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.
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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 woman'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 Kenny Cole, MD; episode 391 with Scott Conard, MD. All of these shows hit this "it's all about the Benjamins, 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 about primary care. She did a whole series on primary care that I wound up listening to after Amy Scanlan, MD, 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.
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.
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.
But yeah … again, listen to the conversation that follows for where we wind up in this third category.
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 Suhas Gondi, MD, MBA, 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." Hmm. Interesting.
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.
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 Web site.
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.
Also mentioned in this episode are Ryan Jacobs; Kenny Cole, MD; Scott Conard, MD; Amy Scanlan, MD; Suhas Gondi, MD, MBA; Aventria Health Group; Payerset; Patient Rights Advocate; Miriam Paramore; and Larry Bauer, MSW, MEd.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at nejm.org, listen to Not Otherwise Specified, and follow Dr. Rosenbaum on LinkedIn.
Lisa Rosenbaum, MD, is a cardiologist at Beth Israel Deaconess Medical Center (BIDMC) as well as the writer in residence at BIDMC's Smith Center. She is also a national correspondent for the New England Journal of Medicine, where she hosts the podcast Not Otherwise Specified. She is an assistant professor at Harvard Medical School.
00:00 Introduction to this episode.
02:17 EP473 with Kenny Cole, MD.
02:21 EP391 with Scott Conard, MD.
03:47 Cognitive atrophy: what is it in terms of primary care providers?
08:56 Why Lisa Rosenbaum, MD, did an entire series on primary care.
11:32 Why physicians need to practice at the top of their license.
13:54 Why a good internist is a "quarterback."
16:23 How family medicine and procedures play into skill atrophy.
20:21 The majority versus the minority in primary care.
21:00 Is cognitive atrophy inevitable for primary care providers?
23:34 Full-spectrum clinical scope versus referrals in primary care.
25:51 The fix for too many referrals in primary care.
27:36 Why the solution is not an either/or.
30:08 Longitudinal relationships versus fragmentation.
32:33 Essay by Miriam Paramore.
36:07 Is this inevitable, or is this fixable?
37:36 EP409 with Larry Bauer, MSW, MEd.
39:02 What every listener in a position of power needs to ask themselves.
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