February 14, 2025
Dear Interested Readers,
Primary Care Has Changed Since 1975
For several weeks, I have felt a need to write about primary care. When I try to write to express my concerns about primary care, I am derailed by yet another outrageous event or announcement coming from “the MAGA world.” The catecholamine surges associated with my spontaneous eruptions in response to the daily output of absurdities coming from the White House have created a barrier for writing about anything other than the ongoing Trump circus. In short, I have found it almost impossible to write about anything other than the absurdities and cruelties that I am expecting will afflict us for the next four years.
I cringe when I hear the voice of our president or the apologetics coming from his minions of sycophants in Congress. Hearing his recurrent use of words and phrases like “it will be beautiful,” “everybody is going to love it,” “like nobody has ever seen before,” “so good,” “everybody knows,” “the best ever,” and the other overused platitudes of our president have become unpleasant triggers for me that I am sure are a threat to my longevity. I am not a linguist or psychologist, but the recurrent use of these phrases and his annoying patterns of speech, indeed the sound of his voice, are becoming intolerable. Surely, these utterings must be flags that indicate a lie or some form of misinformation is about to follow, and that the speaker is incapable of communicating in a way that would convince a thoughtful and knowledgeable listener. These annoying speech patterns shout to me that yet another “con” is in process from this world-class cheat and grifter.
My overarching goal for the future is to be alive when he either leaves office at the end of his term or is finally removed from office following some yet-to-be-committed crime for which neither Mike Johnson nor Lindsey Graham can manufacture a plausible denial. My only reservation about his removal from office would be that our mean-spirited and obviously smarter vice president would then ascend to where he could be an even greater threat to the future that I hope my grandchildren will enjoy in a world that is post-DEI and where our government effectively addresses the social determinates of health as a high priority.
I do hope that someday DEI will be a discussion from the past. I look forward to a post-DEI world that will someday emerge not because it was banned by executive order, but because as a nation, we have finally matured into our ideal as a country that is living out the truth of our central foundational principle that “all are created equal.” In such a brave new world we would not need DEI initiatives because the benefits of equality and opportunity for everyone would be as obvious as the long-term benefit of no longer using fossil fuels because they cause global warming. In such a magnificent future we would look back at our inattention to the social determinants of health in these days with the same dismay that the slaveholders of our past deserve.
As I pondered the reality that without some help it would be a long time before I could write without a MAGA-initiated intrusion, it occurred to me that I could turn once again to the resources available for free, at least for now, from ChatGPT. All that I needed to do was to create a question, report the answer, and then add my comments! It also occurred to me that I needed to give you some background information about my experience as a provider of primary care. I am not a creative storyteller. I usually start at the beginning and go forth in time. In my mind, my personal story and my concerns about primary care are connected. I have experienced the evolution of primary care looking back to the beginning of my accessible memory in the late nineteen-forties when doctors had black bags and made house calls and there were “norms” like “professional courtesy” and “pro bono” care.
My memory goes back to the time when a visit from the doctor or to the doctor was usually for treatment of an acute problem like diarrhea, an infectious disease, a broken bone, or an obstetrical event. Now when children are seen by a doctor it is for their immunizations and assessments of their developmental milestones. Adults are seen primarily for preventative care and the management of chronic disorders.
When I went to work as the only cardiologist at the then-fledgling Harvard Community Health Plan on July 1, 1975, the organization’s policy was that all of its medical specialists would also practice primary care. I was delighted with the policy because I had done a cardiology fellowship so that I would be a more effective adult PCP. I reasoned that much of primary care for adults involved managing cardiovascular risks and realities. As I have written before, my PCP in my late teens and early twenties was also one of the few cardiologists in our community. In medical school my PCP was the retired famous cardiologist from the Beth Israel Hospital, Dr. Hermann Blumgart. In my mind, as late as the mid-seventies, a cardiologist was just a “supercharged” PCP or perhaps more historically correct a GP or general practitioner. Indeed, going back on the maternal side of my family tree there had been GPs scattered through my lineage going back to the early 1800s. What it meant to be a doctor had not changed much in the previous 150 years before 1975.
My initial practice at HCHP was populated by the patients of my predecessor and mentor, Dr. Marshall Wolf, who had moved on to be the House Staff Director at the Brigham. As my practice grew, and I was meeting new patients, I was curious to know why anyone would choose to be my patient when at the time there were many open practices. I learned a lot from the answers to my question, “Why did you choose me as your doctor.” One man chose me because I was so young, I was 30 on July 8, 1975, that he was sure that I would not die or retire as his former doctors had done. He reasoned that there was a chance that I would be available as long as he needed me. I was. Another new patient chose me because I had been recently trained and would certainly know the latest things. One man said that he asked for me because he was, like me, from South Carolina. He felt that since we had both moved to Boston from South Carolina there would be an affinity because we had cultural and geographical ties. He was not comfortable with “northern culture.” More than one person told me that they chose me because I was also a cardiologist and they feared an early cardiac death like their father had experienced. I guess that these days one picks a PCP by availability. Is the doctor’s practice open? Is there an open appointment sometime in the next year? By the time I slid into management duties in 2008, I was the only medical specialist in our practice who still served even a small number of patients as their PCP.
I should also add that from 1969 forward until probably the early nineties each PCP at Harvard Community Health Plan was coupled with either a nurse practitioner or a Physician Assistant. In 33 years of more than full-time practice, I was lucky to have only two practice partners. In that regard, we were well ahead of the “curve.” Indeed, Dr. Ebert founded HCHP essentially as a “pilot” to study how to take advantage of the potential of preventative and ambulatory care. Remember he believed:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
Robert Ebert M.D., 1965
He saw hospital-based practice as inefficient and rarely patient-centric. I believe that he felt that technology had driven care into the hospital and that the result was a decline in patient-centric care and the wide fund of knowledge of most physicians as they became more and more specialized. Sometime in the nineties, organizational finance and professional shortages broke those exclusive professional “marriages,” and I found myself having to share my practice partner and work at times with other NPs or PAs who did not really “know” my practice. Things change.
Against this background, I asked ChatGPT, “Over the last fifty years, how has the character of primary care changed?
ChatGPT said:
Over the last fifty years, the character of primary care has undergone significant transformations driven by changes in healthcare policy, medical advancements, technology, and evolving patient expectations. Below are some of the key ways primary care has changed:
- Shift from Solo Practice to Large Group & System-Based Care
- Then (1970s–1980s): Most primary care physicians (PCPs) operated in solo or small group practices, offering personalized care with long-term patient relationships.
- Now (2020s): The majority of PCPs work within large healthcare systems, hospital-owned networks, or corporate medical groups due to financial pressures, regulatory demands, and administrative burdens.
- Increased Specialization & Role of Non-Physician Providers
- Then: Primary care physicians managed nearly all aspects of a patient’s healthcare, including routine procedures and hospital care.
- Now: Many responsibilities have shifted to nurse practitioners (NPs) and physician assistants (PAs), leading to a team-based care model. Primary care physicians often focus on care coordination rather than direct comprehensive treatment.
- Decline in Continuity of Care
- Then: Patients often had the same primary care doctor for decades, fostering strong relationships and continuity.
- Now: High turnover, system fragmentation, and changes in insurance networks mean that patients frequently switch doctors, reducing continuity of care.
- Growth of Electronic Health Records (EHRs) & Digital Medicine
- Then: Patient records were kept on paper, and physicians relied on handwritten notes.
- Now: EHRs have become mandatory, improving record accessibility but increasing administrative workload. Telehealth and digital medicine have also expanded, particularly after the COVID-19 pandemic.
- Shift from Acute to Chronic Disease Management
- Then: Primary care focused more on treating acute illnesses (infections, injuries, etc.).
- Now: With aging populations and lifestyle diseases (diabetes, hypertension, obesity), primary care is centered on chronic disease management and preventive care.
- Emphasis on Preventive & Value-Based Care
- Then: Fee-for-service models rewarded physicians for the number of visits and procedures performed.
- Now: Value-based care models prioritize preventive health, patient outcomes, and cost efficiency, shifting incentives toward wellness and disease prevention.
- Changing Patient Expectations & Consumerism
- Then: Patients relied heavily on their doctors’ recommendations without much questioning.
- Now: Patients are more engaged, using online research, second opinions, and digital health tools to participate in their own care decisions.
- Increased Administrative & Regulatory Burdens
- Then: Physicians had minimal paperwork and focused on direct patient care.
- Now: Insurance pre-authorizations, compliance regulations, and documentation requirements consume significant time, contributing to physician burnout.
- Expansion of Telehealth & Retail Clinics
- Then: All medical visits were in-person.
- Now: Telehealth has become an integral part of primary care, offering convenience but also disrupting traditional in-person relationships. Additionally, retail clinics (CVS MinuteClinic, Walgreens, etc.) have become alternatives for minor health issues.
- Rising Burnout & Physician Shortages
- Then: Primary care was a more attractive career with reasonable hours and work-life balance.
- Now: Long hours, administrative burdens, and lower pay relative to specialists have made primary care less desirable, contributing to workforce shortages.
Conclusion
While primary care has improved in areas such as technology and preventive care, it has also faced challenges like decreased continuity, increased administrative burdens, and workforce shortages. Moving forward, addressing these issues will be crucial to maintaining an effective primary care system.
The chatbot’s analysis is not poetic, but it rings true. I can relate to each of the items listed although I am not sure that on my own I could have created such an inclusive list coupled with the “then” and “now” comparisons. Using the Infrastructure offered by ChatGPT, I will add my experience to each of these categories.
1. Shift from Solo Practice to Large Group & System-Based Care:
I was never a part of a solo practice. Some of my doctors as a child and while in college were in solo practice. When I joined HCHP, we were a self-governed medical group. In the aftermath of the federal “HMO Act,” the lay management of HCHP began a discussion that advocated that we become “employees.” I resisted this process because I feared the control of the medical practice by the insurance half of the organization. By 1977, negotiations did result in the changes that the insurance half of the organization wanted, but the negotiations created financial benefits for physicians and a “Physician Council” that had fourteen specific responsibilities that included selection of the CMO and input into the selection of the CEO as well as the ability to determine which hospitals we used. The Chairman of the Physician Council also attended the weekly management meeting of the corporation and along with another physician from the Council was a member of the HCHP board.
The physicians could remove the CMO, negotiate compensation, and review the performance of the CEO. I gained a seat on the Physician Council in the mid-eighties and soon became the chairman of the compensation committee which meant that I was negotiating directly with the CEO. By the early nineties, I was the chairman of the council. In that capacity, I was able to utilize those fourteen by-law powers of the Physician Council to promote the environment that my colleagues favored. Those “powers” enabled the removal of a CEO following a period of organizational strain precipitated by the CEO’s contention that many physicians were not “productive.”
In the early nineties, HCHP grew by a merger with an HMO that was a confederation of medical groups in the suburbs of Boston. By the mid-nineties, market forces favored a second merger that created Harvard Pilgrim Health Care. In that merger, many of the physicians affiliated with Pilgrim Health Care were in solo practice. In the new corporation, the power of the employed physicians in what became the “Health Centers Division” was diluted by the small groups and solo practitioners who were added by the merger.
Eventually, the employed physicians in the health centers of HCHP negotiated our “freedom” and exited Harvard Pilgrim as Harvard Vanguard Medical Associates and began to accept patients from most insurers. After Harvard Pilgrim went into receivership in 2000, we expanded Harvard Vanguard by opening up much of the corporate infrastructure of Harvard Vanguard to other practice groups through a new entity, Atrius Health. Many of those groups had suffered during Harvard Pilgrim’s fight for its life. In the post-COVID era with its financial difficulties for medical practice, Atrius was sold to Optum, the physician practice arm of UnitedHealth Group. I present this overview of the practice’s evolution over the past fifty years as one example demonstrating just how primary care morphed from solo practice into employees of large corporations.
I am happy that I escaped working in a large for-profit organization where doctors are employed and have little opportunity to improve the circumstances of practice in the conglomerate. I suspect that the ability we once enjoyed to determine the practice values at HCHP with a Physician Council or in Harvard Vanguard with a mission directed by the Triple Aim has been lost to the pursuit of “shareholder value.” The story of the evolution from solo practice to a system of care dominated by employed physicians is complex and very sad.
2. Increased Specialization & Role of Non-Physician Providers:
As I have hinted in the first part of this letter, I was attracted to the practice autonomy, and interactive involvement with patients and colleagues that existed at HCHP when I first began to practice. I enjoyed being able to manage nearly all aspects of a patient’s healthcare, including routine procedures and hospital care. I found joy in a close relationship with a practice partner, and the collaboration with other like-minded providers including nurses, nurse practitioners, physician assistants, optometrists, dieticians, social workers, and other patient care-oriented health professionals.
I am more than a decade and a half past direct patient care, and now I am on the other side of the sheet. As a patient, I search for the sort of relationships that I once tried to offer. Because of the structural barriers that have evolved through specialization, it is increasingly difficult to find the experience for myself that I once offered to my patients as their ever-present PCP in close partnership with other like-minded clinicians.
3. Decline in Continuity of Care:
Good care requires continuity. I believe that continuity can be promoted by good systems of practice augmented by systems of continuous improvement and excellent computer-based medical records. But, when we diminish the role of primary care we remove the mortar that holds together the components of the system of care that makes it efficient and patient-centered. Without knowledge of the patient over time and without the deep caring that is the product of long-term relationships, errors occur, resources are wasted, and satisfaction on both sides of the therapeutic relationship deteriorates.
4. Growth of Electronic Health Records (EHRs) & Digital Medicine
When I began to practice at HCHP in 1975, we were proud to be a rare practice that had an EMR. It was “read-only.” With each visit, I received a paper printout summary of known medical issues, previous surgeries, and other important events. It was easy to identify current and past meds, social history, and lab tests. Those summaries were amazingly efficient. At the end of the visit, I filled out an easy-to-use form that allowed me to write comments on each problem in 180 characters or less, or to dictate a long note. The new data was input into the automated record by clerical staff. This record was driven by the need for other clinicians to have data they could rely on if the patient’s PCP was not available. That EMR was not a tool for finance. It was a tool for practice continuity. RVUs had not been invented. Encounters were not “income opportunities” that needed justification. Our philosophy made improving the health of patients and not our financial health the primary focus of the EMR. We never denied care to maximize our financial yield. In the early days of organ transplantation, we paid for the housing and care of one of my patients in California. I had referred her to Stanford where Dr. Norman Shumway could do the heart-lung transplant she needed. An organization that would do that was surely putting patient care above finance.
We held the belief that our incomes would be secure if we eliminated waste and focused on preventive care and effective utilization of technology and hospital resources. We tried to avoid doing things that added no value to the care of the patient. We didn’t need to “up code” because what we earned was determined by our collective efforts to improve the efficiency of the practice and the satisfaction of our patients. I believe that an improved future for patients and providers will occur if we can return to primarily using the EMR as a tool to promote practice improvement, patient satisfaction, and clinician “job doability.”
As long as our use of the EMR is driven by finance, we will have ongoing dissatisfaction from patients and providers, and primary care providers will be hampered by administrative work that adds no value to the care experience. I applaud the ability to use technology to avoid direct patient encounters that add no value to what an e-visit call accomplishes. There is a great benefit to the patient’s ability to be confident that they can reach their care team when care is needed. My direct phone line was always on my business card, and as soon as email was available my email address was on my card long before we had “patient portals.” I never felt that patients abused this direct access. Technology is great as long as it is in service of patient satisfaction and provider efficiency.
5. Shift from Acute to Chronic Disease Management:
This is one of the most significant changes of the past fifty years. We no longer wait to go to the doctor when we are sick. We see our PCP with the hope that we will avoid illness. Many of the disorders that were allowed to “fester” until they became almost untreatable in a hospital can now be avoided or mitigated by thoughtful ambulatory care that is primarily dependent upon patient education. I have always believed that the PCP should be central to this process even when we have the advantage of programs of specialty-driven chronic disease management. This is even more important in rural and small-town environments where medical professionals, particularly specialists, are scarce.
6. Emphasis on Preventive & Value-Based Care:
There is some redundancy here with this and item #5. What is not redundant is the fact that for “value-based care” to be an effective financial platform, great knowledge of the patient and effective programs of preventative care and chronic disease management must be in place. Again, a PCP who can know the patient, identify risks, educate the patient to self-care, and be responsible for the critical connections to a necessary specialist while always seeking to prevent the development of disease when preventable is essential to the vision of care as pictured in the Triple Aim which is a distillation of the idea of improving care by organizing the personnel, facilities, and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
7. Changing Patient Expectations & Consumerism:
It is a challenge for many providers that many patients are no longer passive recipients of their advice and care. We do live in an age of information and misinformation. As my years in practice accumulated, it was obvious that I needed to be able to respond to the information and ideas that patients gleaned from the Internet and their own research. If effective management of chronic disease is our goal, it is necessary for providers to have the time and ability necessary to respectfully engage with what the patient has learned from external resources. In my practice it was often necessary to point out that the patient’s discovery was a fact, but a fact that only appeared to apply to them. There must be bidirectional trust and respect for effective conversations and I believe this is one of the most significant responsibilities of a good PCP. Unfortunately, a schedule driven by “volume” considerations is antithetical to such a relationship.
8. Increased Administrative & Regulatory Burdens:
I have heard it said and seen some data to corroborate the assertion that it would take a skilled physician with a panel size of 1800 to 2000 patients with a density of illness and an age distribution that matched the community over 24 hours a day to practice “by the book,” adequately interact with insurers, and meet regulatory requirements. Maybe it is an exaggeration, but I know that many providers feel that it is impossible for them to fulfill all expectations and have a life. It is perhaps hard to believe, but before the institution of RVUs and the documentation requirements that emerged in the nineties, I was able with a little planning and focus, to finish my work and have some time in the evening with my wife and children.
9. Expansion of Telehealth & Retail Clinics:
In 1975 we were exploring the benefits of 24-hour telephone availability for advice for our practices. The PCPs, NPs, and PAs were organized to share the burden of “after-hours” care. We ran “urgent care” clinics in our centers that were available until late in the evening. I believe that telehealth is an extension of these early efforts and again is most effective for patients when connected as closely as possible to the patient’s PCP and care team. The advantage of retail clinics is that they are available to those without a PCP at the center of a well-designed system of care. My concern is that these modalities have become ineffective “band aides” for the deficiencies in our system of care rather than thoughtful innovations to improve care. Getting non-emergency care out of the emergency room is positive, but retail clinics are not as effective as after-hours services designed to complement long-term relationships in primary care.
10. Rising Burnout & Physician Shortages:
In 1975 it was possible to have a very professionally satisfying professional life as a PCP. It’s not impossible now, but it is much harder to accomplish in systems that put finance ahead of patient satisfaction and improved outcomes. Burnout is a growing problem. The use of AI to improve practice support is a hopeful possibility. Infrastructure deterioration in roads, bridges, our electrical grid, and our educational systems is a huge problem driven by our nation’s political divisions. Burnout in healthcare arises from a similar set of societal failures. An even greater concern for me is that our failure to adequately support primary care has led to increasing levels of “moral injury” that are even more “soul-sucking” than burnout.
There is more that needs to be said. The chatbot didn’t discuss the use of hospitalists which represents a huge change. With the confirmation of Robert F. Kennedy, Jr. as Secretary of Health and Human Services yesterday I see little hope for the problems of primary care being addressed by the Trump administration. Indeed, they will likely get worse, so I will soon return to the challenges facing primary care. I asked ChatGPT some other questions and I have its answers. Stay tuned.
It’s Still Winter
Today’s header shows the ice skating rink at the center of my little town between The New London Inn built in 1792 at one end of the town green and the bandstand and town hall that are in the middle of the green. I took the picture around noon time Tuesday when all of the usual skaters were in school. The sky was perfectly clear and the temperature was in the midteens. I wish that I could skate. Skating and skiing have always been orthopedic challenges for me since I grew up in the South and Southwest where the best place to find ice was in a glass of tea. In 1981, I left my right ACL on an icy slope while trying to ski with my sons at Stowe. As I approach my 80th birthday, I must remind myself each morning that the challenge of the day is to keep my long axis perpendicular to the ground.
I will carefully approach the ice on our lake this next week since my grandsons from California are arriving Sunday night. They are looking forward to ice fishing. It will be a new experience for them and a challenge for me. I have gathered the gear we will need, but I am not an experienced ice fisherman. My fishing skills involve liquid surfaces. I hope that by next week, I will have a new fisherman’s tale to tell.
If this year is typical of previous years, it is still two months until the ice on the lake will melt. It will be at least three months before I will be brave enough to bring out my wet suit for a swim. In years past, I have gained the courage to endure the wait for spring when I hear that the Red Sox have headed to spring training which will happen this coming week.
It is Valentine’s Day. I hope that you have something special planned with someone special today. I do.
Be well,
Gene
