Leading the Transformation of Primary Care
By Audrey Provenzano, MD, MPH
On days when it seems the paperwork and mouse clicks are endless, it is difficult to appreciate the changes we are seeing in primary care. There are still significant bureaucratic and financial barriers between physicians and their relationships with patients, but things are starting to change.
Recently, I had the great pleasure of working with four health professions students as part of the GE-NMF Primary Care Leadership Program. The students, who are all interested in going on to careers in community-based primary care, spent six weeks rotating in our health center and participating in leadership training and project work. Their energy, intellect, and passion have given me hope that the coming waves of primary care leaders will catalyze ongoing change in our profession. As the program wound down, the students asked me what my advice might be for health professions students who want to transform primary care as they head into residency or clinical training. Here are my thoughts.
Primary care is a team sport. Medical training immerses you in an intricately constructed and, at times, cruelly enforced, system of hierarchy in which very clear lines are drawn between the duties of physicians, physician assistants, nurse practitioners and other health care providers.
In hindsight, I appreciate that the strict allocation of tasks and clearly defined roles allowed me to build a solid fund of medical knowledge and the clinical judgement necessary to practice medicine independently. But adhering to this stringent hierarchy can be erosive in other workplace settings, especially in the emerging world of team-based primary care. Physicians are increasingly shifting tasks to colleagues – in some cases, sharing care for a panel of patients with a nurse practitioner or physician assistant or shifting the tracking of certain cancer screenings or chronic disease monitoring labs to nurses or medical assistants trained in population health management. For this system to work, we must respect and trust one another as true colleagues – not rungs on a ladder – and cultivate a workplace culture in which all members of the team are valued and treated as equals. After spending our formative years in physician-centric training programs, embracing a flattened team structure requires a change in perspective and attitude. But learning to appreciate the insights and knowledge of each of our colleagues will allow us to take better care of our patients.
Learn from the leaders around you. During your residency and clinical training, you will meet a wide range of leaders: residents leading your clinical team, attendings, chief residents, nurse managers, hospital and clinic administrators, and program directors to name only a few. Watch these individuals closely. Who do you most enjoy working with? Why? Which teams were the most fun and most functional? How did leaders effectively hold team members accountable when things didn’t go as planned? Were there leaders that you didn’t enjoy working with, and why not? Use these reflections to build your own leadership style. Borrow and try out leadership techniques that you felt worked well as a participant when you become a senior resident and lead your own team. Not all of them will work, but some will. That is how you develop your own leadership style aimed at creating a team culture that is collaborative, accountable, and goal-oriented. Learning clinical medicine and team leadership will equip you well for a future in the changing world of primary care.
Get activated. Physicians exhibit a behavior called “pathologic altruism,” that burnout researcher Colin West says may have led to some of the systemic problems in primary care. He points out that physicians inherently put patient care first, and, therefore, as primary care has become increasingly bureaucratic and broken, physicians have ceded ground to administrators and payors because they do not want to harm patients. And, as burnout experts Paul DeChant and Diane Shannon point out, if physicians do not get activated and even angry, motivated, and organized to improve the experience of delivering primary care, no one else will. When administrators ask you to add one more click or to complete one more form that you think will interrupt your relationship with your patients, push back. Do so respectfully, but push back. Ask them, “How does this additional task advance my relationship with my patients?” Tell them, “This is how I think it will inhibit my relationship with my patients.” Try to work with them to offer alternative workflows that will achieve the same outcome. Only then will we become stewards of our profession and an active, vocal part of the solution to make primary care better.
Audrey Provenzano MD, MPH, is a primary care physician at Massachusetts General Hospital Chelsea Health Center. She is passionate about QI and fixing primary care. She is the host of the Review of Systems podcast which focuses on primary care reform.