Are Primary Care Physicians an Endangered Species?

You didn’t hear it here first. The role of the primary care physician (PCP) is changing — and in some vexing ways. Long gone, of course, is the all-knowing, black-bag-carrying (middle-aged White male) Marcus Welby of two generations ago. But the gatekeepers of the 1990s and early 2000s also seem to have left the building. What’s left is a beleaguered, dwindling profession facing too many patients, too much paperwork and not enough pay — or minutes in the day.

Why, then, do two leading PCPs asked about this crisis — while no Pollyannas — sound unexpectedly hopeful?

Ishani Ganguli, M.D., M.P.H., of Harvard Medical School and Brigham and Women’s Hospital, and co-authors sounded an alarm in an article published in the Journal of General Internal Medicine in 2019. They noted that five national surveys had shown declines of 6% to 25% in primary care visits from 2008 to 2016. They cited ways that the Affordable Care Act and other reform efforts have tried to bolster PCPs’ role, increasing reimbursement and promoting such innovations as the accountable care organization and the patient-centered medical home. “The decline,” they wrote dryly, “implies they have fallen short.”

“There is clear evidence,” says Ganguli, “that burnout rates are higher among primary care clinicians compared to other specialties.”

But pressure on PCPs shouldn’t be confused with a lessening need for primary care. Megan Ruth Mahoney, M.D., MBA, chief of staff at Stanford Health Care and a Stanford professor, says the way to solve today’s primary care crisis is to apply more fully the “team” model already used in many offices.

Asked what care will look like 20 years from now, she predicts that “higher-risk, medically complex patients” will see doctors for assessment, diagnosis and conditions involving multiple organ systems. But other patients, says Mahoney, will likely be managed by other health professionals, including advanced practice providers (nurse practitioners and physician assistants), but also pharmacists, nutritionists, nurses, behavioral health specialists and even medical assistants. The PCP will play an important role as “the captain of care, coordinating care. But I’m not sure that needs to be a physician,” says Mahoney.

Both physicians believe in the team approach, but they admit its downside: the potential “dilution,” as Ganguli puts it, of the personal trust between patient and physician that has long been considered vital to adherence and quality care.

Mahoney agrees. The big hurdle, she says, is the change patients face when they encounter the team. “Trust obviously is foundational,” she says, but her group has succeeded “in transferring that trust to an entire team.” And seeing more individuals for care means more people — potentially — to bond with. “I have patients who love the nurse I work with,” says Ganguli. “They see us as a unit.”

The team approach is also good for health equity, Mahoney contends. A team of providers increases the likelihood that patients will find someone in the office with a similar cultural background. Moreover, she says, a care team can convene to discuss all aspects of a patient’s health: food security, social access to community resources, drug-drug interactions. “Longitudinally, it’s better when you have more minds thinking about the patient.”

Teams are no panacea. Ganguli sees an urgent need for a payment system that better reflects what primary care providers — doctors or not, in teams or not — actually do. “It’s a misconception that primary care is easier than specialty care,” she stresses.

Timothy Kelley is an independent journalist in New York.