DOCTOR IS OUT

Most American adults don’t really need a primary-care doctor

Americans know that we’re supposed to have a primary-care doctor. It’s a task as associated with adult responsibility as paying the car insurance and flossing regularly. And yet, when confronted with a form asking us for the name of our primary-care physician at the dentist or the optometrist, many of us leave the space blank.

That may be for the best. Once, maintaining a relationship with a primary-care doctor made sense. But given the nature of our current health-care system as well as changes in the American lifestyle, today, it’s unrealistic for many adults to have one.

First of all, the commonly held belief that we all need a yearly physical is false. An annual physical is not currently recommended for the healthy adults by the governing health bodies in the US, Canada, or the UK.

That’s good news, because the US has a significant supply and demand problem when it comes to general practitioners. America’s physician workforce is composed of roughly 33% primary-care doctors and 67% specialists. Other high-performing health care systems, like Canada or Australia, have more balanced ratios.

In countries where the vast majority of doctors are generalists, it makes sense to expect everyone to have a PCP. They are plentiful, accessible, and effective. But there are good reasons why so many young doctors choose to specialize here in America. Specialists are more respected by the public and in the medical community. And the lifestyle of a specialist is far better, involving less punishing hours while making millions of dollars more over their careers. And so, with a dearth of general physicians, we wind up with situations like Boston’s 45-day wait to see a PCP.

 Gone are the days of independent doctors who felt personally responsible for their patients’ well-being at all hours of the day.  Not only is the supply of primary-care doctors diminishing, the nature of their job is changing. Local hospitals are increasingly acquiring private primary-care practices in order to generate lucrative specialist visits, via PCP referrals, within their walls. When PCPs are no longer their own boss, the loyalty and passion they once dedicated to their business tends to fade. Gone are the days of independent doctors who felt personally responsible for their patients’ well-being at all hours of the day. Now PCPs are largely shift workers, part of a large team of physicians overseeing patients and generating referrals. There are some benefits to this system for the doctors themselves. But ultimately, the transition means that patients no longer have a primary-care doctor. They have a primary-care doctor group, and may wind up seeing a new doctor every time they visit.

There are other obstacles involved in building doctor-patient relationships today. A visit with a primary-care doctor typically lasts 10-15 minutes because, in order to financially stay afloat as a PCP, you’ve got to churn through patients. There’s not a whole lot doctors can achieve in that amount of time, unless the patient’s health problem is quite simple. When the issues are more complicated, doctors typically handle some items on your list and then make you come back for another visit, and another co-pay, to tackle the rest. Meanwhile, the average time that patients have to take out of their day for a doctor visit is conservatively estimated to be 121 minutes.

All relationships, both personal and professional, are built over time. Does it qualify as a relationship if you’ve seen a doctor three times over three years?

But there’s an even larger issue: Our society is becoming more and more mobile. People are constantly moving to new neighborhoods and new cities; they change jobs every two to three years. They frequently change health insurance companies, and therefore doctor networks, as they or their employer search for a solution to rising insurance premiums. Not only does a primary-care doctor need to take Aetna, they need to be in your specific plan’s network within Aetna. And doctors drop and pick up new networks on a monthly basis as they prune low-paying insurance companies from those they accept.

Compounding all these socioeconomic and logistical issues is the fact that it is primarily children and the elderly who need consistent relationships with generalists. Children get sick and hurt all the time. They also have a very set schedule for pediatrician visits to keep vaccinations and check-ins on other developmental milestones up to date. A pediatrician who knows both the child and the parents can more efficiently diagnose and manage frequent issues.

But people in their 20s and 30s face fewer health problems than kids and the elderly, except for the occasional injury or acute illness. People in their 40s and 50s are also frequently lucky enough to stay generally healthy. It is only as we get into our 60s and beyond that we need an old-fashioned, close relationship with an internist again.

Kids need a consistent pediatrician. The elderly need a consistent internist. The chronically ill, no matter their age, need a consistent team and place to receive care. But for the rest of us—around 75% of the population—the old-fashioned “doctor-patient relationship” is unrealistic and largely unnecessary in our society. Rather than spend time and energy trying to pin down a primary-care doctor, it could well make more sense to simply stick with an urgent-care clinic when you come down with the flu.

Americans need a better solution. We need a system that’s as mobile as we are and that stays constant even as we change cities, jobs, local hospital networks, and insurance companies.

This means that we are most in need of access to our own health data and histories. No matter where you get medical care in America, your records should be a part of your personal profile that you own and control access to. Companies like Apple are already, albeit slowly, trying to implement this concept.

When primary-care doctors are no longer our first point of contact, we also need help understanding exactly how to navigate a system composed of a hodgepodge of health-care services and specialists. Given the cost of medical care, a mistake in how to best spend your money can be financially catastrophic.

Insurance companies have already tried to offer patients medical guidance by providing nurse phone lines, and video visits with doctors have also recently attempted to increase access to health care. But both of these strategies are reserved for very simple issues. For more complex problems, we need an online, integrated service made up of doctors and nurses who can help Americans make sense of a system of specialists and coordinate treatments and care. Such a project would be an ambitious undertaking–but it could go a long way toward fixing the problems with our current health-care system.

It’s a wonderful thing to have a trusted relationship with a primary-care doctor. But as our society changes, we must adapt. It’s time to admit that our system isn’t set up to allow a PCP for everyone, and demand something better for American patients.

We welcome your comments at ideas@qz.com.

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