The pandemic highlighted health inequities across the board and the need for access to evidence-based primary care. Primary care delivers care to every patient population, bridging the gap in access to the underserved, vulnerable, and marginalized patient populations, and treating stigmatized health conditions. Treatment of substance abuse, mental health, end-of-life, women’s health, obesity, and LGBTQ issues are only a few examples integrated into primary care. We aim to elucidate the value and importance of interprofessional care in the future of primary care, physician well-being, patient outcomes, and population health.

The Role of Primary Care

The National Academies of Sciences, Engineering, and Medicine reports that the role of primary care is to improve the population’s health, reduce cost/waste, and improve the patient experience.1 It is at the core of the primary care physician’s training to provide support, access, and continuity of care. The patient describes his/her/their primary care physician, “as my doctor!” Yet despite everyone’s beliefs that primary care is the solution to all the above, primary care continues to be the least appreciated, funded, supported, and the most overwhelmed. Primary care physicians suffer a high burnout rate, and this shortage is one of the highest compared to other specialties.

Are Current Solutions Enough?

Recently, President Biden’s the Build Back Better plan proposed an increase in residency positions targeted at primary care, mental health, and other critical specialties. The new legislation would require 25% to be allocated to primary care. This legislation, although promising, is not sufficient to solve the primary care crisis. The new physician force will need dedicated primary care track programs with robust training in community and population health. A great example is Montefiore’s Primary Care and Social Internal Medicine, a program that has a comprehensive curriculum on caring for marginalized and underserved patients, learning about advocacy, and different avenues to improve patient, community, and population health.2 Caring for a complex patient population requires years of experience and advanced training.

With more than 50% burnout rate among the current physician force,3 aging population, increased medical, mental, and social complexity of patients worsened by the pandemic, and the ongoing reluctance of trainees to pursue primary care, the crisis will worsen even with the best intentions. Initiatives like the Patient Center Medical Home did not reduce burnout, mainly because the expectation and accountability solely focused on the individual physician’s performance and did not extend to the team members. Many states have authorized and expanded the independent practice of nurse practitioners and physician assistants to fill the primary care access gap, yet this also requires standardization of training and advanced skills to meet the increased complexity of patient care.4

The Challenges and Solutions Are Complex

It will not only require adding more residency slots and increasing funding. A culture shift must also occur in the mentality of policymakers, payers, healthcare systems, administrators, physicians, their patients, and the interprofessional team. The primary care specialty needs a transition from the individual to a team-based approach, and the physician from direct care to the leader of care. This will require a fundamental change of the current force of primary care physicians and interprofessional team members via continuous medical education requirements and restructuring of graduate interprofessional medical education. We also need to address payment structure, quality measures, and patient experience, the latter relying on physician face-to-face encounters. In the surveys and metrics, the individual primary care physician is still held accountable for the poor access to care, delay in care, and health outcomes. The increased burden of in-basket, patient portal messages, and automatic release of patient results, has added to the inundation of forms, documentation, and quality measures, all of which affects physician mental health and wellbeing. When practicing in any current form of team-based care, the primary care physician must support the team while still holding the primary responsibility for everything else and expected to go above and beyond in patient care, service, teaching, community work, and/or research. Practicing in rural areas or safety nets where hospitals are less resourced and caring for socially complex patient populations carries further challenges for the primary care physician.5

Telehealth promises to expand access to primary care, but are the teams prepared to support the physicians to care for patients outside the in-person office visit? Many healthcare organizations and medical societies provide training and best practices for the physicians to practice telehealth. Who is training the nurses and medical assistants to provide virtual team-based care? How are we deciding their roles and their value to the patient care in the virtual realm? Who is providing funding to ensure they are part of the virtual primary care experience?

How Do We Transition to Team-based Care?

To transition to team-based care, we need high quality primary care implementation. The primary care physicians need training, time, and empowerment to lead the team beyond the 10% administrative time. Each team member needs to be equally accountable to patient experience and quality metrics. The team’s structure and training should include culturally sensitive care and a design responsive to the patient population’s needs.

Transition to team-based care requires funding, sharing best practices, and, most of all, policy support. Primary care practices need to move from the face-to-face encounter that relies on the physician to a value-based system and a population model that incorporates patient experience and quality metrics. Advocacy for funding and accountability for allocation of funding requires a different approach and perspective. It is not about funding primary care—but funding the right care. Healthcare organizations are better paid for emergency room and inpatient care than prevention and chronic disease management. There is no incentive to improve staffing.

Reflecting on the COVID-19 pandemic, we learned that defeating the pandemic required alignment between policy, science, the media, and health care. It also needs primary care to manage chronic and behavioral issues, promote preventative care, reduce vaccine hesitancy, to name a few, to end this pandemic. Healthcare organizations worked quickly to share knowledge and exchange ideas to save lives. Primary care saves lives and requires a similar framework to evolve in this unprecedented time.

Conclusion

We envision the primary care physician leading an interdisciplinary team, including pharmacists, registered nurses, medical assistants, community health workers, social workers, and care coordinators, to name a few, using models that support optimizing clinical outcomes via equitable, high-value care. The right funding structure and policy support remain the biggest hurdle to the transformation of primary care. SGIM and others have put this at the forefront. We must take it a step further by including policies that require institutions and/or community-based practices to demonstrate their budgetary plan to sustain the change after the grant funding runs out. The policies should include appropriate funding percentage details to be allocated directly towards salaries and clinical resources. Lastly, hospitals and health systems ranking criteria need to include primary care’s measures of excellence in care with an equity lens.

References

  1. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press; 2021.
  2. Montefiore Primary Care and Social Internal Medicine. https://einsteinmed.edu/departments/medicine/education/residency/primary-care-social-internal-medicine/. Accessed January 15, 2022.
  3. Agarwal SD, Pabo E, Rozenblum R, et al. Professional dissonance and burnout in primary care: a qualitative study. JAMA Intern Med. 2020 Mar 1;180(3):395-401. doi: 10.1001/jamainternmed.2019.6326.
  4. Brommelsiek M, Peterson JA. Preparing nurse practitioner students to practice in rural primary care. J Nurs Educ. 2020 Oct 1;59(10):581-584. doi: 10.3928/01484834-2020 0921-08.
  5. Loeb D, Bayliss EA, Candrian C, et al. Primary care providers’ experiences caring for complex patients in primary care: a qualitative study. BMC Fam Pract. 2016 Mar 22;17:34. doi: 10.1186/s12875-016-0433-z.

Issue

Topic

Health Equity, Health Policy & Advocacy, Leadership, Administration, & Career Planning, Medical Education, SGIM, Wellness

Author Descriptions

Dr. Alkhairw (Hadeel.Alkhairw@mountsinai.org) is a clinical instructor in the department of medicine at Icahn School of Medicine at Mount Sinai and the clinical lead of the primary care public health corps at Elmhurst Hospital/NYC Health + Hospitals. Dr. Torres-Deas (lmt2183@cumc.columbia.edu) is an assistant clinical professor in the department of medicine, director of the Ambulatory Care Network Internal Medicine Primary Care Clinics, and director of the Internal Medicine Community and Population Health at the Allen Hospital at Columbia University Vagelos College of Physicians and Surgeons.

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