On the Conservation of Primary Care Physicians

How modern primary care misallocates its scarcest resource

I am always thinking about the plight of the primary care physician. My ideas vary depending on what kind of day I am having. I deeply enjoy the thoughtful submissions that we have received on the topic. Kuma Folmsbee’s post, A Plan to Refocus Primary Care, was one of my favorites.

Today, Bobby Scott is back with another idea, one that I am sure I will be returning to frequently.

Adam Cifu

Much has been written about the plight of the primary care physician (PCP). Often, these are lamentations over the loss of medicine as it once was—when doctors enjoyed greater autonomy, plenty of time with patients, and simpler documentation. These losses are significant and certainly worth grieving.

But concealed within this grief is an unsettling truth often left unspoken by PCPs: the job has become too big for us. A frequently-cited study estimates that it takes 27 hours per day to deliver guideline-recommended primary care for a typical panel of patients. We simply have too much to do in too little time. And what remains is a feeling of inadequacy, because we know that we cannot be the type of doctor we think we should be.

It’s a heavy emotional burden for practitioners in a field already prone to imposter syndrome. It is a key source of moral injury and a frequent contributor to burnout. To cope, we often let our minds drift towards counterfactuals.

We tell ourselves that we could do a good job if only the EMR was better, or if AI could write our notes, or if we could hire staff to help with all the excess paperwork. These things can help—I love my AI-based ambient scribe—but they don’t fix the problem. I still can’t do the job the way I want.

The problem with primary care is a resource scarcity problem, but it’s not the one you think. Primary care is struggling because it fails to protect its most valuable and fragile resource: the physician’s mind.

Physicians bring value to patients in multiple ways. There’s a real, but often intangible, benefit in the clinician-patient relationship. We might employ technical skills in performing procedures that correct a physical condition. But our clinical judgment, the wisdom that comes from years of training and deliberate practice, cannot (yet) be fully replicated.

It is, in fact, our superpower. And for the primary care physician, the American healthcare system is the kryptonite.

If it’s clear that we can’t do it all—what, if anything, do we let go? Previously, Dr. Folmsbee offered up the well visit, arguing that our time would be better spent treating the sick than discussing interventions with healthy patients who have little chance of improving outcomes. He suggested that we offload prevention to public health. I think this would be a mistake.

The specialty of public health is policy. Physicians specialize in patient care. What makes sense for a population (like vaccines, disease screening, and preventive therapies) doesn’t always translate to an individual patient. As has been covered extensively on Sensible Medicine, prevention decisions are probabilistic, ethically nuanced, and sensitive to patient preference. Patients need someone to interpret and apply complex population data to fit their unique situation. Nobody is better suited for this role than a primary care physician.

So the well visit shouldn’t be abandoned, but perhaps be made less frequent. An arbitrary cadence of annual visits is likely unnecessary. ACOG learned this when the COVID-19 pandemic forced them to realize that most pregnant women could have fewer prenatal visits and remain healthy. It might make sense to design a tailored schedule of fewer, milestone-based prevention check-ins at certain ages, not unlike a car’s maintenance schedule.

Therefore, instead of handing off prevention, I propose that it’s time to let go of stable chronic disease management. It’s not that it’s unimportant, but it is mostly predictable and amenable to management by protocol. Much of this work does not require a physician’s judgment at every step and can be delegated to a team that includes pharmacists, nurses, and advanced practice providers operating within physician-defined protocols.

Medications could be added, adjusted, and monitored without a physician’s direct involvement. EMR messages regarding refill requests, insurance coverage, and treatment-related issues could be handled by this team. Much of this routine care could be conducted virtually, or even asynchronously, freeing many patients from missed workdays.

Delegation of these tasks does not mean abdication. Physicians would still be responsible for the patient’s overall care, yet the maintenance logistics are managed by other professionals. Care would only be escalated to the physician when certain criteria are met or when the team’s clinical judgment deems it necessary. If a patient decompensates, they see the doctor. If a patient has a new, undiagnosed problem, they see the doctor.

From a patient perspective, although they would see their PCP less often, those visits would be much more meaningful. Our current system of “routine follow-ups” forces patients to slip in their concerns when they sense an opportunity, hoping their doctor has time to address them between checkboxes. By offloading protocol-driven visits, patients can schedule appointments that align with their agenda, not ours.

Physician cognition is a limited resource. We must be strategic with its use. When a patient’s hypertension is stable, the marginal value of a physician’s intellect is low. When a patient with hypertension develops exertional dyspnea or orthostasis, the marginal value becomes substantial. A system that requires physicians to exert the same cognitive effort on both is a gross misallocation of its most rare and precious resource.

The emergence of direct primary care was a natural response to the rising cognitive demands of primary care medicine. With smaller patient panels and longer visits, it is an elegant solution that remains a great option for small, independent practices. Unfortunately, it’s not scalable to larger healthcare systems where most US physicians are now employed.

So it makes little sense for the rest of us to go on elegizing about the way things used to be. The reality is that if primary care is to survive, we must stop expecting physicians to be—quite literally—everything, everywhere, to everyone, all at once. We all benefit from the skilled minds of our primary care physicians. A system that fails to protect them ultimately fails us all.

Bobby Scott, MD, is a practicing family physician and associate professor at Wake Forest University School of Medicine. On his Substack, Statcast & Stethoscopes, he uses baseball stories and stats to help clinicians make better decisions under uncertainty.