A few weeks ago, Elation Health made its debut at the American Academy of Family Physicians’ National Conference in Kansas City, Missouri. The National Conference is the singular annual event geared toward family medicine residents and medical students considering a future in family medicine. Elation’s goal was to connect with these future leaders of primary care and help them consider a career in independent primary care.
Challenging the path of least resistance
The common expectation these learners seem to have during training is that after graduation, they should work for a hospital or health system. It's the path of least resistance. Being employed offers financial predictability to help pay down medical school debt. It avoids the additional challenge of having to learn how to operate a business (private practice) while also starting a clinical career – a daunting idea for all but a few entrepreneurs. And, it’s what they know: most of them have trained primarily in that health system environment, and familiarity feels safe.
But there’s a cost to this path, both personally for the physicians involved, and across the entire U.S. healthcare system. Health systems make their money by keeping hospital beds and operating rooms full and expensive subspecialists busy. For these organizations, primary care is not where their revenue is generated; it is a loss leader to feed the cash cows downstream. The parent system is designed to milk primary care until even the best physicians can do little more than throw pills and referrals at their patients because they are so overwhelmed.
Primary care's main job is to prevent those very outcomes. In primary care, we keep our patients healthy and well, less likely to need hospitalization or expensive procedures.
The dominant agenda of the hospital system is in direct conflict with the values and purpose of primary care, and the primary care physicians who take employment in these systems are set up to fail in every way. What follows from this is the moral injury in medicine described so poignantly in Dr Wendy Dean’s bestselling book, If I Betray These Words. In both her seminal article for STAT News, co-authored with Simon Talbot, and her recently released book, Drs Dean and Talbot define moral injury as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” She goes on to say that “in medicine, those deeply held moral beliefs and expectations, at least in a professional setting, are the oaths that we took to put our patients first.” This concept of moral injury goes beyond burnout, and is a significant – perhaps the number one – contributing factor to our crisis-level primary care shortage. Tragically, it often starts with a new residency graduate accepting a job offer with a hospital system.
As primary care leaders, and as an industry, we must do a better job of exposing where the path of resistance leads, and how to best support the next generation of physicians.
Inspiring alternate pathways that deliver high value care
One of the most important messages we shared from the Elation booth was this: independent primary care, divorced from a hospital or health system, is crucial for the well-being of the physician, the patient, and the future of healthcare. Hospitals won’t fix healthcare in America, but primary care can deliver meaningful change:
for the physician - independence offers autonomy of practice and alignment between actions and values;
for the patient - independent primary care allows them to receive personalized care, focused on prevention, designed to keep them healthy; and
for the healthcare system - Independent primary care is the best lever to improve health outcomes and decrease downstream health costs.
It was disturbing, yet important to note, that many students had not yet learned why independent primary care, autonomous of a health system, leads to better patient outcomes. They often did not realize that even if launching a private practice is out of reach, there are options to maintain primary care independence in an employed role – working in value-based primary care organizations, or joining a growing direct primary care practice, for example. Discussing these career options and the imperative of primary care independence is not common enough, and change is needed.
The work of primary care is unique in all of medicine. Such comprehensive, longitudinal, relationship-based care leads to a challenging cognitive burden at the point of care, where primary care physicians are managing more data, information, tasks, and work per patient than any other medical specialty. We owe it to them and to their patients to set them up for success, considering their tremendous impact on the health of society. It is clear that health systems are not designed with this in mind, which all too frequently results in a primary care experience that both physicians and patients regret.
Talking to these early family medicine careerists reminds us at Elation why we strive to build an experience that humanizes our frontline clinicians and helps them address these daily challenges, empowering independent primary care physicians to deliver phenomenal care that puts their patients first.
The National Conference is ground zero, where the future of family medicine is born. We loved having the opportunity to influence and broaden these students’ thinking at this event. We hope that many do choose the path of independence instead of following a familiar pattern which could lead them to moral injury. Independent primary care is not only a viable option, but crucial to survival of family medicine and saving healthcare in America.
Sara J. Pastoor, MD, MHA is Elation's Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.