Curbside Consult with Dr. Jayne 6/30/25

The Journal of Graduate Medical Education published a thought-provoking article this week titled “A Eulogy for the Primary Care Physician.” It reflects on the original purpose of a primary care physician as the trusted physician “who knows their health inside and out, who guides them through the complexities of the medical system, and who fosters relationships not with charts, but with people.”

This is exactly the kind of old-timey family physician that many of my peers and I thought we would become. That’s what we were trained to be during our residency programs. Little did we know that the forces that would actually align against our being able to do that.

First, there were the turf wars. I was trained to perform a variety of procedures during residency, including minor office-based surgeries, biopsies, wound management and repair, and sigmoidoscopy. I was also trained to deliver prenatal care and perform non-operative deliveries in partnership with local OB/GYNs who served as backup.

I quickly found that I wasn’t able to do most of those things in my hospital-sponsored practice. Family physicians weren’t allowed obstetric privileges, full stop, even if we had an OB/GYN who agreed to back us up. One of the hospitals where I was forced to be on staff didn’t even have obstetrics, which somewhat limited my ability to recruit newborns to the practice.

After six months of appeals, I was allowed to seek newborn nursery privileges at a competitor hospital in an attempt to maintain that part of my skillset, although caring for infants became increasingly rare.

Second was the pressure for primary care to support the volumes of all of the other specialties. If there was a procedure to be had, I was expected to send those patients to my proceduralist colleagues so that they would have adequate volumes.

Numerous procedures can be done by appropriately trained primary care physicians in a high-quality and cost effective manner. However, I was told that it was unseemly to hoard those procedures, and I needed to refer them out and show that I was a team player. It didn’t matter that patients would prefer not having to make a second appointment, take off work again, or pay a second co-pay.

The only thing I was able to hang onto were the skin biopsies, because I could do them relatively quickly and they didn’t have a significant supply need or cost therefore they were somewhat “invisible” to the medical group administrators who actually ran the show.

There were a hundred other things that steered my work as a family physician in a different direction from what I thought it would be. When I was offered the opportunity to work with the electronic health record project, I jumped at it. Maybe that would be the answer to regaining autonomy since I would be able to run reports and see data on my work without external support. Previously, I had to rely on the business office to do so via our green-screen practice management system.

Because of my protected time to work with the EHR, I was somewhat buffered by the pressures to constantly see more patients, although I was still juggling dozens of patient messages and requests on the days when I wasn’t in the office. In hindsight, I probably worked 1.25 FTEs during that time, despite being paid as a 1.0 FTE, but I was the only person in my position and I didn’t know how to push back given the pressures that were on the other primary care physicians in my group and which seemed worse at the time.

Although the Eulogy article cites burnout, declining reimbursement, and private equity as significant contributors to the demise of the primary care physician, I would add other elements. The consumerization of healthcare continues to be a major force, as physicians are incentivized around patient satisfaction, sometimes to the detriment of quality of care.

As an example, two areas on which physicians are incentivized are patient satisfaction and avoidance of unnecessary antibiotics. For every patient who calls wanting a Z-Pak for what is undoubtedly a viral illness but who “wants to get ahead of it” or says “I know my body and what I need,” there is only a lose-lose situation. I’ve been roasted via online review sites for refusing to call in antibiotics without seeing a patient. I’ve been threatened with complaints to the state board. I’ve been ripped in Press Ganey surveys.

My quality numbers remained high, but when you get bad reviews (justified or not), your paycheck suffers. Physicians should not be placed in these crosshairs, but we do it every day. I know it’s the proverbial dead horse, but educating patients about the risks of unwarranted antibiotic prescriptions is another public health intervention at which we’re not very good.

When I had the opportunity to expand my informatics work and change to a different environment for patient care, it was bittersweet. Although I missed the regular “continuity” patients with whom I had bonded over five years, I was glad to get out from under all the patient portal messages and communications that didn’t stop while I was out implementing the EHR, training peers who refused to work with non-physician trainers, and trying to figure out our group’s strategy for health information exchange.

I thought that would be the death of my career as a primary care physician, but little did I know that once I started working in the emergency department and urgent care settings, more than half of my work would be primary care anyway, since many of our community used those environments for their primary care services.

The Eulogy states, “The PCP is survived by the independent physician assistant, nurse practitioner, and generative artificial intelligence.” As someone who is starting to have more encounters with the patient side of the healthcare system than I would like, I worry quite seriously about how my generation will be cared for in the future.

Every time I see my own primary care physician, who is a few years older than I am, I don’t leave without asking the question of when he sees himself retiring so that I’m not caught in the lurch. Fortunately, most of my subspecialist physicians are younger than I am, so I’m less worried in those areas.

With regard to generative AI replacing primary care, I think we have many years of it augmenting rather than replacing. I’ve been unimpressed by many of the solutions that I’ve seen. I hope clinicians remain skeptical as developers work through issues with quality.

What do you think about the death of primary care in the US and how healthcare information technology might be able to resurrect it? Leave a comment or email me.

Email Dr. Jayne.