Clearing Out the Chaos

— Let's make primary care more inviting for Internal Medicine residents

MedicalToday
A young male physician speaks to his mature female patient in an examination room.

How can we ever expect those who are undergoing the intense training that is life in an Internal Medicine residency to choose a life of primary care if their main exposure is a few practice sessions every 2 months, accompanied by sometimes traumatic levels of chaos?

Residents who chose Internal Medicine after graduating from medical school are mostly pluripotent, still unsure what they want to be before they end up deciding on a career path. Sure, some are destined for a life of research or some specific specialization, moving down a path long-planned. But for the rest, to make this life of primary care seem like a viable -- even desirable -- alternative, we have to create a time and a place for them to see patients in the outpatient world where everything goes in the best ways possible.

Historically, residency practices have been considered second-class sites, less worthy of support, with fewer ancillary and auxiliary services, and not an environment where someone might choose to spend their career. That's been the case even though most of residency isn't like the life they're going to have no matter what they choose, unless they end up becoming an intensivist or an invasive proceduralist.

During internship I learned a lot about managing sick patients in the hospital, and I could get an IV in anybody and do LP's in my sleep (well, maybe not while actually asleep, but with no sleep for like 36 hours). But I learned less about doctoring and taking care of patients over the course of their lives. I often tell residents that the life of a cardiologist or gastroenterologist is more filled with their longitudinal care than the acute care of the critically ill.

For many years, our practice consisted of two month-long rotations a year in outpatient clinic, accompanied by weekly continuity clinic practices as well. But then we transitioned to what is called a 6+2 rotation, where residents are in outpatient practice for 2 weeks at a time, followed by 6 weeks completely away from the practice on inpatient services. This was designed and implemented to provide the residents with more time managing and running an inpatient team, as well as opportunities for more elective rotations.

Under the old system, we got to know our residents much better, and they got to know their patients better -- all because residents ended up being more likely to take care of their own patients. Now, more often than not, when calling for appointments patients are told that their doctor isn't available, and they have to see somebody else. This discontinuity creates nothing but chaos, over-prescribing, over-testing, and loss of the very thing that comes from a patient and their doctor getting to know each other.

The underfunding of residency practices and the separation of patients with public insurance such as Medicaid -- who are mostly seen by residents at teaching sites -- from those with private insurance, who are mostly seen in private outpatient facilities, creates a two-tiered level of care, with Medicaid patients suffering from lack of support on the phones, far fewer ancillary services, and less inviting physical office spaces.

When we look at a life of seeing patients in a primary care outpatient resident clinic, it feels like there's almost no way that anyone would choose that life. For this reason, even our primary care residents -- those who expressed interest up front in staying in primary care -- end up rarely choosing to stay with us, or even in most cases, sticking with primary care.

I often hear from folks that because we are a tertiary-care subspecialty hospital, many residents fresh out of medical school choose to come here to be trained in very specialized levels of care, sometimes not available elsewhere -- training under the best in the country. But if we created a world where patients got to be taken care of by their primary care doctor, seeing only their primary care doctor for most of the care they need, with a balanced and effective system of coverage, we would probably create more happiness for both the patients and the doctors.

Having the resources to take care of all the stuff around the fringes of medicine, the stuff that has been left as sediment, that has drifted to the bottom of the healthcare system, the forms, the paperwork, the prior authorizations, the nonsense that really isn't healthcare, would let residents really practice medicine up to their license, learning to love taking care of patients in the best possible healthcare model.

I know this is going to be an expensive proposition, to build this right, but it's only right that we build the system that works for all of our patients and for all of our providers. Only then will we re-instill the joy of primary care in our trainees, and then and only then will they start to choose once again to stick with us, to stick with our patients, to help us fix this broken healthcare system.