Profiles in Primary Care
With many documented pressures facing primary care physicians, what will the future hold for the field that has long provided the gatekeepers and served as the foundation of the health care system? While much is influenced by external forces, the strength and success of primary care in the years to come may depend on individual choice, adaptation and the development of new opportunities, as our final installment in this multipart series shows.
“I enjoy facing new challenges every day – that is the beauty of primary care – no two days are the same. I like being involved in people’s day-to-day struggles and helping them as best as possible to overcome or at least make the best of the situation with which they are presented. I like being somebody’s doctor.”
Bruce Berry, MD ’83, GME ’86, expresses a fairly universal motivation for primary care physicians. The prospect of developing doctor-patient relationships built on trust and compassion has attracted many to the field, but it’s also a commitment of time that many say can be difficult to maintain in today’s climate.
Dr. Berry, an internist on the south side of Milwaukee, makes it a priority to balance his practice, raising his four kids, teaching and engaging in clinical study. He teaches nurse practitioner and physician assistant students from Marquette and recently published research demonstrating the safety and efficacy of influenza vaccination for hospitalized patients.
Such multi-tasking often requires compromise, but Dr. Berry said he remains happy in his career choice through nearly 30 years in practice.
“To do everything I want to in a day, I sometimes can only do the must-do work at the office and delay other work for the next day or take work home to do after family activities are complete and the kids are in bed,” said Dr. Berry who now practices with a group after 21 years of having just one partner. “Nobody starts the day wanting to be second best at their job or for their family, so trying to be excellent in both arenas can be challenging.”
Jubilations & tribulations of independence
Leon Driss, MD ’80
Leon Driss, MD ’80, has accepted plenty of challenges through the years but reports increasing strain on his general internal medicine practice in the Lakeside, Ariz., area. He believes that the prospect of investing in electronic medical records (EMRs), quality reporting or joining an accountable care organization combined with declining reimbursements, lower earnings and rising overhead eventually may be too costly for his practice to endure.
“The future pressures are not only driving primary care to extinction but making it near impossible to be a solo practitioner or be in a small group practice,” he said.
To make ends meet, he said he has aggressively cut overhead, moved to a smaller office, hired a PA and begun working night shifts as a hospitalist while maintaining his office hours. He enjoys his work greatly but is prepared to transition to administrative medicine if his practice becomes nonviable.
“I am good at primary care,” Dr. Driss said. “I am especially good at taking care of the most complicated patients. I enjoy the challenge of seeing patients who have had difficult health problems, been to many practitioners and come away dissatisfied. I am often able to figure out what is wrong, address it and leave the patient smiling. I am an old-fashioned internal medicine physician. A dinosaur. There are others out there like me who take pride in taking care of the sickest of the sick while using fewer resources, but every day, there are fewer of us.”
One benefit of solo practice? Taking an afternoon bike ride once all of your patients have been seen, says Sandy Brown, MD ’73.
Dr. Driss was once part of a six-member practice. One by one, he said, his partners left the field. Now he is a solo practitioner.
Sanford “Sandy” Brown, MD ’73, is a lifelong solo practitioner who views independent practice as the means to a healthy future for primary care. Drawing young physicians to this model, however, would require role models and exposure to tools that could prepare them to hang their own shingle, he said.
“My practice model works for me, but there appears to be little motivation for others to follow my lead since most young doctors never had a solo primary care physician and were never taught how to run a practice either in medical school or residency,” Dr. Brown said.
Dr. Brown champions solo practice for the ability to decide what’s best for the patient without interference, he said, but new practice requirements such as EMRs, electronic prescribing and other information technology components are obstacles for the independent physician.
The value of primary care remains and is demonstrated daily in Dr. Brown’s office, located in rural Fort Bragg, Calif. For the physician, the greatest reward stems from “being able to have long-term relationships with my patients,” he said. “We’ve grown old together.”
Primary care lends itself to a number of different practice models. Some doctors find a less conventional structure yields personal and professional advantages.
Sharing the load
Jill M. (Pagels) DeVries, MD ’96, and her husband, Mark DeVries, MD, met and married during their family medicine residencies in South Carolina.
Jill M. (Pagels) DeVries, MD ’96, practices family medicine part time by job sharing with her husband, Dr. Mark DeVries, in Taylorsville, N.C.
Immediately after training, they began a job share arrangement at a hospital-owned network with an eye on growing their family. They and their employer favored the arrangement, so when the family moved six years later to rural Taylorsville, N.C., they sought another job share, this time with an independent, physician-owned family practice group.
“Personally, the job share model works well for us and our family because we each have a good amount of time home with our younger kids and are able to be involved at school and with the older kids’ activities,” said Dr. DeVries, who has six children ages 3-13. “I can’t think of any negatives to the job share arrangement from the personal standpoint other than the lower income; we could earn about twice as much if we both worked full time, but that’s not what’s most important to us.”
Although the couple’s patients accept that they each have limited availability, the Drs. DeVries have maintained consistent schedules to lessen this challenge. They are also able to cover the acute problems of each other’s patients and can share information with each other at home in preparation for the next day.
These adjustments are minor compared with the gains of being able to spend more time with their children, she said. The schedule may also provide some insulation against the stressors of a job in which they are caring for an underserved region with 10 percent unemployment and 18 percent of its population on Medicaid.
“Professionally, being part time helps protect each of us from burn-out, which seems particularly prevalent in primary care medicine these days,” she said. “I suspect that job sharing will increase in the future in medicine. With more females in medical school these days, there may be more desire to work part time and job share with a colleague so that each of the women would have more time with her family.”
Mark Lodes, MD ’97, GME ’01, is President of Froedtert & the Medical College of Wisconsin Community Physicians, a joint clinical practice between MCW and Froedtert Health in southeastern Wisconsin.
Changes in medicine also have led many primary care physicians to join multispecialty group practices or integrated hospital and health systems, observes Mark Lodes, MD ’97, GME ’01. This does give doctors who were otherwise facing mounting practice expenses without concomitant increases in revenue some additional protections and compensation guarantees. A practicing primary care physician, Dr. Lodes is President of Froedtert & the Medical College of Wisconsin Community Physicians, a joint clinical practice between MCW and Froedtert Health in southeastern Wisconsin.
Of Community Physicians’ 400+ providers across 30+ locations, more than 200 are primary care physicians. All of the sites are National Committee for Quality Assurance (NCQA) – certified medical homes, and all are linked, along with the academic medical center, by a common electronic health record. The community-academic partnership makes the practice unique.
“We bring the best that community-based practice has to offer, with high quality primary and general specialty physicians practicing locally while pairing this with the best that academic medicine has to offer,” said Dr. Lodes, who notes that the partnership helps bring clinical trials and other emerging therapies to patients locally. “Our primary care physicians feel extremely confident that their patients are being provided the highest quality of specialty care, knowing the resources available to them both in the community and at the academic medical center.”
The macro-economic reform that is driving health care from a volume-based reimbursement model to a value-based model will further emphasize primary care physicians’ roles “on the front lines” in managing the overall health of populations, reducing costs within the system and promoting healthy outcomes for patients in the future, Dr. Lodes said.
“The need for high quality primary care physicians will only increase in the next two decades,” he said. “The next generation of providers will need to be prepared for the challenges of caring for populations and, more than ever, become integral parts of outpatient care teams aimed at delivering on this promise.”
The development of new medical education campuses additionally demonstrates how MCW is being proactive in planning to help support the anticipated, critical need for more primary care physicians in Wisconsin. Read more about MCW-Green Bay and MCW-Central Wisconsin on page 9.
“I believe that we will look back a decade or two from now and cite this initiative as an important contribution toward meeting the state’s primary care demands,” Dr. Lodes said.
Generations to come
Thomas L. Carter, MD ’03, works with a resident at the Scripps Clinic in La Jolla, Calif. Dr. Carter is
the associate program director for ambulatory medicine at the Scripps Clinic/ Scripps Green Hospital Internal Medicine Residency Program.
At this moment, a number of MCW alumni are engaged in training the next generation of primary care providers, including Thomas L. Carter, MD ’03, the associate program director for ambulatory medicine at the Scripps Clinic/ Scripps Green Hospital Internal Medicine Residency Program. Dr. Carter is the primary care site director for Scripps Clinic in La Jolla, Calif.
“We have attempted to create a curriculum that exposes residents more to the environment of primary care,” said Dr. Carter, who notes changes in the program have included providing residents with panels of patients to follow throughout their training and designating time for exclusive discussion of primary care cases. “But they don’t come prepared for the primary care perspective and the business side of medicine, and it’s hard to prepare them in a primary care residency program that is focused on hospital medicine.”
Dr. Carter’s patients are middle to upper middle class and include many biotech industry employees, from custodial staff to executive leadership. His clinic doesn’t face the challenge of serving indigent populations but does need to navigate reimbursement changes.
“We have to figure out where we take the first step in moving from fee for service to population management,” he said. “It’s like trying to rebuild a house while you’re living in it.”
Current payment models continue to disincentivize primary care as a career, and graduating medical students sometimes find their interests at odds with their income potential, he said.
“I don’t think the importance of primary care doctors is misunderstood, but encouraging students to go into primary care is not a priority for the overall industry of medicine based on the monetization of procedures,” Dr. Carter said. “I do think there has been an uptick in residency applications stating an interest in primary care, but I don’t know how that relates to residents actually taking jobs in primary care. That’s where the rubber meets the road – the point of graduating from residency – do you take a job in a clinic or go for a fellowship?”
Justin M. Bailey, MD ’03 (right), helps teach the next generation of rural primary care physicians in Idaho, including resident (and MCW alumnus), Tobi Gopon, MD ’11 (left).
In eastern Idaho, where Justin M. Bailey, MD ’03, practices, primary care is critically important for the underserved. Fifty percent of the population is uninsured and his full-spectrum family medicine clinic is the largest provider for Medicare/Medicaid in the state of Idaho. In addition to being a federally qualified health center, the practice places providers in elementary schools, staffs the local free clinics and offers services on a sliding fee scale.
Dr. Bailey is involved in the clinic’s family practice residency program, which has a primary focus of training residents for rural, underserved care. Diminishing compensation is only part of the problem; mounting debt also drains the primary care field, he said.
“It would be nice to see more assistance to help cover the growing medical debt burden,” he said. “Many of our residents seek underserved, rural areas to try and get assistance to pay off loans. However, for many of them, where and how they want to work is strongly influenced by the concern of loan repayment and trying to serve two conflicting interests.”
Despite this, Dr. Baily remains optimistic about the future of primary care and the physicians who will define the next generation of medical practice.
“The applicants we get in our residency program are top notch,” he said. “They come to primary care in spite of the pressures to be elsewhere. It’s not the pay and it’s not the praise of specialists that draws them. It’s that boots-on-the-ground desire to make the world a better place than they found it and knowing that primary care is that hammer for that nail. I don’t see anyone killing that anytime soon.”
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