By: Akhil Gonuguntla, PGY2

Primary Care, while taken for granted in favor of more decorated fields of medicine, it serves as the first and, arguably, the most important point of contact with the healthcare system. Outside of providing preventative care, primary care represents an opportunity to fortify trust in and engagement with the system. Throughout residency, I’ve come to appreciate the different forms of primary care that is available to cater to various populations.

Training at UAB provides the opportunity for a range of exposure from uninsured populations via Equal Access Birmingham to home-based primary care via the Birmingham Veterans Affairs Medical Center (VA). However, most of our exposure is via our own primary care panel at either the VA Red Clinic (RC) or at the UAB Whittaker Clinic (IM4). I had the unique opportunity to experience both and gain perspective by learning how to deliver care in these two different environments. I have learned that a physician must not only take care of the patient, but also fill out disability paperwork, coordinate prior authorizations, and manage a clinic message pool. With the diverse exposure to primary care, I’ve come to gain an understanding of its universal challenges and find myself excited for potential solutions on the horizon.

Number 1: Administrative burden

A significant proportion of time goes towards documentation and paperwork. For me, this is possibly the single most important contributor to burnout working in primary care. Unfortunately, documentation consumes both time during patient encounters and a portion of my evening after seeing patients.

Understandably, the electronic medical record system (EMR) dictates the overall experience of this endeavor. In fact, a day in the RC will inevitably highlight this notion as the EMR at the VA has a steep learning curve and demands a greater time commitment to navigate patient charts. On top of documentation, we’re tasked with filling out short-term disability and FMLA paperwork. This adds an extra layer of work especially when there is an effort to ensure that the patient gets all their primary care needs met in the same visit. Given the challenges with access and transportation that many of the patients we serve experience, that visit for paperwork may be the only viable opportunity to provide any primary care at all.

So, what solutions are gaining traction to save our evenings? With the recent artificial intelligence (AI) boom, AI scribes have dramatically improved with recent studies showing up to 1-2 hours of time saved per day on documentation. In addition, AI-augmented EMRs may help streamline the completion of prior-authorizations and leave/disability forms. I am hopeful that the integration of AI into our daily workflow will allow for more time with patients and a better work-life balance. However, will investment in AI architecture reduce physician compensation per patient? Will it demand that physicians see more patients offsetting its effect on burnout?

Number 2: Non-billables

While documentation/paperwork forms a chunk of the after-hours time invested in patient care, there are other tasks that we perform that are not accounted for. Responding to patient messages, reviewing lab results, and approving patient refills are among the many services that are essentially “free” with having a primary care provider (PCP). Moreover, these services often result in direct communication with patients that can last just as long as performing actual patient care despite the lack of compensation.

A single day covering the IM4 message pool is a great representation of this as many phone calls can last as long as a normal patient clinic visit. So, what solutions are possible to help compensate PCPs? A standardized billing system that translates these traditionally non-billable activities into increased compensation for PCPs may incentivize more responsible use of these services by both patients and providers. However, will increased PCP compensation transmit more costs to patients by insurance companies? Will these increased costs discourage them from seeking primary care in the first place?

Number 3: Workforce shortages

 On any given day, residents scheduled for primary care clinic will have a full list of patients without fail. I’ve had patients that travel hours for their primary care at the VA or UAB, often as a function of access. Birmingham is surrounded by several rural communities that do not have reliable primary care systems. This puts pressure on the city’s existing PCPs and alludes to the supply-demand mismatch in primary care.

Recent data shows that the number of physicians going into other fields is much higher than those choosing to practice primary care. In addition to administrative burden, relatively low compensation coupled with debt from student loans are potential culprits. So, what solutions are gaining traction to address the mismatch? Primary care saves the health system money and increasing compensation for primary care will incentivize more healthcare workers to pursue primary care.

In addition, a growing number of advanced practice providers (APP) serving as PCPs may relieve this pressure on existing PCPs. Investment in telehealth infrastructure may help address demand in access-challenged areas without physically relocating providers. Moreover, companies like Amazon, Google, and CVS are investing in digital healthcare delivery platforms to improve access to patients. However, with increased supply of PCPs via APPs and corporates, will this further drive physician compensation down? Will this discourage more physicians from entering primary care?

While I’m optimistic about the potential changes that will take primary care by storm over the coming years, this thought experiment on its present/future challenges drives me towards pursuing subspecialty medicine. I find myself torn between a field that can make an enormous impact on patients and a system that seems highly burdensome and ineffective. However, I anticipate with how nuanced preventative care is becoming that specialists will become increasingly responsible for certain aspects of traditional primary care. I look forward to leveraging these experiences to make a meaningful impact in preventative care as a specialist.

• Patients who have a good relationship with their PCP trust the health system as a whole better.
• India has a primary care system that is underfunded, which has people seeking private care. 
• A third of the U.S. does not have a PCP
• HRSA – number of physicians going into specialties is higher than those going into primary care. (State of the Primary Care Workforce, 2023)