As I lay on the stretcher in the pre-op area before my shoulder replacement, I fretted about what could go wrong. I had selected an excellent surgeon and hospital, but one very specific concern popped into my mind: the doctor operating on the wrong shoulder. Just then my surgeon came in. With hardly a word, he took out a black marker and made a big “X” on my right shoulder.

“Perfect,” I thought to myself. “He addressed my one worry.”

Throughout my surgery and recovery, the only tasks he did were ones no one else on the health care team could or should do.

In his office, he had a scribe enter data in the EHR and staff who performed all other paperwork. In my entire 12-month course of care, I think he spent no more than five minutes on data entry. At the hospital, he had registration receptionists, followed by pre-op staff, operating room scrub nurses, post-op staff, floor nurses and aides, and occupational and physical therapists. They all supported the surgeon during my one-day stay in the hospital so that he was able to work at the top of his license.

If only primary care physicians were able to do that.

A POWERFUL PRINCIPLE

Working at the top of one's license is an operations management principle I learned 30 years ago in business school. Eliyahu Goldratt's classic book The Goal¹ describes it well: If you are manufacturing a product (in my case, a new shoulder), you want all your resources to support the most valuable piece of equipment (i.e., the surgeon) to make sure no bottlenecks or constraints prevent that piece of equipment from functioning as efficiently as possible. This basic manufacturing principle has now become widely adopted in medicine, with good results in places like operating rooms and emergency departments. But clearly it's not been fully operationalized in all medical settings.

I contrasted my surgeon's situation to my experience as a primary care physician, formerly in private practice and more recently as an employee in a hospital-based system. In both settings, I was lucky to have a receptionist and a medical assistant. No nurse, no scribe, no other ancillary staff.

Why the difference? First, a surgeon's work is much more highly valued than a primary care physician's work — despite studies showing primary care's high return on investment.^2,3 Second, our foremost purpose as primary care physicians has been recast from being relationship-based comprehensivists to being documentarians.

THE SECRET SAUCE

Many years ago, I had the honor of having dinner with the great primary care physician-researcher Barbara Starfield, MD, MPH. She said the “secret sauce” of primary care was providing comprehensive care within a therapeutic, trusting relationship.⁴ But that's difficult to do these days. Due to the amount of money that depends on proper documentation of quality metrics, severity of illness calculations, and the like, health care organizations and even independent primary care practices have repurposed the workload of primary care physicians from providing that secret sauce to “documentation medicine.” Primary care doctors are left to perform myriad menial tasks anchored by mind-numbing data entry that now consumes more than half our workday.⁵ This takes away our most important tool: face time with the patient — the family physician's equivalent of the surgeon's scalpel.