An Open Letter to Primary Care Physicians

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Dear Doctor,

The future is in your hands.

You have the opportunity to make primary care better.

More efficient.
More accessible.
And more affordable.

We know you and other primary care doctors have more responsibilities than ever. But you also have great influence, along with the ability and opportunity to change this country’s health care system for the better.

Primary care is essential to the quality of health care, and we need you now more than ever.

Maneuvering the Minefield

According to research firm Harris Interactive, “the practice of medicine is … a minefield. … Physicians today are very defensive – they feel under assault on all fronts.’’* Harris questions, “how much fight the docs have left in them. Some are still fired up … while others have already been beaten down.’’

Those who feel frustration, anger and burnout say they are squeezed by administrators, regulators, insurance companies and more. They worry about the possibility of a lawsuit that could destroy your career.

The question is: What can be done about it? Some of you may choose to remain in the status quo. Some of you have chosen to retire early or otherwise leave the field of medicine entirely. Yet some of you have said enough is enough and found specific solutions that mark a pathway forward. You sought – and found – specific solutions that mark a pathway forward.

If you’ve rejected the status quo and joined your fellows in search of innovations from other practices that you have applied at home, congratulations. You’re a physician leader who’s doing great things for your patients, your colleagues and yourself. You are undoubtedly more satisfied in your work than before, and you are quite likely providing better care.

To those of you who aren’t sure of how to proceed, there is a way out. But you have to act.

First, take a look around at what some of the most highly functioning primary care organizations are doing. Whether your goal is to address access, flow, safety, staffing or other issues, know that these are issues that others have tackled successfully. The solutions to what ails your practice are out there.

To identify and adapt those solutions requires you to actively engage in the Learning Coalition, defined in The Doctor Crisis as “an organic gathering of people, organizations and activities that exist within the fabric of health care today … a dynamic coming together of physicians and other caregivers along with health plans, policymakers and patients with the core mission of turning the best work anywhere into the standard everywhere.”

Seek Out Examples

What does it mean to be an active participant in the Learning Coalition? It means getting outside your own walls and finding solutions in other places that you can apply at home. It means seeking out others who have done excellent work in primary care improvement. It means taking the time to understand what is out there and what might work best in your setting.

There are numerous examples of the power of the Learning Coalition throughout the country. Drs. Chris Sinsky and Tom Bodenheimer and their colleagues authored the Joy in Practice report, which identified 23 high-functioning primary care practices.** Sinsky et al are blunt in their assessment that “the current practice model in primary care is unsustainable.”

They recommend simple solutions that work. One example is proactively planned care with pre-visit planning and pre-visit laboratory tests. One primary care site Sinsky visited was not doing pre-visit planning. She told the team about the work being done at some other clinics and the team subsequently implemented pre-visit labs. “It decreased the number of phone calls for lab results 89 percent, decreased the number of letters sent out with lab results by 85 percent and decreased visits by 61 percent.’’

Dr. Bodenheimer, professor of medicine at the University of California-San Francisco, has conducted a good deal of work in this area and, as we noted in a recent blog post, he suggests that there are essentially two types of adult primary care practices: “bright spots” and “dark shadows.”

He defines the bright spots as having many of his 10 Building Blocks of Primary Care***:

  • Engaged leadership, Creating a Practice-wide Vision With Concrete Goals and Objectives
  • Data Driven Improvement Using Computer-based Technology
  • Empanelment
  • Team-based Care
  • The Patient-Team Partnership
  • Population Management
  • Continuity of Care
  • Prompt Access to Care
  • Comprehensiveness and Care Coordination
  • Template of the Future

How many of these building blocks are present in your practice? If your answer is “too few,” what can you/will you do about it? How do you shift from being in the shadows to becoming a bright spot?

The Learning Coalition is the answer. If you have the courage to stand up and lead, you will quickly find that identifying great practices from which to learn isn’t that difficult. Don Berwick, MD, former head of the Centers for Medicare and Medicaid Services (CMS) for the United States, puts it this way: “It’s not hard to describe the health care system we want; it’s not even hard to find it. … Among the gems and the jewels throughout our country… lie answers; not theoretical ones, real ones where we can go and visit these organizations and see how good they are.”

So, when we add these elements together, the pathway forward emerges:

  1. Step forward as a leader
  2. Identify problem areas within your practice
  3. Find practices that have done a nice job of solving those problems
  4. Learn from others
  5. Apply what seems like the best fit to your practice

Take comfort in the fact that whatever your most challenging issues are, there are practices out there doing it better than you are. Go out and learn from them. And if it doesn’t work entirely as expected the first time, go back, make adjustments and try again!

If your goal is to improve your practice, then what’s the meta-goal? We think Arnie Milstein, MD, at Stanford University describes it well. “We need to shrink that gap between top performers and all the rest by a lot,” he says. “Think about a race in the Olympics: the last sprinter in the 100-yard dash doesn’t finish two or three seconds after the leader, he or she finishes two- to three-tenths of a second after the leader. All Olympic sprinters are excellent. That’s what we need in medicine — everyone crossing the finish line on the heels of the winner.’’

Gary Kaplan, MD, spoke to a gathering of his Virginia Mason team soon after he became CEO 14 years ago. He looked at where Virginia Mason was at the time, and he looked into the future. Then he bluntly told his team: “We change or we die.”

What will you choose?

* Kaiser Permanente internal study, “US Physicians and the Language of Health Care Reform: Preliminary Findings from Qualitative Research and the SHP Physician Study,” November 2012.

** “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annals of Family Medicine, May/June 2013.

*** Bodenheimer, et al, “The 10 Building Blocks of High Performing Primary Care,” Annals of Family Medicine, March/April 2014. 

Jack Cochran, MD, FACS, (@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.
Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States.