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Rebuilding the Social Contract, Part 1
For the past year, I have been examining the broken social contract between our society and what might be termed “big medicine.” I have seen a number of articles in the past year that, while not using this terminology, make essentially the same point. Rather than looking at these though, I want to look at what we can do to start rebuilding our social contract. I think it starts by looking at where “little medicine” is failing and what we can do to fix it. When I went into private practice, the older associates often said the key to building one’s practice revolved around the three “A’s;” availability, affability, and ability, always in that order. Over my years in leadership, I added two more: affordability and accountability. In this article, I want to look at availability. At its most basic level, availability reflects the intersection of the demand for medical care and the willingness of the individual provider to provide that service. In my early career, the willingness eased off as the physician established his/her reputation and acquired a cohort of patients. Waiting time for new patient appointments would move further into the future, a problem that could be “solved” by bringing in a new associate, who would be drilled on the importance of availability. But this has changed. The corporatization of medical practice means that decisions about hiring new associates is made by the hierarchy. By itself, that would not be a problem, but the ruthless efficiency imperative of corporate management means it is no longer financially optimal for the aging associate to slow down and let the demand spill over. Instead, every provider needs to be seeing the maximum number of patients per day to maximize revenue. Given the difficulty in accounting for differences in patient needs, provider needs, and practices styles, this means there is always a temptation to set the speed of the system at the highest possible rate. We have previously considered the issue of burnout and its corollary, moral injury, but a recent study looked at when and why physicians deliberately chose to leave practice for reasons other than age or disability. 1 They studied all physicians providing care to Medicare patients from 2013-2022, of whom 70.8% were male and 90.8% were in urban locations. Unadjusted annual attrition from clinical practice increased from 3.5% in 2013 to 4.9% in 2019. Using adjustments, the attrition rate was higher among women and those practicing in rural areas. Attrition was associated with caring for patients with higher medical co-morbidity, greater age, and those with dual eligibility (a marker of lower economic status.) The authors note their findings are robust, but refrain from prescriptive statements. But to me, the data are consistent with the notion the treadmill is set too fast. Corporatization is not going away, but that does not mean every patient and every provider has to be standardized. It does mean that we need to pay more attention to managing demand with a view to finding a more optimal balance. This study identifies some patient characteristics associated with higher demand, but there are other issues related to demand. I was in the leadership of my group when we first opened our drop-in, extended hours primary care service. Since we had not been able 1 Rotenstein LS, He Z, Dziura J, et. al. Trends in and Predictors of Physician Attrition From Clinical Practice Across Specialties: A Nationwide, Longitudinal Analysis. Ann Intern Med 2025;178:1698-1708. doi:10.7326/ANNALS-25-00564. to hire enough physicians, we depended on our traditional primary care doctors to cover some time slots. Once we had no one to cover the last three hours on a Sunday evening, so I covered it. I saw 12 patients, and could not figure out why six of them were there. Two needed work excuses for Monday, two had worsening of chronic symptoms, one had an acute injury and one an acute illness. I guess the others were what we used to call “worried well.” Recently, Dr. Lisa Rosenbaum has done a series of articles looking at availability, particularly in primary care. She noted the proliferation of issues primary care providers are expected to address in addition to needed medical care. As she wrote: “Worthy goals are infinite; physician time is not. Eventually, one worthy goal comes at the cost of another.” 2 She also notes that primary care is being increasingly oriented toward preventive care and population health, draining even more time away from clinical encounters; but most physicians go to medical school to deliver medical care, not public health. At the same time, advanced practice providers and urgent care clinics increasingly chip away at the less acute problems, leaving those with severe, often multiple problems to be seen by over-extended physicians, (leading to more attrition, as described earlier.) The economic motives for providing care through APP’s is evident. They cost less, and can produce almost as much revenue. I had a recent conversation with a former primary care clinic manager for a solo family practitioner, whose practice was acquired by a corporation. They were quite frank with her in their desire to get the doctor out of the office, so they could run it their way without interference. She was surprised; I was not. Another demand which drains availability is the “gate-keeper” function. In theory, if all patients had a primary care physician, they could use specialists for “consultation” to guide management after a one-time assessment, or they could be referred for a procedure. But as the time (and energy) of the PCP continues to be spent on other issues, the physician’s “comfort” level managing complex regimens decreases. So, the vast majority of specialty visits involve co-management of complex issues, not short-term contacts. For the insurance company, the gatekeeper is supposed to cut down on (expensive) specialty care. Once, many years ago, we did a modified managed care program with a local industry. We decided that patients usually did not overuse doctor time, so we only did “case-management” when a beneficiary had unusually high utilization that was not obviously related to a medical event. We ended up needing “controls” on about 2% of our panel. So, what we have in a gate-keeper, is an expensive, energy and time draining process that has minimal impact. Similar results have been seen in studies of prior-authorization schemes. Said another way, inappropriate demand is rare, so why do we continue to accept and perform these functions that reduce the physician’s availability for medical care? Since most practice in a corporate setting, why aren’t these issues a corporate responsibility to be fulfilled by clerks? A simple first step to addressing the availability crisis is making it possible to get physicians back to providing medical care—not healthcare. 30 January 2026 2 Rosenbaum L. PCPs, APPs, and the Everything Bagel Problem—Choosing Not to Choose. N Engl J Med 2025;393:1955-1959. doi:10.1056/NEJMms2510428. |
Further Reading
Adding Versus Subtracting A recent study suggests people favor additive rather than subtractive solutions to problems. Advisory Report on Burnout, part 1 Health care worker burnout has become so prevalent, the US Surgeon General has issued an Advisory Report on immediate steps needed. Asking the Right Questions Solutions for problems in health care abound, but are we asking the right questions? Getting the Tempo Right Effective doctor and patient communication requires getting the tempo of the conversation, not speed, but the current production system makes this a rare event. Population Health Population health is a phrase that disguises some hard realities as illustrated by two recent reports. Primary Care Like Mom and apple pie, primary care medicine is more honored in principle than in practice. Simple Ideas Making simple ideas work turns out to be complicated and hard. The Primary Care Dilemma When people are well they want convenient care, but when they are sick they want "the best." Is that possible? What Matters What really matters to practicing physicians? |