoff at their ignorance.  Yet, each of us have our own lead pipes, those modern “marvels” that future generations will shake their heads at.  We have at our fingertips inventions and practices later proven to be catastrophic to our health and well-being.

It’s one thing to learn about these blind spots after the fact.  What if you knew in REAL-TIME what was happening?

What if you had secret knowledge about your OWN lead pipes . . . ?

What if you were among a small group who knew which of our modern inventions and practices were slowly killing our health and vitality . . . would you still turn a blind eye?

Or, would you make the simple change that set you free?

After reading the following two articles, I now understand why I must spend 17-18 hours a day working to keep up.

I thought that maybe it was just me.  However, this study published in the Annals of Internal Medicine found that during a typical office day, just a quarter (27 percent) of a physician’s day is spent having direct face time with patients – while nearly half (49.2 percent) of a physician’s day is spent on EHRs and other administrative work. This roughly translates into two hours of additional time spent on EHRs and desk work for every hour physicians spend face-to-face with patients.

Over the years, we’ve hired more staff and I now have six and a half staff members to every provider. It’s taken part of the burden of time off of our shoulders, yet, in an era of rising inflation, hiring more staff isn’t affordable.  It’s not a sustainable model financially.

This second study found that with an average primary care practice responsible for roughly 2,300 patients, doctors would need to spend 21.7 hours of patient interaction per day to provide “all the recommended acute, chronic and preventive care” for a panel of this size.  The average internist has 3000-4000 patients in their panels.  There literally are not enough hours in the day to take care of all the office tasks required for a panel size of 2000 patients or more.

It has become physically impossible to do what is now required on treating acute, chronic and preventative care for the patients that we see day to day in the primary care setting. The inability to fully meet patient needs due to factors outside of their control results in frustrated patients and very frustrated physicians who lose sight of why they decided to practice medicine in the first place. This can leave physicians feeling depressed, cynical and suicidal, pushing them to contemplate early retirement, search for other practice options, quit medicine altogether – or worse, take their own life.

This has created the general feeling and perception in the mind of patients across the country that physicians just don’t care, they don’t have time for me and “they just want my copay.”

It isn’t that we don’t care.  If I didn’t care, I would have quit practicing medicine 15 years ago.  I love the practice of medicine.  It is the immense burden of documentation, the paper work, the seven page FMLA forms, and the thousands of ancillary treatment plan reviews & signatures, the providing proof of performance to Medicare and payors required every day that makes it so very hard to complete lab reviews, refills and callbacks in a timely manner.

I haven’t taken a real vacation in 15 years.  Who has time?!

Today, mounting evidence shows that the day-in-day-out pressures experienced by primary care physicians – caused by long hours, excessive fatigue and the sheer emotional toll of the work – can lead to burnout, depression and suicide. Sadly, the medical profession has among the highest risk of death by suicide compared to other occupations in countries around the globe. Recent studies reveal the concerning rate at which primary care doctors feel as though their personal lives are negatively affected by work, feel stressed at work and wish that they had more time to do more for their own health. When it comes to patient care, physician burnout is associated with higher rates of self-reported medical error, substandard patient care, longer recovery time and lower patient satisfaction. Layer on top of the burnout syndrome what some are describing as “moral injury,” the distress weighing on physicians because the business of medicine has overtaken the doctor-patient relationship. And for some, it seems that practicing medicine is literally killing physicians.

To regain control over their practice and personal lives, some primary care physicians are leaving the profession and others are taking steps to deal with work-related emotional exhaustion and chronic over-stress. Over the years, I’ve inherited a number of patients who’s doctors have left practice or moved to concierge models.

I’ve offered concierge services to my patients for years, but few patients have shown much interest up to this point.

Does one just leave medicine altogether?

Maybe.

References:

  1. Sinsky C., Colligan L., Li L., Prgomet M., Reynolds S., Goeders L., et al., “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties,” December 2016, (Accessed online June 21, 2022)
  2. Altschuler, Justin et al., “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based Task Delegation,” 2012, (Accessed online June 21, 2022)

Coronavirus, the Cancel Culture and Tiny Betrayals of Purpose

In the last two decades, it has become more and more clear that the average American has trouble facing reality.  The average American has trouble facing truth.  It affects each of us, and it is affecting physicians, nurses and health professionals individually.

At least once a week, one of my patient’s refuses to get on the scale.  Why would you visit the doctor to improve your health, and yet refuse to look at a measure of health?  Yet, that is the accepted culture of today.

Language of Euphemism

Another evidence of this can be seen in the changes to our language. Our language has become flowered with euphemism and politically correct phrases.  It is why we have a whole generation hyper-focused on “cancel culture.”  People have set aside their faith to live by their feelings.  People no longer accept another’s right to share their perspective or express themselves, especially if it hurts another’s feelings.  We’ve created soft language that has taken the life out of life and medicine.

Shell Shock to PTSD

An example of this change is the softening of language describing what happens to a persons nervous system when in combat.  During World War I from 1914 to 1918, if a soldier’s nervous system became overwhelmed due to the fatigue, stress and horror of battle it was called “shell shock.”  The term describes the power and struggle that occurs with this overwhelming stress. The word almost echos the rattle of a cannon on one’s soul.  Men would return home with hysteria, muscle contractions, heart palpitations, dizziness, depression, blindness, paralysis, insomnia, loss of appetite, flashbacks, nightmares or unable to speak without any physical damage to explain the symptoms.  Because little was understood about the cause, it was seen as a sign of emotional weakness.  Many were even branded as deserters or cowards because of the condition shell shock would cause.  At the end of the war, 80,000 men were diagnosed with shell shock in the British Army medical facilities.

But instead of addressing the pain and addressing the trauma, we buried it under the jargon and euphemisms.  After the second world war in 1945, we toned the term down because we didn’t want to hurt anyone’s feelings describing them as “shell shocked.” So, we called it “Battle Fatigue.”  It is the same problem, overwhelming a person’s emotional coping mechanisms and nervous system with stress to the point of failure, but “battle fatigue” just sounded better, and softer.

Enter the Korean War of 1950-1951.  Actually, we softened that too.  It wasn’t really a war, we were told, and our leaders turned it from war into a softer more acceptable “Korean Conflict.”  Men and women who encountered the same overpowering effects on the nervous system from witnessing the horror of battle, death and destruction were told they had “operational exhaustion.”  This was an even softer term that allowed for a further avoidance of the truth.

Five years later, the U.S. entered a 19 year “conflict” with Vietnam.  The politicians of the time didn’t want to call it war either.  The same trauma causing shell shock in World War I was experienced by men and women in Vietnam.  Seeing the horrors of battle on a daily basis and only being allowed to police those attacking you with guerrilla warfare in a foreign country led to severe trauma in many of our soldiers.  Fighting was intense and millions of people were killed including 60,000 U.S. soldiers.  Yet, we further softened the term “operational exhaustion” with the same symptoms of shell shock to “Post-traumatic Stress Syndrome (PTSD).”  (Hey, at least they added a hyphen, right?)

Waking The Tiger – Working Through Trauma

Trauma is trauma, no matter how or where you experience it.  Because of it’s complexities, the treatment of trauma can’t be addressed here, but according to Peter Levine in his book Waking the Tiger, trauma, no matter what the cause, must be worked through.  Peter Levine does a wonderful job in explaining this in his second follow up book In An Unspoken Voice.  There are additional treatments for burnout.  The brain has a consistent pattern that it follows to resolve trauma and burnout.  If that pattern is disrupted, shell shock, battle fatigue, operational exhaustion or PTSD ensues.

Elizabeth Metraux describes this in her 2018 article this way:
“I was on my honeymoon in Colombia when I first became aware of the true extent of my post-traumatic stress disorder. My husband and I were walking across a smooth, granite platform to take a closer look at a fountain in downtown Cartagena. As we neared the structure, mist from the fountain’s jets dampened the ground at my feet.

“I froze, paralyzed with fear by a flashback — my first — triggered by something as ordinary as wet pavement on a warm day.

“Two years earlier, I was working in civic engagement efforts in Baghdad. One morning, as I walked across a smooth, granite platform toward my apartment, gunfire erupted. I tried to run, but my flip-flops bested me on the pavement, still damp from an early mopping. I slipped and fell backward, hitting my head hard enough to knock me out. When I opened my eyes minutes later, the platform was covered with my blood.

“That happened 15 years ago this week, those Ides of March when American forces invaded Iraq.

“Back home in the U.S., it was clear to those around me that I had PTSD. It wasn’t until six months after my honeymoon, however, that I had the courage to acknowledge that I needed help. It’s not easy seeing your own weaknesses, much less conceding them. But when my habitual glass of wine with dinner became a bottle, and fireworks left me sore and sleepless for days, it was hard to fight the signs.

“Celexa for guilt. Ambien for sleep. Therapy for months. My psychologist and primary care physician spoke regularly to coordinate my care. Most importantly, family and friends became members of my care team. Isolation is a trauma victim’s ill-advised drug of choice, one my loved ones and clinicians wouldn’t let me take.”

Most Physicians Suffer from Moral Trauma combined with PTSD

What concerns me is that many of today’s heath-care workers, physicians and nurses, suffer from PTSD and moral trauma.  Dr. Metraux goes on to describe a conversation she has that is reminiscent of many recent conversations I’ve had with my colleagues:

“A few weeks ago, I was talking with a physician who served our country in Iraq. We chatted nostalgically about the taste of sand and shawarma before he said something that gave me pause: ‘You know, I’d go back to the field any day. Beats practicing in my clinic.’
“‘Why’s that?’ I asked.
“’I didn’t become a doc to put up with billing codes and power struggles. I thought that PTSD would hit when I came home from Fallujah. It’s so much worse when I come home from the office. Truth is, I’ve lost my sense of purpose.’”

Physician burnout is easily chalked up to the 4-8 minute hurried visit with 30-40 patients per day, and the additional 6-8 hours spent each day entering patient information into an electronic medical record, combined with the life-and-death decisions this profession requires routinely every day.  Add to it a time when a physicians and nurses are called upon to be the only people in the clinics and hospitals taking care of a viral infection still unknown in its full spectrum.  But, that doesn’t even scratch the surface.

Thousands of Tiny Betrayals of Purpose

The real cause of injury is the fear created by a society that doesn’t really want to hear or face the truth, and the hundreds and thousands of tiny betrayals of purpose that occur every day in the clinic or the hospital.  Most physicians find themselves expressing horror and disgust at how far they’ve been steered away from their primary purpose of taking care of people.  Clinicians and nurses, much like combat veterans, are forced to take actions every day that contradict their core purpose – sometimes compulsory, sometimes voluntary.  It causes a slow imperceptible unwinding of character.

The 4-8 minute visit means the physician can’t take time to build a real relationship with you or take care of the whole person whose real diagnosis can’t be logged into a computer.  The 8 hours of daily charting requires the clinicians eyes to be taken off their patients, missing the humanity that brought us to the work in the first place.  The government mandated “quality metrics” imposed on every patient encounter by Medicare, Medicaid and intrusive insurance plans that crowds out the deeper connection with patients to help them manage triggers, feel truly cared for and navigate treatments.  Each of these are a “tiny betrayals of purpose,” 30-40 times a day over the course of weeks and months and years.  When you subconsciously betray yourself with every interaction you have throughout the day, it adds up.

Medicine now requires clinicians to practice in a manner inconsistent with their values, because it saves costs, increases access and improves quality, . . . maybe.  Then, add a new virus with an unknown morbidity, mortality and infectivity to the spectrum without a clear treatment protocol. Then add to that layers of bureaucratic regulation and mandates around treatment and insurance.

In 20 years of medical practice, including battlefield medicine, I’ve never seen physicians express public fear, angst and fatigue in the course of their duty.  I’ve seen it every day in the last year.

We Lose a Physician Every Day

Since 2018, over 400 physicians committed suicide per year.  Every day, at least one physician commits suicide (Tanwar D, Amer Psych Asso 2018 Annual Meeting).  That is the highest rate of suicide in any profession.  40 suicides per 100,000  is twice that of the general population.   This rate is higher than the military.  The claim is that doctors are under-treated or untreated for their depression.  It is more than that.  Doctors and nurses alike are experiencing “shell shock,” or in today’s vernacular, “post-traumatic stress disorder” and being force to live, work and function all while suffering with subconscious moral injury.   It goes untreated and unrecognized.

It’s why your doctor is curt with you.  It’s why he or she can only spend five minutes with you in the exam room.  It’s why you get the sense of fear from them when dealing with COVID-19.  It’s why there is confusion about wearing masks and why so many physicians struggle to keep up with the ever changing science.  It’s why 30% of them are divorced.  It’s why 73% of the physicians and 50% of nurses you meet are effected by burnout, trauma and PTSD.

The challenge, is it’s only going to get worse before it gets better.  Some will leave medicine, some will leave life.  Others will suffer until it kills them.  Unless, you and I change it.  Until then, society will be offended.

Burnout

Ask yourself the following questions:

  • Does your job limit interaction with people and/or do you spend most of your time with a computer screen?
  • Have you become cynical or critical at work?
  • Do you drag yourself to work and have trouble getting started once you arrive?
  • Have you become irritable or impatient with co-workers, customers or clients?
  • Do you lack the energy to be consistently productive?
  • Do you lack satisfaction from your achievements?
  • Do you feel disillusioned about your job?
  • Are you using food, drugs or alcohol to feel better or to simply not feel?
  • Have your sleep habits or appetite changed?
  • Are you troubled by unexplained headaches, backaches or other physical complaints?

burn outThese are the ten most common signs of “burnout.”  46% of respondents in surveys indicate at least one of the above symptoms of burnout. Two or more of these imply that you are suffering from some degree of “burnout.” The classic triad of burnout is:

  1. Exhaustion
  2. Cynicism
  3. Questioning the quality of your work, or questioning whether you are making a difference in the world any longer

What is burnout? It is defined by “Mr. Webster” as “physical or mental collapse caused by overwork or stress.” But, that definition doesn’t seem to do it justice, and many people experiencing burnout don’t actually “collapse.”  They do, however, become significantly less productive, depressed, and loose the enjoyment of life.  Work begins to feel like slavery, exercise becomes a chore, food begins to have associations with guilt, friendships are seen as obligations and love looses its luster and looks more like a social construct.

Burnout is often likened to discontent, however, these are two very different emotional feelings.  Discontent can be defined as dissatisfaction with ones circumstances. There are two kinds of discontent in this world: the discontent that works and the discontent that wrings its hands.  The first kind often gets what it wants and the second looses what it has.

Burnout differs from discontent, in that continued work toward a goal brings on the triad of emotional exhaustion, depersonalization and the feeling of reduced personal accomplishment. Burnout is, in reality, the sum total of hundreds of thousands of tiny betrayals of purpose.

Burnout can occur in any field of work, however, a study published in the 2012 issue of JAMA reveals that over 40% of the ~800,000 U.S. physicians are experiencing burnout and are more prone to burnout than any other worker in the United States.  The journal Academic Medicine recently reported that medical students, when compared to age-matched fellow college graduates, reported significantly higher rates of burnout.

So, how do you overcome burnout?

I’m an Osteopath.  I see disease in the context and inter-relationship of the mind, body & spirit.  Overcoming burnout requires one to restore balance in these three areas.  I am impressed by the work of Charlie Hoehn in his book, Play it away: A workaholic’s cure for anxiety.  Charlie does a wonderful job of describing the broken inter-relationship of the mind, body and spirit in a person experiencing burnout.

The first step to repairing the broken inter-relationship is to recognize and remove those anchors keeping you tethered to the feelings of burnout.  The anchors are the stressors that cause you to worry on a daily and weekly basis.  Journaling these stressors, writing them down in 3-5 word sentences is the start.  Identify which of these stressors is the biggest or causes the most angst, then write out the following question.  “How can I eliminate [stressor] from my life?  Do this with the largest two or three stressors. Then write out a solution that is small and uncomplicated to each stressor.  Put the solution to work immediately. If your solution has not improved your feelings of stress and anxiety within a week, then drop the first and try to find a second stressor, or otherwise switch to a second solution. Journaling these thoughts, questions, feelings and answers allows your mind to change from a self-centered focus to an action based focus.  It clears the mind to move into action. Nothing is more important in reducing burnout, than nourishing the imagination. Using a journal helps stimulate thought and the imagination.

The second technique is scheduling some real play. Write down the five most fun activity involved with play that you did as a child. Then, set aside dedicated time for your favorite activity of play.  It is essential that you actually schedule this play time into your daily activities.  There are a couple of rules associated with play time.

  1. Disconnect from all social media
  2. Harmony of the playtime is more important than winning
  3. Have some serious fun
  4. Shoot for 30 minutes of play time per day
  5. This should ideally be done outside in the fresh air and sunlight

“A lack of play should be treated like malnutrition: it’s a health risk to your body and your mind.”  (Stuart Brown)

“Play is the highest form of research.” (Albert Einstein)

Technique number three is related to sleep.  It is essential that you have a consistent bedtime and give yourself the opportunity to take an afternoon nap.  You can optimize your sleep by turning off electronics before getting into bed, going to bed at the same time each night, decreasing the room temperature to 68-70 degrees Fahrenheit, draw the curtains to make the room dark, and use a relaxing loop of quite background sound like ocean waves, or the sound of a trickling stream to ease your mind (can be found on a number of apps).

It may take up to a week for your body to unwind and get used to this schedule.  Also, schedule a 20 minute afternoon nap.

Meditation and/or prayer is the fourth technique.  Sit or kneel, close your eyes and observe the thoughts that enter your mind for 10-15 minutes. Listen to and keep your breathing calm and deep. Pay attention to the rhythm of your breathing.  Reading can also be a form of meditation and has become an important refreshing part of alleviating burnout.  We can only be as good as the books that we read.  Read, ponder over and talk about good books.

Fifth, eat healthy meals with healthy friends.  Decrease the carbohydrates and increase the good omega 3 fats in your diet.  The insulin response to carbohydrates stimulates the inflammatory and parasympathetic nervous system making you more fatigued and tired. Reduce the bread, rice, pasta, potatoes, carrots and corn intake in your diet.

Increasing the good fat in your diet (like Kerrygold Irish Butter, Coconut Oil, Olive Oil, and real animal fats) actually increases your bodies access to essential B vitamins and improves the use of Vitamin D.  Making dietary changes become a habit is often easier when it is done with a friend.  Schedule opportunities to eat healthy meals with family or friends attempting to do the same thing.  You will help support each other and be more likely to succeed.

The last recommendation is spend time in nature.  One weekend a month spend at least two hours out in nature. Take a hike, go on a nature walk, go camping, swim in the river, etc. Give yourself permission to unplug during these times.  Then, pay close attention to how you feel when your in different environments.

In the words of Shakespeare, “Self-love, my liege, is not so vile a sin/As self-neglecting” (King Henry V, Act 2, scene 4).

I conclude with the rhetorical question, “If you work for a living, why do you kill yourself working?” (The Good, The Bad, and the Ugly)