For National Primary Care Week, Physician’s Weekly board member Dr. Alex McDonald speaks with Dr. Marc Price about primary care’s role in the broader healthcare system, addressing current challenges and common misconceptions. 

Dr. McDonald: Welcome, everyone, to this week’s podcast. As many of you know, October 6th through 12th is National Primary Care Week. I thought it’d be a great opportunity to have a conversation with a primary care physician.

I’m excited to welcome Dr. Marc Price to the podcast. He is a good friend and a fellow family physician. Hopefully this will be an interesting and enlightening conversation. Dr. Price, thank you so much for joining us.

Dr. Price: Welcome to everybody who’s joining, and thanks for inviting me.

Dr. McDonald: Absolutely. Let’s start with the typical, standard fair question here: tell us who you are and what you do.

Dr. Price: My name is Marc Price. I am a family doctor in independent practice in upstate New York. I’ve been there for about 19 years. Prior to that, I was with a larger group for a few years after residency.

That is my job. I mean, people wear all these hats. I can say I have medical students who rotate through my office, and I can call myself some type of assistant clinical professor, whatever title they give you. I’ve been a medical director at a few different organizations, and I’ve done a lot of things through my professional academy. But, in the end, I’m the family doctor who works in primary care, seeing patients five days a week, taking calls on the weekend, and taking care of my community.

Dr. McDonald: Awesome. So it is possible to practice solo independent practice in this day and age. A lot of the medical students and residents I work with just think that’s not even a possibility anymore.

Dr. Price: Oh, it’s absolutely a possibility. I started my practice from the ground up. My patient census when I first opened was zero. It’s built, and I did that for many years solo, like you mentioned. Now I actually have a partner. We just had a new physician start with us this week. I have a PA with me. I have a nurse practitioner starting in December.

We’re hoping to hire and expand a little bit, only because patients are showing more of a desire to search out independent practices. We’ve seen this because the larger group practices and hospital-owned practices sometimes don’t have the same personal touch and personal care that we can provide. So it absolutely is possible.

Dr. McDonald: That positions you very well to have this conversation and talk about primary care from your perspective, given the fact that you are the CEO, the CMO, the CFO, you’re the everything, right? And you’re practicing.

Dr. Price: Don’t forget CIO.

Dr. McDonald: Oh, CIO, sorry. When the IT system goes down.

Primary care has lots of definitions from lots of different people. But in your perspective, tell us, what is primary care? Is there a definition or is it like you know it when you see it, but you can’t describe it?

Dr. Price: It’s taking care of your community. Plain and simple. We take care of the community, we fill the gaps, whether we like it or not. That’s our job.

For for instance, I have a practice that straddles rural and suburban. I’m more suburban than rural, but I’m still considered a rural site for one hospital system. When money was being given to primary care for taking care of rural patients, I got money for that. But I also take care of a very diverse population. I take care of the community around me.

When I say diverse, I don’t necessarily mean by race or ethnicity. I’m talking socioeconomic. I’m part of a large ACO as well, and they were telling me, “We’re going to focus on a different population. We’re focused on the Black population.” And I said, “Great, find them and I’ll be happy to take care of them.” My population is 98% white, 2% Asian, and then 0.005% Other. I have several Black folks, so I guess that’s the “Other,” I’m not sure who they’re accounting for with that. But my point in saying that is that we take care of everybody.

We take care of folks who are little babies, adolescents, young adults, older adults, and everything in between. We also take care of transgender folks. We take care of everybody—but you can only take care of the people around you, and they happen to be my community. So when I say we take care of the community, that’s exactly what I mean. We take care of everybody in my community. If they want me as a primary doctor, I don’t turn people away. We’re accepting of everybody.

Dr. McDonald: Yeah. Dr. Wanda Filer has described family doctors as the pluripotent stem cells of the healthcare system. You can take a family doctor and put us into any community or any environment, and we can adapt and meet the needs of that community based on the factors around us. I think you’re a great example of that, practicing in suburban-rural community.

Dr. Price: We do have the benefit of having some specialists around us, but at the same time, if there’s a lack of a specialty option, we are the de-facto person. Now, does it make me comfortable to do that sometimes? No. For instance, psychiatry. I never knew that psychiatry would be such a big portion of my practice, but it’s one of my top three diagnoses that I take care of: anxiety, depression, and bipolar.

Do I need help? Absolutely. We sometimes need to find those specialists, and we’re turning to avenues I never thought were going to be available or the best options. For instance, psychiatric nurse practitioners are not necessarily my first option, but if they’re specializing in that, at least there’s some higher level of training or care. I would hope we have telemedicine folks who are doing it that way.

But we do as much as we can to try to avoid having the folks see those other providers. And when I say providers, I don’t mean physicians; I mean providers. I’m a physician. I went to medical school. It’s not arrogance, it’s my degree. I do a lot of orthopedic stuff in my office. Even though I don’t have a CAQ in sports medicine, I do a lot of sports medicine. I do a lot more neurology than I thought I would do. I don’t like doing pain management, but I will do pain management, obviously without narcotics. And we don’t do injections, but we try to help those patients too. We still use our specialists, but with a lot fewer referrals than you would think.

Dr. McDonald: Yeah, and I think your point is spot on. Primary care is the first and sometimes last line of defense when it comes to taking care of the community and treating whatever they come in with, or at least getting the ball started if necessary, escalating to higher levels of care.

Dr. Price: By the way, I didn’t mention the normal stuff we do, like the diabetes, blood pressure, cholesterol, heart failure, asthma. To me, that’s just bread and butter stuff. You don’t mention that.

Dr. McDonald: Right, all the preventative stuff. I love the statistic that for every dollar spent on primary care, you save $13 down the road in other healthcare expenditures. It’s really about treating things early and often and prevention. And that’s why I’m proud to be a family physician and a primary care physician myself. That could be a whole podcast.

Dr. Price: We could have a whole podcast on that. I would love to have us tell people what we need to do. I mean, as you’re aware, the American healthcare system is one of the least effective healthcare systems when it comes to developed countries. We’re only #1 in one thing, and that’s spending. We spend the most for some of the worst care in the world, and that’s just a shame. We talk about best practices in medicine and how to improve care of patients, but we don’t follow it when it comes to our healthcare system.

Dr. McDonald: That’s a perfect segue to my next question. Are we investing enough in primary care? Are we encouraging enough medical students to go into primary care? Do we even have enough primary care doctors in this country?

Dr. Price: Absolutely not. That’s why we have those other providers that are not physicians. They’re hoping to fill the gap that the country’s leaving behind. One reason is we’re not valued as much as we should be. Other countries, I mentioned, have a higher rate of primary care because they value them more and it strengthens their healthcare system, not weakens it.

To give you a prime example, my son is considering going to medical school. He’s studying for the MCATs right now, but he already told me, unequivocally, “I don’t want to be a primary care doctor. I think very highly of what you do, but I don’t want to deal with that.” So he wants to go into specialty care. He is looking at different schools, one of which is NYU. And the reason for that is they offer a free ride to all their students. He said, “I don’t want to come out with all this debt.”

So now, of all these graduating medical students from NYU, the majority are going to go into a non-primary care specialty without any loans. Whereas the primary care specialties are coming out saddled with debt and looking at this, saying, “Well, wait a minute. How are we going to pay off our debt if we’re one of the lowest paid specialties in medicine?” I say “one of,” because every year we compete with the pediatrics group to decide who’s lowest. One year we win, one year they win. It’s a shame that we have to do that at all.

As you know, I’m a big fan of the fantasy genre, like superheroes and Star Wars and all that stuff. I think of us as the Batman of the medical world because we’re the detective. We find out what’s going on. We use our tools. But we’re not valued like a Batman, and that’s what we need.

Dr. McDonald: I think there’s no question that primary care is a specialty. I think it’s a very challenging specialty. Anytime I’m working with a medical student or a resident that has already chosen primary care, I describe that we have this huge breadth of knowledge. We know a little bit about lots and lots of things versus specialists who have a depth of knowledge. They know a lot about a very narrow focus.

Dr. Price: You just fell into the same faux pas that I just fell into, calling them specialists when we’re specialists also. That’s true. Absolutely. So you’re 100% right. That’s just what we’re trained to do. They’re actually sub-specialists. I mean, most of those specialties that we talk about had to start off with internal medicine and divide into something else, so they’re sub-specialists. We’re specialists, and I agree 100% with you about what you just said, that we have this breadth of knowledge and what we need to learn.

Dr. McDonald: And I think that primary care has a PR issue, honestly. Patients don’t understand what primary care is. Other physicians, other sub-specialists, they don’t understand what primary care is. They think we just refer things and we’re sort of like the gatekeepers.

I would argue that about 90% of what I see in my clinic, I take care of. Ten percent of the time, they need to be referred. But truly strong, robust, comprehensive primary care is all about, like you said, taking care of community, taking care of the patient in front of you, and having that huge breadth of skill to be able to do that. I think it’s extremely challenging. It’s extremely rewarding, but it’s also extremely challenging.

Dr. Price: How many times have you had a patient come in and say, “I saw the cardiologist and I wanted to get your opinion. I didn’t understand what they said,” or, “Can you explain this better?” or, “They just told me I should do this. What do you think?” When I say I take care of the community, I don’t mean just the medical specialties and all the different systems. I’m talking about being a trusted confidant of your patients.

It’s also interesting to me when specialists call me—which, every now and then they do—when they call me and say, “Well, I’m seeing one of your patients and I just wanted to talk to you.” And I’ll look at the chart and I’ll either know them from top to bottom because I’ve seen the patient for years and years, or I’ll say, “I don’t know them that well. I’ve only seen them for a year and a half.” A year and a half for a specialist is forever. For us, that’s just a blink, because we take care of them throughout their lifetime. So it’s a difference of perspective. We are there for them always.

Dr. McDonald: I completely agree with you. And that trust piece is so, so powerful, especially when it comes to things which are slightly controversial or not very well understood. The biggest thing right now is vaccines. Nobody wants their vaccines. Nobody trusts vaccines anymore. Well, not nobody, but there’s a large portion. A lot of times, having taken care of the parents, the grandparents, and the grandchildren, I’ve taken care of the whole family for years and years, and they trust me. When I say, “Hey, I really recommend you get your flu vaccine,” they end up taking it and they listen to me, as opposed to the doctor on the screen or someone who they don’t really know. I think that trust is so valuable.

To answer your other question, I’ve had multiple times where patients are seeing a surgeon and they come back and they say, “Well, they recommend surgery. What do you think?” One of my favorite examples is a gentleman in his late sixties who had heart failure. He also had chronic kidney disease. His cardiologist was telling him to take more Lasix, his nephrologist was telling him to take less Lasix, and they were not communicating. And the patient was totally confused.

I was able to navigate between those specialists, looking at the whole body as opposed to just part of the body. The way that I explain it to people is medicine is a wheel and primary care is the hub of that wheel. We hold the wheel together, and we translate the tensions from one side to the other side.

Dr. Price: When you talk about telemedicine, do you know where the hub is defined?

Dr. McDonald: Where the patient lives?

Dr. Price: The patient. We are a spoke on the patient’s wheel. I personally think it should be: the patient is the whole wheel, we are the hub, and the specialists are the spokes. That’s one reason why, with telemedicine, if they’re not in your state, technically you’re not supposed to be seeing them, or at least not billing them anyway.

Dr. McDonald: I think the other piece too is that understanding and having specialists understand that it’s about trust and knowing your community. It’s about patients knowing that. I think patients who have a strong relationship with their primary care doctor understand that.

But I think a lot of patients, particularly younger patients who just want to get care on their app or on demand or video—the Amazon generation, if you will—I worry that they’re going to have worse health outcomes because they don’t have that continuity of a primary care physician who knows them, and they know, and there’s trust. When they get care on demand, is that really quality care? And how is that going to impact that patient population as they age, as they move into middle age and even older age and start having more medical problems? I worry about that.

Dr. Price: I think that’s going to be a problem. I think that a lot of the providers, not physicians, are going to start playing into that because they’ll have a checklist of things. They can check off a box of what they did. Did you do this? Do you do that? Do that.

With most of my physicals, I run down the list of the things that we do with our physicals and the information that we review and update, then what shots you’ve had, if you’re up to date with this screening or that screening and everything else—but it becomes a conversation. That conversation leads into their families, or what they do for their hobbies, or if they’re traveling. And that leads into more conversation, which opens up another avenue of, “Oh, wait, you didn’t tell me about that. Have you thought about this?” That conversation and relationship are huge.

And I agree with you. I think that as more things become amazon.com care and telemedicine, people are going to lose that. Also, I think that it’s dangerous. We’ve had people who’ve been diagnosed with ear infections by telemedicine because it was more convenient. It was promoted by the insurance company to save visits to the doctor and urgent care. We’ve had people who have been diagnosed with bronchitis and pneumonia via a telehealth visit. I have no idea how they look at an ear or do telehealth to diagnose bronchitis or pneumonia without any type of exam.

Dr. McDonald: Some parts of medicine are very algorithmic. You can do this, and then you do this, and then you do this, and then you do this. And I think primary care, and to your point earlier, is so much more intuitive. I remember this so clearly: I was an intern on the medicine service, and we were admitting a patient in heart failure. My attending, who was a—I don’t want to call him grumpy, but he was a slightly bitter, older family doctor.

Dr. Price: He was grumpy. If he’s older, he’s grumpy. I’m getting grumpy right now. Either hungry or grumpy, I can’t tell.

Dr. McDonald: He was grumpy. The patient was in heart failure. Elevated BNP, rails on the lung exam, swelling in the legs. Everything about this said fluid overload. And I said, “We should give him Lasix.” And the doctor looked at the patient and said, “No, we should give him a liter of normal saline.” And I was like, wait, what? Why are you giving him saline?

The next day, somehow, that fluid restarted his kidneys. He peed like a racehorse the next day, without Lasix. He felt great. He went home. And I thought, that’s completely counterintuitive. That was just his gut reaction to that patient. You can’t learn that in any textbook. You can’t teach that in medical school. You just have to learn that through experience in doing and, as you said, knowing your patients.

Dr. Price: Yeah, absolutely.

Dr. McDonald: How do we help educate our patients? How do we help educate other parts of the healthcare team about the importance of primary care, and how they can better understand what we do and interact with us, and vice versa?

Dr. Price: Obviously, through lobbying efforts, through professional organizations. The other thing is, if any of your patients happen to be legislators, that helps. I have a sitting assembly woman. I have a retired New York state senator. I have some chief of staff of different organizations. When you do that, you actually get a little bit of an in. They start calling you when they have questions, and then, by the same token, if you have any concerns, you can go to them.

For instance, last year I was talking to one of them about facility fees, because that’s actually a big thing between primary care and other outpatient offices versus hospital loan practices. We talked about how to narrow the gap of what they get paid, that type of thing. I was talking to her about that. We talked about different things that she can do to make changes, and by educating, it helped.

The other thing is: talk to people. With a lot of my patients, we talk about exactly what we’re talking about today, primary care. In New York, we’re a big fan of universal healthcare among the family doctors, and I am a fan of that myself, too. We end up talking about that. We talk about vaccines. “Oh, you have to go to the pharmacy for this one.” “Why do I have to go to the pharmacy?” “Well, because you have to, because Medicare puts it in part D and not part B, and that is what we get paid from.” By educating people, it helps.

To answer your question—you’re asking, how do we change the system? I think we’re still trying to figure that out. We can talk to everybody and educate everybody, but those aren’t the people who are making the decisions. Until we are able to bend the ear of someone who’s willing to ignore big pharma and hospital systems and associations and say, “You know what? Let’s look at what can help and best practices from other countries that have better healthcare system than us,” I don’t know that we’ll ever be able to make change. We need to get someone who is sympathetic to the plight of the poor, dwindling family physicians and primary care in the U.S.

Dr. McDonald: Yeah. So what you’re saying is it’ll be quick and easy, no problem. Right?

Dr. Price: Yeah, of course. It’s funny, I have a friend who felt that we should let the whole system fail, and out of it, a better system would rise like a phoenix. But I told him it’s not like that. It’s sort of like a boat. We have this big pirate ship.

Dr. McDonald: Who doesn’t like pirates?

Dr. Price: Who doesn’t like pirates, exactly. So our pirate ship has holes in it, and it’s slowly sinking, and we keep putting tar on the deck and patches here and there, and it stops it and slows the sinking. I see a huge boat right next door that’s shiny and new and lacquered and looks amazing. All we need to do is make that tough trek to the new ship and move all of our stuff over, and we’ll be fine. But we’re so intent on sticking with what we have that we’re afraid to move to that new ship.

Maybe the new ship won’t be as good as ours. Maybe we won’t have enough space. Maybe that lacquer won’t last. Instead of reaching for it, taking a chance on it for a better way of doing things and a better ship, we’re stuck on our old ship and we’re refusing to let it go.

Dr. McDonald: That’s a great analogy. You should get your PhD in philosophy after this. You could be Dr. Dr. Price. Yeah, I think change is scary. That’s the bottom line. People sometimes would rather stick with the devil they know than the devil they don’t know. There are a lot of incentives to maintain the status quo. But, ultimately, we know, and we have great data from just about every other OECD nation in the world, that a system based in primary care and comprehensive coverage and access does far better and costs far less. Primary care is the foundation of the healthcare system.

Dr. Price: Absolutely.

Dr. McDonald: In our nation and our country, it’s a completely inverted pyramid, where we have a very tiny fraction of primary care, and we’re trying to balance all these other things on top of it, and it’s just not functioning properly.

Dr. Price: It’s also interesting because primary care in this country gets dumped upon by everybody, the insurance companies and the specialists. I’m assuming you’ve done one or two pre-ops in your life.

Dr. McDonald: A couple, yeah.

Dr. Price: Have they ever said, “Okay, your primary care will get this blood work or the EKG,” or whatever it is? There’s actually no recommendation to do blood work or EKG unless it’s indicated. But they need that for the anesthesiologist before they can do the surgery. I have a policy in my office that I won’t do the test unless I need it for something. If the patient has some type of heart disease, I’ll do an EKG. Other than that, we don’t do the blood work. We have the surgeon order it.

The ones who send things to me or say something disparaging saying, “This is your job,” no, it’s not. I did my job. I cleared them for surgery. Now, it’s your job to make sure the surgery goes on. My partner has a little bit more of a direct message: not your secretary. We make it a point that unless we choose to do it, or if they have heart disease, we don’t do the surgeon’s blood work. We send it back to them and say, “Yeah, we’re cleared. You can get the blood work, and if you have any questions about interpreting it, you can let us know and we’ll help you out.” Just because we are not trying to do everyone else’s job.

How many times have specialists said, “Your primary care will fill out this paperwork?” We don’t do that either. We push it right back to them. They need us to refer them patients, so why would they treat me poorly? So most of them are understanding and follow suit.

Dr. McDonald: I think that’s a great point of helping educate, changing hearts and minds one at a time, so to speak. My last question, and perhaps the most important one that I always ask my guests, is what makes you most proud to be a physician and, in this case, a family physician?

Dr. Price: There are a lot of things that make me proud. One thing that I puff my chest up for is when I’m walking in the supermarket with my kids. One of my kids, or two or three. I have four of them, so usually not all four together, that would be terrible. But I’m walking with my kids, and a patient comes up to me and recognizes me, and it’s almost like I’m a local celebrity. “Hey, Dr. Price, how are you doing?” And we have a little banter back and forth for a minute.

And then, as they walk away, my kids look at me go, “Is that a patient?” And I’ll say, “Yeah.” And I see them smile a little bit. That’s what makes me most proud. That means that I’m doing something good and I’m a role model for someone.

Dr. McDonald: Yeah. Thank you so much for your time. Thank you for sharing your perspective. I hope we didn’t offend or ruffle too many feathers, but I think it’s important that we share that perspective and have a conversation about it. If someone’s out there listening and Dr. Price has something that makes you pissed, send me an email and we’ll have you on the podcast so we can have our conversation.

Dr. Price: Invite me back to sit down with a bourbon and we’ll talk.

Dr. McDonald: Perfect. I like it, I like it. Thank you all for listening. Have a great evening, afternoon, morning from wherever you may be, and we’ll talk with you all soon.

 

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

This transcript has been edited for readability.