Strong family physicians, strong medicine, strong patients
An excerpt from the inaugural speech of the new TAFP President
By Rebecca Hart, MD
I am so humbled, joyful and happy to begin work as your new president. Thank you for electing me and giving me this opportunity to serve you. I hope you join me this year in working harder than ever to keep our profession strong, our physicians inspired, and our workforce increasing.
When I began my career as a resident in Family Medicine at Baylor College of Medicine Residency Program in 1988, I was naïve. I knew nothing of the big issues that would face me in my future as a family physician. I knew nothing of CMS, preauthorization, payment reform, physician shortages, mid-levels, MACRA, EHRs, quality incentive programs, or Medicare Advantage plans. Heck, most of these things didn’t even exist back then! I knew only that I loved every rotation back in medical school, so family medicine was right for me. I wanted to be a full-scope family doctor, deliver babies, and work in a small town in Texas to make a difference in people’s lives.
In 1991, I joined Dr. Tom Mueller in La Grange where I had my chance to practice full-scope family medicine, doing all the procedures I had been taught. Delivering babies, performing C-sections, flex sigs, dermatologic procedures, minor surgery, and inpatient and outpatient care—the whole nine yards. I was in heaven.
But, call was every other night and when I got home from work, I got called back in for admissions or emergencies at the ER. Very soon I found myself depressed and upset. I was working harder than I ever had before. I had a 2-year-old at home and a supportive husband but I never saw them. I went home and passed out, slept a while, then went back to work. I was burned out and it didn’t take long.
We tried to recruit another physician with no luck. No one was interested.
Dr. Mueller introduced me to TAFP and I joined the Section on Rural Health and Maternity Care. It was then that I learned of our physician workforce problems in Texas affecting all rural areas. La Grange, 45 minutes from Austin, was in fairly good shape. We had a hospital and five physicians, two who delivered babies. But we could not attract doctors to this small Texas town.
Sadly, the problems plaguing our rural communities back then are still true today. Today, 80 of 254 Texas counties have five or fewer doctors, 35 have no doctor at all, and at least 18 rural hospitals have closed since 2013. This lack of access to care has resulted in skyrocketing rates of preventable disease and maternal mortality among rural residents.
One solution to this problem would be to reconfigure our physician workforce. According to the Association of American Medical Colleges, nearly two-thirds of medical students pursue subspecialty training instead of primary care, further exacerbating our primary care shortage.
According to the Council on Graduate Medical Education, there is significant evidence that optimal health care outcomes and health system efficiency are demonstrated when at least 40 to 50 percent of the physician workforce is composed of primary care. A new AAMC study reports that Texas will face a shortage of 6,400 primary care physicians by 2030. And currently Texas ranks 47th out of 50 for the number of primary care doctors working in the state per capita.
Despite compelling and conclusive evidence calling for a health care system grounded in primary care, academic institutions lag far behind in producing enough primary care physicians to care for a population that is rapidly growing, aging, and presenting worse and more complex health conditions.
Perhaps it is time to for our Legislature to incentivize our medical schools to produce more primary care physicians for all of Texas and to hold the schools accountable when they don’t. If we are going to fund medical schools to the level we do, then isn’t it time we hold them responsible for the workforce they produce?
I eventually left La Grange with many tears and sadness. After consulting with my mentor Dr. Roland Goertz, I felt the best way I could make a difference was to go into academia, to recruit and train the best and the brightest to family medicine. I spent the next 20 years teaching in and leading residency programs.
Now I’ve returned to my first love, private practice, where I have been happily caring for patients for the past six years. And yet we continue to face a great need for more family doctors. We also face a more insidious problem, the moral injury of practicing in a system that prevents us from providing the highest quality care we can the care we know our patients need and deserve and that we could deliver if not for the burdensome constraints of our untenable health care system. This moral injury is what burnout is, and we have all felt it in one way or another.
You want to give a patient the best antibiotic for their infection but the insurance company requires a pre-authorization form, which takes three days to be approved, so you have to settle for a less effective med and hope it does the job. You feel defeated.
You want to send a patient to an orthopedic surgeon right away, but they are on Medicaid and it takes four months to get the next appointment with the only orthopedist that will agree to see them. Again, you feel defeated.
You want to admit your elderly patient to the hospital but they don’t meet the strict criteria of Medicare to be admitted, so they sit in the ER for hours, only to be sent home after 24 hours of observation on a hard gurney because they didn’t meet admission criteria. Once again, you feel defeated by the system.
Then you have a ton of paperwork to get your patient home care, phone calls with case managers and medical directors of insurance companies, and you are ready to throw up your hands. After which you spend hours after work typing out the office notes you couldn’t complete during working hours. Maybe you have an hour or two once you’re done to talk to your spouse and kids, but wait—you need to finish your Maintenance of Certification, so you’d better read another article and take a quiz before bed. Help!
Yes, doctors today are facing a moral burnout. We can’t do what we were trained to do and that feels wrong. This isn’t what we want to show our fledgling medical students wondering if they want to be a family doctor. But that’s what they see.
Hence fewer students are choosing family medicine. More older doctors are leaving right when we need to increase the workforce of well-trained family doctors to serve our aging population.
As you can read 0n page 12 0f this issue of Texas Family Physician, TAFP has adopted a new strategic plan that prioritizes the health of the physician and the practice, the health of our patients and the public, and the health of the specialty and the Academy. Over the next year, we will be laser focused on engaging our members and helping them decrease administrative burdens, understand new and emerging payment models and new models of care, and provide better care for mental and behavioral health problems in their patients and communities.
We still have aspiring medical students and residents who are excited to help their patients and to do the right thing for them. I see them all the time. They are our future.
People ask me if I would do it all again if I had the choice. Without hesitation I would. Was it a hard road? Yep. But I’m proud to be a family physician. I’m proud of what I have done these past 27 years. I want to keep doing it and keep my relationships with my patients strong.
We need to light it up and show people that being a doctor today is as noble a profession now as it ever was. That the Hippocratic oath is not dead. That no one can take away your knowledge. That you can practice as a family doctor anywhere in the world. That the intimacy and trust you establish with each patient is sacred and held to a very high moral standard. That patients want and need that intimacy and trust with their doctor. That the moral standard should be held up and should not be compromised by a constant barrage of payer nonsense, so that we as physicians can do the right thing for our patients. That we can stay cost-effective and continue to give the very best advice based on excellent training in diagnostics and therapeutics. That all this hard work is worth it.
As I grow older, I know I want an excellent, excited, hardworking physician workforce, not burned out embers, but glowing flames, enjoying how wonderful it is to be a family physician in this country. Let’s work together to build strong physicians, and with strong medicine, to build strong patients!