Primary Care Breaking Point
[00:00:00] Stacey Richter: Episode 519, The Current State of Primary Care, Inevitable or Fixable. Also, Advice. Today I speak with Dr. Lisa Rosenbaum.
[00:00:31] Stacey Richter: Hello, all you Relentless Tribe members. Today let's start here. Right now we are watching a very visible exodus of brilliant, consummate primary care and other, honestly, physicians leaving traditional practice for concierge medicine or otherwise.
And look, it could easily be argued that the rise of concierge or direct primary care and otherwise is a symptom of a profession that has been decimated by structural forces. I mean, no one would need to go outside of the status quo if the status quo served their needs and or the needs of patients.
So today we, meaning Dr. Lisa Rosenbaum and I are looking at the realities of primary care, and I wanna be incredibly careful not to lump all primary care docs or other primary care clinicians into one homogeneous group.
There are still those, especially in rural areas, who continue to practice wildly broad spectrum medicine. They're doing podiatry procedures, sewing up wounds, some oncology care, and their next appointment is a women's health annual exam.
But for many employed physicians, they are caught in a structural framework that they really did not ask for. Many doctors really find themselves kind of forced into these models by the health system corporations that employ them, and the reasons for this mostly boil down to financial ones.
Listen to, oh, there are so many episodes where this gets discussed. You could start with episode 504 with Ryan Jacobs, episode 473 with Dr. Kenny Cole. Episode 391 with Dr. Scott Conard. All of these shows hit this, it's all about the Benjamin's baby, from a myriad of angles.
And I wanted to have Dr. Lisa Rosenbaum on the podcast today because she was the host for a whole series of shows on her New England Journal of Medicine podcast, link in the show notes about primary care. She did a whole series on primary care that I wound up listening to after Dr. Amy Scanlan suggested I get Dr. Rosenbaum on the show to hash out some takeaways from that series. And that is the backstory for how this whole thing happened.
Three Forces Reshaping Care
[00:02:56] Stacey Richter: But these takeaways, I kind of wound up summing them up in a very high stakes. Frankly, kind of game show. I'm gonna call: Is it Inevitable or Is It Some Kind of Needless, Suboptimal Inefficiency That We Should All Get to Fixing?
I asked Dr. Rosenbaum to weigh in on three categories of like force majeures that are pushing against primary care in this country today.
So the first of these three, is it inevitable or just a needless inefficiency category that we hit is a tough one to talk about and might have some strong feelings for good reason, but it comes up from a whole bunch of different directions in that New England Journal of Medicine series, so we'd really be remiss to skip over it.
Cognitive Atrophy Explained
[00:03:46] Stacey Richter: So yeah, we're talking about the old so-called cognitive atrophy. When you force brilliant physicians to stop using their judgment and doing what it takes to form relationships and earn the trust that goes with those relationships and really get to know their patients and instead just double down on checking a whole lot of boxes.
And if every procedure gets referred to a specialist, clinical skills can go dormant. Volume matters.
As Dr. Lisa Rosenbaum today points out if we are not careful, we could be facing a generational loss of some really key primary care skills because you might have your older PCPs who just continue to do what they are really good at. But younger doctors may find it harder and harder.
And then Dr. Rosenbaum answers the, Is this inevitable? No spoilers. You need to listen.
Second category we tackle here is full spectrum clinical scope versus PCPs value, mostly being their ability to refer into profitable service lines for a health system corporation.
And listen to all those episodes I mentioned earlier for a much more robust and nuanced discussion of the financial whys here. But it is nearly inarguable that the system is structurally optimized to force early and frequent referrals in many, not all many cases.
And there's good reasons for this and not so good ones, right? I don't think anyone thinks it's a good idea for PCPs to do like valve replacements. Medicine has advanced since Perry Mason and no one wants a world where what good looks like is a PCP doing something that these days you really need a subspecialist for.
But is current state inevitable or a needless non Goldilocks inefficiency? Stay tuned for Dr. Rosenbaum's take after talking to as many folks as she spoke with in that original NEJM series.
Third category in our show today is transactional fragmentation, not longitudinal, relational whole person care. Is fragmentation inevitable or just needless inefficiency? I mean, often enough we have traded the relational expertise of having a doctor who knows a patient over time for fragmented algorithmic throughput. And what happens?
The average patient ends up bouncing between something like eight different specialists and using the ER for the most expensive primary care money can buy. When that happens, they become stuck in a downward fragmentation spiral simply because nobody is really quarterbacking or taking responsibility for those patient outcomes, the whole person patient outcomes [Ordinary Rural Death]. But yeah, again, listen to the conversation that follows for where we wind up in this third category.
Agency Over Inevitability
[00:06:59] Stacey Richter: Okay. I will give you one big spoiler, so earmuffs for all those opposed. But I've been thinking about it since I talked to Dr. Lisa Rosenbaum and also while I was prepping for my conversation with Dr. Suhas Gondi, which is coming up here in the next few weeks.
But I found it pretty interesting that Dr. Rosenbaum, in my conversation with her unprompted She says, and this is the short version, hers is far more eloquent, but Dr. Lisa Rosenbaum says, and I'm quoting her now, "If we just blame everything on a structural inevitability, we strip ourselves of our own agency." Hmmm. Interesting.
Meet Dr Lisa Rosenbaum
[00:07:38] Stacey Richter: My guest today, as I have said approximately, probably 19 times already, is Dr. Lisa Rosenbaum. Dr. Rosenbaum is a cardiologist at the Beth Israel Deaconess Medical Center [BIDMC].
She also works for the Smith Center there, which is tied to the BIDMC. She is the writer in residence. Also, Dr. Rosenbaum is a national correspondent for the New England Journal of Medicine where she hosts the podcast Not Otherwise Specified, which recently as aforementioned dedicated an entire season to the state of primary care.
I'm Stacey Richter. This podcast is sponsored by Aventria Health Group and also this year's series underwriter Payerset. Check em out. They have a new 2026 Price transparency field Guide available on their website.
I also very much want to thank Patient Rights Advocate for a really nice donation to help support our work over here at Relentless Health Value. Thank you so much. Patient Rights Advocate. Go to patientrightsadvocate.org. There are some really great resources available there for free.
So let's get to it. Here is my conversation with Dr. Lisa Rosenbaum.
Dr. Lisa Rosenbaum, welcome to Relentless Health Value.
[00:08:52] Dr. Lisa Rosenbaum: Thank you so much for having me.
Why She Made The Series
[00:08:54] Stacey Richter: Before we get into the conversation, why did you do that series? You know, like what was the impetus behind doing an entire season on primary care?
[00:09:02] Dr. Lisa Rosenbaum: I think it was one of those things where like, once I opened the lid, I just like couldn't stop looking.
I had an experience now, nearly two years ago, a friend of the family asked me for a primary care physician recommendation in Boston, and I very quickly knew that if he wanted to be seen within a year, would have to get a concierge doctor. Because I'd heard that there were no primary care openings in Boston for at least a year, which was consistent with my experience in trying to get my own patients' primary care doctors.
And that felt like an inflection point. That was not something I had experienced before, and it felt like a big deal. And it was happening alongside watching an exodus of physicians I really respected, not just in Boston but across the country, kind of in my networks leaving for concierge medicine and not physicians, like who I might have assumed would have been the phenotype in the first place.
These were people like consummate internists and you know, I'm always trying to bring to my writing and the podcast sort of the things that science can't quite cover because I, you know, I have to compliment what the New England Journal is doing.
So it felt like a cultural moment. And once I started researching concierge medicine, it quickly became obvious that you couldn't understand this inflection point without understanding what was happening in primary care in the first place. That concierge medicine was in fact a symptom of what was happening in primary care. And so that's how it all started.
[00:10:32] Stacey Richter: As I was listening to that series, I kept reflecting on a sort of a fundamental question, and not like this was a game show or anything, but I kept thinking to myself. Is this inefficiency or is this inevitable? Like does this have to be? Or is this something that we're just not thinking about it right. And therefore if we did switch up the paradigm or whatever, it wouldn't have to be the way that it is.
So I appreciate you participating today, Dr. Rosenbaum, because this is what I would like to do. I'd like to tee up three sort of very large concepts and then ask your opinion on: “Is it inevitable or is it sort of needless inefficiencies?” So.
[00:11:15] Dr. Lisa Rosenbaum: That's a great framework. I'm excited.
[00:11:17] Stacey Richter: Well, prepare yourself.
[00:11:18] Dr. Lisa Rosenbaum: Okay.
Category One Cognitive Atrophy
[00:11:19] Stacey Richter: Here's the, here's the first one. So you did spend several episodes talking about and talking around this topic, Cognitive Atrophy of Clinicians.
We talk about practicing at the top of the license, but if you're not practicing at the top of your license for long enough, then it becomes sort of hard to practice at the top of anybody's license. Because these skills go dormant.
So could you just explain that a little bit more, and then I'm gonna ask you the, does it have to be this way?
[00:11:51] Dr. Lisa Rosenbaum: Right. So I think that a lot of what we're seeing in primary care landscapes, not all of them, but a lot of them, especially in large corporate systems where people are under pressure to get through a visit in 15 minutes, and also to go through a checklist by which a lot of their value is measured is that people are responsible for a host of preventive measures or population health metrics like blood pressure management, diabetes management, cancer screening, things like that, or even like screening for social determinants of health.
So those are things like the more algorithmic it becomes, the less you really need somebody who's trained as a physician to do it.
And to go back to sort of this cultural moment I was witnessing and why I was so taken by this exodus, and also the types of people who are exiting is because a lot of them fit into this archetype that I have like long internalized. I'm a third generation physician and there's something about a brilliant internist that I think exudes this idea of like just utter competence and brilliance.
And it's very, I think if we really understood what makes for a good doctor, we would do a better job making everybody really good doctors.
There's a judgment, there are instincts, there's a breadth of knowledge, and there's also just this like human kind of intelligence, like maybe sometimes it's what we call emotional intelligence, but I think it's deeper than that, and a way of being able to sort of understand not just like multisystem disease and how that's playing out in any one person's body, but how it fits into the broader constraints of a person's life.
And also, and this is like a dimension I think that we really talk about. How caring for that person is part of being part of a larger healthcare system. I think a lot of people, when they express frustrations with our healthcare system, it's because care feels fragmented. You hear that all the time.
What an internist does, really good ones. They're quarterbacks. They know how to take what any specialist says and communicate that to a person, but not just like, this is what the cardiologist said, they want you to be on a statin. Also, like, yeah, the cardiologist wants you to be on a statin, but I know you well enough to know if you don't believe in statins, so we're gonna come up with something.
And like that is a skillset that I am so worried. Part of why I was wanting to write about this in the first place, and I think what you're getting at is like if once we lose that, it's very hard to get it back.
But I will tell you what I really worry about is a generational loss. So I think to develop these skills, like anything in medicine, medicine is an apprenticeship. And so to recognize the importance of practicing in a certain way and to sort of mimic that behavior in somebody you respect, you have to be exposed to it.
So more than anything, it's less that I'm worried about like the 70-year-old internist in practice in rural Alabama is gonna go through a bunch of checklists in a visit and forget how to be that internist who can do everything.
It's more I'm worrying, worried that the trainee who comes to the clinic and precepts with him or her isn't going to have an idea of what that could look like. And that's a different type of cognitive atrophy.
[00:15:15] Stacey Richter: What I'm taking away. This could be a generational issue more than any, as exactly like you said, like someone who practiced medicine in the before times suddenly forgetting how to do it.
But the fact is, because of maybe the structural constraints around them, if you, again, if you have a 15 minute visit, and I hear this a lot actually from clinicians, where somebody comes in with a horrible something or other like norovirus, they're like vomiting all over the place. And then these things pop up that says, ask him if they got a breast cancer screening.
Right? Like it's just sort of like inappropriate.
[00:15:54] Dr. Lisa Rosenbaum: It's wildly inappropriate. You're right.
[00:15:55] Stacey Richter: Wildly inappropriate types of things. But like if that's happening and then what good looks like is, did you actually ask the question? You can definitely see there's this term moral injury that we've all heard and has taken on.
[00:16:10] Dr. Lisa Rosenbaum: A life of its own. I will say it confidently. People use it indiscriminately, but in this case, I think that is a type of moral injury.
[00:16:17] Stacey Richter: Right, because you're like, I'm doing what's right for my patient, and then I walk out and, and get slapped on the back of the head.
[00:16:23] Dr. Lisa Rosenbaum: I think it's more relevant when you think about like family medicine and procedures.
So if you're someone who's trained to do some podiatry and work in the uterus, for instance, you know, because you, you're broad spectrum family medicine doctor, and then suddenly you’re beholden to these like mindless checklists and that's how you fill your days. Of course your skills are gonna atrophy.
And so I think that that's a more clear example. And then I think my hesitance in just saying like it's universally happening is through my reporting. I just saw such heterogeneity in how people practice. So I agree with you. I think there's a risk to the people practicing now of cognitive atrophy, of procedural skills, atrophy.
Like we would never, we would never allow a surgeon to like, spend their time going through a mindless checklist. Like that would just be absurd. Right? So why are we doing that to other doctors?
[00:17:17] Stacey Richter: Yeah. And just the practice of that happening, right? Like, if I am really good at doing whatever I'm doing, I am advanced, and then I sort of have to go through this checklist or I have to do things that I sort of know. Like I often say you can't process your way into judgment.
[00:17:34] Dr. Lisa Rosenbaum: Right. Right.
[00:17:34] Stacey Richter: But if the process starts to take on prominence and my judgment is completely like, why would I read the latest studies? I'm not using them anyway.
[00:17:43] Dr. Lisa Rosenbaum: For the last year and a half. I'm at a different institution and I'm not seeing ICU patients and I can feel my instincts for critical care eroding.
So like just not using that, those skills, that type of judgment, the familiarity with all the pressors and like the event settings and all those things, like I'm not probably as good at at it as maybe I had been when I was doing it all the time. That's like a very sort of rational and predictable thing that might happen to all of us and yeah, I feel it happening in myself in just a different area of medicine.
[00:18:18] Stacey Richter: Yeah. And I underlining the point that you made a couple of minutes ago about how, depending on where you practice and the patient demographic that you tend to see, primary care looks entirely different. If you're in a rural, you know, you're the do an oncology and you know, sewing up wounds. It's a very different practice than if you're in some suburb where everybody pretty much just comes in looking for a referral.
[00:18:47] Dr. Lisa Rosenbaum: Exactly. And that distinction is so important and it's so easy to just lump everyone together. But I'm like, I don't wanna act like all these people out there are not practicing like broad spectrum primary care still because a lot of people really are. I think there's like another kind of type of doctor too that I got exposed to in the reporting who just shuts out the noise. Like that's how I think of it.
They're just like, this is dumb and I don't really care about my metrics. Like I'm good at this. I know I'm good at this. I'm beloved by my patients, by the institution. I'll just do what I need to do.
And that's not possible, especially for a lot of young people at the beginning of their careers. But I think that's just another, you know, type of rebellion that is sustaining primary care in its own weird way.
[00:19:34] Stacey Richter: These sort of cognitive atrophy questions are going to be different depending on the human that we're talking about, but also the environment. Where are they? Because that also could make a very, very big difference.
Like if the closest specialist is 500 miles away, that's a very, very different ecosystem, maybe, or scenario than if there's three specialists down the hall.
[00:19:55] Dr. Lisa Rosenbaum: Exactly.
[00:19:56] Stacey Richter: And then also maybe wrapped around this whole conversation is the organization that they may work for again, and just how diligent is this organization in pursuing revenue goals, let me just say.
[00:20:13] Dr. Lisa Rosenbaum: Yeah.
[00:20:13] Stacey Richter: So maybe there's, those are the three sort of factors here.
[00:20:15] Dr. Lisa Rosenbaum: Yes. I think that the reality is, which is why you asked this question in the first place, is that I think, you know, 70% of physicians are employed these days. I think more the minority who is practicing in rural America and doing everything for people.
And a lot of people are beholden to these healthcare organizations where there's tremendous pressure on them to practice primary care in a very specific way, and there are consequences if they don't.
Is Atrophy Inevitable
[00:20:46] Stacey Richter: So let's just focus then on the 70% who are employed. There are employed physicians. Boss is the health system. Maybe a little less often private equity, but let's just put them all together here. Is it inevitable? Cognitive atrophy? Or is it a needless inefficiency?
[00:21:04] Dr. Lisa Rosenbaum: I'm gonna speak in terms of risk. 'cause that's what doctors do. Like there is a clear risk if you have physicians spending their days engaged in mindless activities, that they will lose the skillset that they possess when they were at the peak of their, training and competencies and aptitude.
Do I think that risk is inevitable? No, because that risk is conferred by systemic constraints. It is not inherent to the individuals who are practicing primary care. I mean, obviously we're all human. There are gonna be issues, you know, in any profession.
But what I'm trying to say is that there's nothing inevitable about a 15 minute visit. There's nothing inevitable about the way we've decided to measure quality in primary care. There's nothing inevitable about the way we pay primary care doctors.
I could go down on and on and on in the list, but like none of these things are inevitable. They were created by us as a health system, and then they have been tolerated by the profession culturally and by society.
I say society because I don't think that we can look at the evolution of the healthcare system and our insurance system and, and just like pin that on the profession. Like it is on some level a reflection of societal preferences over time.
But I also think you can look at a moment like after what happened with the murder of the United Healthcare CEO, and realize that a tremendous amount of people hate our healthcare system.
I always have a little bit of reservation being like, society wants this. Because it seems like they don't really want much of what we're giving them. But for whatever reason that I can't fully understand, we haven't summoned the will either within the profession or the public to dramatically change the way we're doing it.
And some of that might be just because it's too complicated and it feels inevitable. So I want to emphasize that it is not inevitable.
[00:22:55] Stacey Richter: We get what we pay for, and if we don't switch up what we're looking for or what the potential of primary care is, and then enable that, incentivize that, then we're getting the downstream of that.
And one of the downstreams is we've got primary care doctors, there's no absolutely no way they're gonna be able to work at the top of their license.
[00:23:19] Dr. Lisa Rosenbaum: I think that's fair.
Category Two Scope vs Referrals
[00:23:20] Stacey Richter: Let's move on to our second. Is it needless inefficiency or, or the, the error of our ways coming back to roost? Or is this an absolute inevitability, it has to be this way?
So the, the second one is, are we looking for from primary care, a full spectrum clinical scope, or are we looking for referrals?
A lot of times right now, what the sort of critique is, is that primary care is a lost leader. That is a referral machine. If you are a health system, primary care is considered a gatekeeper. A gateway, and you buy up all the primary care practices in an area. This is like health system playbook 101, and then you use 'em for referrals.
[00:24:02] Dr. Lisa Rosenbaum: Right.
[00:24:02] Stacey Richter: And there is an in-network referral metric. And the more the better.
[00:24:07] Dr. Lisa Rosenbaum: So that just comes down to also basic, like, I don't know if I should call it economics, but like if the incentive exists at the system level, so like you get, you know, X amount of dollars for a primary care visit and x plus a hundred for a specialist visit for your system, then you'll always be creating a system that favors that specialist referral.
Now, is that a bad thing? I think that's actually like a more interesting question. I'm obviously a specialist. I think there are a lot of data that are all observational that suggests that when you have like a higher density or a higher ratio of primary care doctors to specialists in areas your overall like health outcomes improve. Those data are old. I don't know if they would still be true.
And I think that, you know, the more that primary care is whittled down to this bare bones algorithmic type of care, and the more specialist expertise is not just coveted, but coveted for a good reason.
For instance, a patient can't get like an aortic valve replacement, you know, by a structural cardiologist unless they get to a cardiologist.
So I think it's easy to poo poo like referrals, but some of it probably has to do with the fact that our specialists can do a lot of cool things that help people live longer and healthier lives. So I wanna be careful about like, we don't need to bash anybody in this conversation.
But I think there is a clear incentive on a structural level that favors specialty care over primary care, more holistic management of complex patients, and that there's nothing inevitable about that.
[00:25:51] Stacey Richter: How do we fix that then?
[00:25:53] Dr. Lisa Rosenbaum: I think you just have to increase the amount of dollars going to primary care. So right now, about 5% of every healthcare dollar goes to primary care when they see about, I think close to 35% of all outpatient visits.
Nothing inevitable about that.
Middle Ground On Referrals
[00:26:10] Stacey Richter: So is a, let's just say not full spectrum clinical scope, is that inevitable that referrals are gonna happen early and often, maybe a little bit too fast? Or is it an inefficiency or suboptimal in a way that we can fix? And if so, how would you fix it?
[00:26:32] Dr. Lisa Rosenbaum: So I don't think it's inevitable.
I think there's been a cultural and structural evolution forcing people to refer early unnecessarily. And I think that the flip side is that specialist expertise has grown over time. And I think we shouldn't. You know, just for the sake of propping up primary care, pretend that like everybody should be doing valvular replacements and appendectomies, like, I don't think that that's true at all, and specialists exist for a reason.
I think there's a middle ground that we have lost and we've lost it by encroaching upon primary care doctor's time and inserting a host of meaningless tasks that could be done by other people if they're gonna be done at all, that don't need to be done by physicians.
And in that sense, again, I don't think that what we're seeing right now is inevitable, but I think we've lost the middle area where physicians primary care doctors can do what only they can do.
[00:27:36] Stacey Richter: The first thing that strikes me about the answer that you just gave is that it's not an either or at this juncture. That you can't say, Oh, do you wanna have a full clinical scope or do you want to refer that the right answer is someplace in the middle, that there is an optimal moment when a referral happens for optimal reasons.
The point that you're making is that that optimal moment may become suboptimal if two things, if a primary care physician does not have enough time, and maybe just 'cause the visit is short, or maybe because there's all kinds of paperwork or, you know, we often talk about this elusive team-based care, which is generally speaking, a euphemism for …
[00:28:20] Dr. Lisa Rosenbaum: Nothing.
[00:28:21] Stacey Richter: Nothing. Oh, I don't much, the number of dysfunctional teams. It probably exceeds the number of functional teams at this juncture. And then what we wind up with is primary care doctors not performing the magic that they certainly can perform.
[00:28:35] Dr. Lisa Rosenbaum: And I guess the one thing, you know, we started out by talking about like what is this expertise?
Do primary care doctors even have an expertise? Because we tend to refer more often to specialist expertise. One of the biggest takeaways for me from doing the whole series is that, there is expertise that lies in a relationship.
And sometimes the best way for me to understand that is, again, through my own experience. If I see a patient five days in a row on a clinical service in the inpatient setting, my ability to make a decision for that patient on the fifth day is so different than it is on the first day. It's not something that I can calculate. It's a feeling.
And I think that the fact that it's a feeling, the fact that it's a relationship, which sounds like so cheesy and not that important, has led to some of the diminishment of primary care.
But to go back to this idea of what is that magic secret sauce that primary care offers, like they are the people who have relationships with patients over time. Does that mean cardiologists don't have relationships with patients? Absolutely not. A lot of specialists have relationships with patients too.
But primary care, that is the foundation for us of relational expertise. If we lose that, we lose the judgments and the type of clinical excellence that is associated with being able to make decisions from within a relationship.
Category Three Fragmentation
[00:30:03] Stacey Richter: Which leads us to our third core question here, which is longitudinal relationship versus transactional throughput/fragmentation.
So again, is it inevitable or is it a needless inefficiency? And it definitely sounds like you just gave a couple of great reasons why having a relationship matters, and there's been plenty of literature about this also, just the importance of relationships. You can't have trust without relationships. And as we all know, without trust, doctor can say whatever they want and patient may or may not actually do it or even hear it.
Is it inevitable in this timespace continuum with AI and bots and if anyone needs help, they just run to the urgent care? Like there's a lot of reasons why fragmentation can happen or if they have 10 specialists.
I read someplace the average Medicare patient has something like, like 8 to 10 specialists or something like this, right? There's a lot of people that are involved in care. So is fragmentation then inevitable?
[00:31:10] Dr. Lisa Rosenbaum: No. The fragmentation that we see results from a very myopic view of healthcare. So if you, if you don't value the relationship, then you end up in these situations where by virtue of not having time or having had skill atrophy or whatever it is, you're just referring to a bunch of specialists.
And the irony of all of this is that if we devoted healthcare resources upfront to the people who wouldn't need to be referring so much.
I think there is a compelling argument to be made for investing in upfront, outstanding, holistic primary care.
These start to sound like buzzwords, so I kind of groan inside when I say them, but I really do think that then the returns to the healthcare system down the road would be greater, but in years and years, like not immediately.
And part of that investment is paying primary care doctors more relative to their peers. We have to attract really good people into the field for it to thrive. That's just how culture works.
[00:32:14] Stacey Richter: Let's just say that the referral happens optimally. A patient who is at some rising or high risk still could wind up with eight specialists.
[00:32:24] Dr. Lisa Rosenbaum: Absolutely. But there are probably a lot of people who wind up with eight specialists who don't need to be with eight specialists.
[00:32:29] Stacey Richter: Is it inevitable then that care is fragmented? Miriam Paramore wrote a great essay about this on LinkedIn recently, where her father, needed a back operation, so he had his back surgeon. He also had kidney issues and cardiac issues.
The nephrologist and the cardiologist could never get together and make a recommendation in a way that the orthopedic guy would take as an okay to proceed. Therefore, her poor dad was in terrible pain and could never get them all on the phone at the same time. It's like a downward fragmentation spiral.
What structural fixes this. Is this, to your point, you said figure out how to pay primary care more. Does that ultimately solve this or is there more?
Culture and Closing the Loop
[00:33:15] Dr. Lisa Rosenbaum: I think some of that people are gonna yell at me again, but like that's a cultural issue too. So that when I was talking about the moments that you can predict. So let's say I am a consultant, one of the, I'm the cardiology consultant who needs to bless this patient for lumbar fusion or whatever it is, and why can't I pick up the phone and call the nephrologist?
There's not a structural answer for that. There's a professional ethic that we have to uphold and to get back to this moral injury thing, sorry. This is where I really worry about when we blame everything, everything, everything on the structure. We fail to see our own responsibility.
And so I'm not, I don't think this is not a primary care problem. This is just a problem of humans who are busy, who somehow have not internalized that part of our job is to communicate with all the other specialists and to close the loop.
I mean, I think that's like the other thing. It's just part of Communication 101. Is like, I can't just send a message into a chat if nobody responds to it. I have to get on the phone and maybe I need to do a phone call with everybody on at the same time. God forbid, maybe I need to talk to them in person.
The other part of that is when you look at our demoralization as physicians, I think not doing that has contributed to our demoralization because all of these people are just they're abstracted figures who are just like weighing in in this way that has nothing to do with us.
But like when you get him on the phone, you're like, Hey, I'm really worried about this guy actually. He's got coronary disease and he's got moderate aortic stenosis and his creatinines too, but at the same time, he can't walk and I don't see this getting any better. Do you think we should just bite the bullet and let him get this surgery.
You share something in that moment. You're like, I care about this person. You care about this person. Now we're friends because we both care about this person. I just don't think that's a structural problem. I think the culture of medicine needs to pay more attention to moments like that.
None Of This Is Inevitable
[00:35:13] Stacey Richter: So having gone through these three, is it inevitable or is it a needless inefficiency? Probably the needless inefficiency is not the right terminology. It's something like, is this a structural, or a cultural, or a human.
There's a lot of forces that have been inflicted on medicine really fast, and we've gone down some weird rabbit holes, and some of the fixes might be structural. Some of the fixes might not be. Some of them might be just like humans catching up with the reality of the situation and what our own responsibility and accountability and ownership is. You know, sometimes when cheese gets moved real, real fast. You sort of lose track of who owns what and who's the roles and responsibilities that there are.
Not in all cases for sure, and we certainly have these perverse incentives in the mix. So it sounds like our either or is on one side, like is this inevitable or is something that is fixable if we spend the time and energy to work on fixing it.
[00:36:14] Dr. Lisa Rosenbaum: I wouldn't have written the series and done the podcast if I thought the state of primary care was inevitable. So I don't think that any of its inevitable.
I also think that what I just said, when you blame everything on the structural constraints around you, you become blind to your responsibility. Not everybody does, but I mean, you have to be able to talk about the structural constraints too. And I think in the case of primary care, the structural constraints are problems like one through nine.
But for all of us in the profession I do think that there will always be things that we just have to do because we recognize their importance, whether or not they're rewarded, and part of choosing to go into this profession is accepting that.
[00:36:59] Stacey Richter: Really interesting that if everything can be blamed on some structural inevitability, that deepens the lack of agency.
If we feel like there's nothing that we can do about it, and therefore why try that actually makes it worse, and the feeling of being disenfranchised grows.
[00:37:21] Dr. Lisa Rosenbaum: And let me just say, there are so many people who reached out to me who have found a way to practice outstanding primary care and to love it.
And those people would not be doing it without their own agency. It's not like they practice in a perfect system.
[00:37:36] Stacey Richter: There was a show a couple of years ago with Larry Bauer at the Primary Care Innovation in the Primary Care Innovation group. We had him on the podcast. He talked about three.
But I think, you know, if, if you, as I'm distilling some of the insights that he had, it was very similar. It was just someone took it upon themselves to figure something out.
[00:37:58] Dr. Lisa Rosenbaum: Right. I don't think there's any progress without that impulse, alongside structures that can support true comprehensive primary care.
[00:38:08] Stacey Richter: And advocating against those structures, then is is part of this also?
[00:38:11] Dr. Lisa Rosenbaum: Yes. That is something that I hope for. I think a lot of primary care doctors are so far in the weeds that they're not out there advocating for themselves. They're advocating for their patients instead.
But we're starting to see unionization, things like that. But no, I think we need to hear from them more. One of my ambitions was to collect their voices onto a podcast.
Advice For Leaders and Buyers
[00:38:32] Stacey Richter: Is there any summary advice that you would offer either for physicians themselves who may be tuning in or those who are buying the services of primary care, of which we have a number who are listening right now, either trying to figure out how to do direct contracting or hiring on-prem primary care doctors or navigators. Right.
Do you have any thoughts or takeaways that you feel like it's really important for people to know?
[00:39:02] Dr. Lisa Rosenbaum: I mean, I would ask every listener who's in that position of power to say, what do I care about? What do I care about for my doctors? What do I care about for the patients? What do I care about for society? Why am I in this business?
Then I would listen to your doctors and their patients about what it takes to give that kind of care.
[00:39:22] Stacey Richter: Sage advice. Dr. Lisa Rosenbaum, if someone is interested in your work, we certainly will link to this podcast series in our show notes, but is there anywhere else that you would direct anyone?
[00:39:33] Dr. Lisa Rosenbaum: Well, I write, um, so nejm.org, if anyone wants to read the essays I wrote on primary care, I think everyone gets three free essays a month.
So even if you don't subscribe. You can read and, um, but yeah, definitely listen to the podcast Not Otherwise Specified wherever you get your podcasts.
Closing Thanks
[00:39:52] Stacey Richter: Dr. Lisa Rosenbaum, thank you so much for being on Relentless Health Value today.
[00:39:55] Dr. Lisa Rosenbaum: Thank you so much. It was really fun.