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Partners In Family Medicine

A multiplicity of challenges face primary care in the United States today.1'2'3 Dissatisfaction among practitioners has been matched by a waning of medical student interest after its peak in the late 1990s. Surveys of physicians have revealed grievances; e.g., competing specialties, the growing cost of technology, less time with patients, increased workloads, life style burdens and declining incomes.4

Few research efforts have simultaneously examined the range of primary care specialties and none have utilized a generational perspective. This study sought to explore how three generations of Primary Care Physicians in Rhode Island and Southeastern Massachusetts perceive their practice- climate, the future of primary care, and the practical and systemic solutions they would advocate for their field.

METHODS

The Brown University Center for Primary Care and Prevention organized a weekend research retreat. Twenty-four physicians who practice full-time in Rhode Island or southeastern Massachusetts, representing Internal Medicine, Family Practice, and Pediatrics, participated in this two-day retreat in the fall of 2002. They were selected because of their reputations as regional exemplars in their fields and as representatives of their generation. Three representatives for each of three practice generations were invited. They were: "new practitioners," who had completed residency between one to seven years previously; "middle age practitioners," who had been out of residency for ten to twenty years, and veteran practitioners or "founders," who had been in practice for more than twenty-five years.

A multi-disciplinary team of investigators designed a series of qualitative and ethnographic activities to encourage constructive, dynamic group interaction.

Our research methods were informed by qualitative ethnography5,6 and methods used in assessing public engagement in science.7-13 On day one, physicians, along with many of their spouses or partners, attended a facilitated evening discussion that set the charge to the groups for the following day's focus groups. On day two, the physicians, in their respected specialty, participated in focus groups lasting three hours, exploring the benefits and barriers they face in primary care. While physicians mingled over lunch, moderators and observers did a preliminary analysis of the major issues that came up in the morning groups. This quick review directed discussion in the afternoon 2-hour consensus groups in which the participants considered various scenarios for the future of Primary Care. At the conclusion of the afternoon, each group chose a representative to report back to the larger group.

Each of the groups was moderated by a social scientist and observed by both a designated note-taker and a silent observer. The observers were teaching faculty and researchers from Memorial Hospital of Rhode Island and Brown Medical School who had been involved in the design of the research project. Audiotapes were made of all groups for analysis. Thematic analysis was performed, both individually and as a group using recognized methods.6,14-16

FINDINGS

Themes that emerged from the discussions and analysis included relationships with patients, income, business aspects, practice organization, scope of practice, sense of identity, perceptions of respect, generational differences, and empowerment.

RELATIONSHIPS WITH PATIENTS

Primary care physicians get much gratification from their relationships with patients. They believe that benefits to their patients' health largely accrue from a strong, trusting doctor-patient relationship. This sentiment was strongest among the older physicians. One doctor echoed the feelings of many: "I am amazed what I can do for my patients." However, all physicians (except pediatricians) felt that this type of doctor-patient relationship was harder to achieve and maintain than in the past. While physicians wholeheartedly supported the principles of continuity and comprehensiveness of care, they worried about its erosion. They were unsure how to balance these principles with their own needs for quality of life, balance, and professional limits. This concern was widespread.

INCOME

Participants believed that their incomes should be higher, especially when compared to specialists' incomes that range from three to ten times those of primary care physicians. Participants expressed resentment about the high incomes derived from specialties that they considered not particularly demanding or tiring. In spite of the concerns with income, many, but by no means all, of the physicians would still select their chosen field. This sentiment was especially strong among the pediatricians.

BUSINESS ASPECTS

Uniformly, participants felt tyrannized by health insurers and sensed a loss of control over their practices. They decried the deluge of paperwork-a few noted that they spent more time on paperwork than on direct patient care. They generally felt ill-prepared to deal with these outside economic and business forces encroaching into their relationships with patients, and urged that some school or agency develop a course on how to cope with such issues.

PRACTICE ORGANIZATION

There was no one preference among practice models - solo, small or medium, single specialty group, or large multi-specialty group. Flexibility was the watchword. While important to all ages and both genders, flexibility was especially important to younger women doctors with substantial family responsibilities.

The groups believed that information and communication technologies (ICT) have a far- from-realized potential to improve medical records, prescription filling, and practice evaluation protocols. They believe care can be improved, errors reduced, efficiency and productivity enhanced through the use of ICT. However, in the current financial stress of primary care, capitalization of hardware, software, training, and start-up is impossible for most practices.

SCOPE OF PRACTICE

The groups expressed resentment about scope of practice demanded by most health insurers. These requirements outline the procedures a primary care physician should/must perform to be designated a participating physician. Many participants saw this as a maneuver to reduce specialty referrals, save money, and make primary care physicians do procedures that they did not feel fully fit to carry out. Here again the group wanted flexibility. Family physicians are trained in a number of office procedures such as vasectomies. Yet once in practice, die family doctor rarely performs these procedures and typically refers patients to a specialist, such as a urologist. The family physician participants asked why this should be the case. "Why shouldn't we organize ourselves in a way that would give these referrals to one of our own, one who would do all the vasectomies for a group practice or a number of practices?

With medical education, the groups believed that the residency curriculum includes material that has no relevance to practice. Participants want a serious conversation with medical educators to explore what in the curriculum is irrelevant and what is missing.

SENSE OF VALUE AND IDENTITY

Sense of identity was closely tied to specialty area. The pediatricians were very clear about who they are and what they do. They exhibited camaraderie and mutual support. They love their work and would not hesitate to choose the same career again-in spite of relatively low incomes. Family physicians have a strong sense of purpose and identity. Some, however, report having to spend considerable time explaining to patients what family medicine is as a discipline. General internists showed the least sense of identity. This was due in part to the broad career possibilities within internal medicine, with multiple subspecialties, hospitalists, and generalists. While all received affirmation and respect from their patients, the groups felt strongly that they were not highly respected by academic faculty or specialists. Several commented that medical students report that specialty faculty members suggest that students are "too smart for primary care."

GENERATIONAL DIFFERENCES

The older generation sees medicine as a calling: "the first principle is to fix our patients and then fix our lives." Very long hours have been the rule for this generation, which has been dedicated to seeing patients in all settings, whether hospital, office, home, or nursing home. The younger doctors responded: "We care about our patients as much as you (the old timers) ever did but we want a life and a defined work week." Moreover, they view it acceptable to confine practice to the office, to be a hospitalist, or to work exclusively in nursing homes. Many doctors, male and female, in the younger generation feel they must control their time in order to accommodate a spouses career and also take care of their children-a scenario much different from their mostly male senior colleagues who often have wives at home full-time while they themselves work long hours.

FUTURE VISION

The participants believed that primary care had little political or economic influence, and that this lack of clout was in part responsible for poor reimbursement and excessive hassle. The groups encouraged dialogue and the development of common policy among the Academy of Family Physicians, the Academy of Pediatrics, and the American College of Physicians. A few supported the merger of the three organizations into one powerful voice for primary care. The notion of a unified certifying board for primary care was discussed but did not evince much support.

DISCUSSION

The physicians in our study all discussed the need for large-scale, systemic changes in terms of:

* insurance companies and reimbursement

* physician training

* structuring incentives

* the ability to join together within the field to lobby business and legislators for what they need to practice medicine.

Our findings support much of the research concerning the state of primary care. Family Practitioners, Internists, and Pediatricians in our study wholeheartedly supported the principles of continuity and comprehensiveness of care, and worried about erosion, but were unsure how to balance these principles against their own needs for quality of life, balance, and aprofessional limits. This was most keenly seen in the juxtaposition of older and younger physicians.

Physicians all cited the mounting pressures of declining reimbursements and the widening pay differentials between Primary Care practitioners and specialists. Physicians are working longer hours, and earning less. Many feel devalued in the medical system and demoralized that reimbursement pressures are restricting the time they can spend with patients as well as their very freedom to practice medicine and have lives of their own.

If doctors can no longer play the role of Marcus Welby, patients must become more adept at filling in any gaps of care. Worthy of exploration is how the patients' role can be enhanced through more active shared decision-making. Showstack calls for patient-centered care as the first of his seven principles for guiding the next renaissance of primary care.17 This care, "includes the patient as an active participant in the clinical decisionmaking process and incorporates an understanding of the patients preferences and needs. Such care is user-friendly to both patients and clinicians, with everything from the design of information systems to the hours of operation structured to create a partnership between patient and clinician." There are calls for reinvigorating the doctor-patient relationship by learning to collaborate with patients so that they are the masters of their own care."18

Primary care does not have a unified voice in policy debates with large health corporations and in politics at state and national levels. Consider how the balance of power in medicine might shift if we were to unite 70,000 family physicians, 70,000 general internists, and 20,000 general pediatricians into a national organization. Leaders in academia, in government, and in the insurance industry would receive some powerful new messages about the future of primary care and how it should be supported.

In summing up, there is a lively debate about the challenges facing Primary Care in the health care system. While research has identified major Stressors, few efforts have simultaneously examined the range of primary care specialties, and none have utilized a generational perspective. The insights from our participants reflect the challenges in primary care, the differing perceptions of younger and older physicians, and provide direction as to where the field might go. Overall, stresses have created fault lines indicative of the need for restructuring both medical education and practice demarcations.

ACKNOWLEDGEMENT

This project was supported by a grant from the Center for Primary Care and Prevention, Memorial Hospital of RI/Brown Medical School

REFERENCES

1. Keystone III, The Role of Family Practice in a Changing Health Care Environment: A Dialogue. Edited by: Larry A. Green, Robert Graham, John J. Frey, G. Gayle Stephens, Published by: The Robert Graham Center, American Academy of Family Physicians, Washington, DC, 2000.

2. Geyman JP. Family practice in a failing health care system: New opportunities to advocate for system reform. J Am BoardFam Pract 2002;15:407-15.

3. Kahn R. The future of family medicine: A collaborative project of the family medicine community. Annals of Fam Med 2004;2:S3-S32.

4. Schroeder SA. Alan Gregg Memorial Lecture: The Future of Primary Care. Associations of American Medical Colleges Annual Meeting, Washington, DC 2001.

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6. Morgan DL. Successful Focus Groups: Advancing the State of the Art. Newbury Park: Sage Publications, 1993.

7. Abelson J, Forest PG, Eyles J, et al. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Social Science & Med 2004. (in press)

8. Beckerlig A, Lewando GA, Borkan JM, et al. Eliciting local voices using natural group interviews. Anthrop & Med 1997;4: 273-88.

9. Borkan JM, Morad M, Schvats S. Universal health care? The views of Negev Bedouin Arabs on health services. Health Policy & Planning 2000; 15: 207-16.

10. Carr DS, Halvorsen KE. 2001. An evaluation of three democratic, community-based approaches to citizen participation: surveys, conversations with community groups, and community dinners. Society and Natural Resources 2001; 14:107-26.

11. Rowe G, Frewer LJ. Public participation methods: A framework for evaluation. Science, Technology, & Human Values 2000;25:3-29.

12. Stevens T, Wilde D, Hunt J, Ahmedzai SH. Overcoming the challenges to consumer involvement in cancer research. Health Expectations 2003;6: 81-8.

13. Pleasant AS, Kuruvilla C, Zarcadoolas J, et al. A Framework for Assessing Public Engagement with Health Research. WHO:Geneva Switzerland. 2003.

14. Patton MQ, Qualitative Evaluation and Research Methods (2nd ed.) Sage, Newberry Park, Ca. 1990. 1 5. Crabtree BF, Miller WL, eds. Doing qualitative research in primary care; multiple strategies (2nd edirion). Newbury Park, CA: Sage Publications; 1999.

16. Krippendorff K. Content Analysis: An Introduction to Its Methodology. 2nd ed. Thousand Oaks, CA: Sage, 2004.

17. Showstack J, Rothman AA, Hassmiller S. Primary care at a crossroads. Ann Intern Med 2003;138:242-3.

18. Sox HC. The future of primary care. Ann Intern Med 2003;138:230-2.

JEFFREY MICHAEL BORKAN, MD, PHD, CHRISTINA ZARCADOOLAS, PHD, ANDREW PLEASANT, MD, ROBERTA GOLDMAN, PHD, MELINDA THOMAS, MA, JOANNA BELL, H. DENMAN SCOTT, MD

Jeffrey Michael Borkan, MD, PhD, is Professor of Family Medicine, Brown Medical School, and chairman, Department of Family Medicine, Memorial Hospital of Rhode Island.

Christina Zarcadoolas, PhD, is Assistant Professor (Research), Brown Medical School.

Andrew Pleasant, MD, is a Visiting Lecturer, Brown Medical School.

Roberta Goldman, PhD, is Clinical Associate Professor of Family Medicine, Brown Medical School.

Melinda Thomas, MA, is Associate Program director - Office of Primary Care, Memorial Hospital of Rhode Island.

Joanna Bell, is a research associate, Memorial Hospital of Rhode Island.

H. Denman Scott, MD, is Professor of Medicine, Brown Medical School, and former chair of the Center for Primary Care and Prevention.

CORRESPONDENCE:

Jeffrey Borkan, MD, PhD

Address already cited.

Copyright Rhode Island Medical Society Nov 2004
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