Wed. Jun 23rd, 2021

How much impact do social aspects have on one’s health? Recent studies in healthcare suggest that the area of social health has a larger impact than what was previously thought. This has led to certifications in Trauma-Informed Care and studies on Adverse Childhood Experiences (ACEs). These studies suggest that there are many undiagnosed individuals who fall into these categories and calls for primary care physicians (PCP) to be able to screen and identify patients that fall into these groups. To do this, physicians are asked to build rapport with patients and spend the time necessary to be able to fully assess if a patient has had trauma in their past. But do primary care physicians have the time to add this to their already overwhelmed schedules?

It has commonly been said that a PCP has a patient panel of about 2500. A 2016 JABFM article estimated it to be more accurately described as between 1200-1900 patients. Although, they do note that it is particularly difficult to quantify the number of patients in the public sector because patient’s use “ambulatory care sporadically.” Therefore, only about one-third of practices were able to report their patient panel size. A 2018 Survey of physicians found that 80% reported that they were at capacity or above capacity for their practice. 88% of physicians responded that some, many, or all of their patients have serious impediments to their health from social situations. I don’t believe that these physicians that describe themselves as at capacity or over capacity have the necessary free time to adequately access the social aspects that are seriously impeding so many of their patient’s health. 

Adverse childhood experiences (ACEs) are known to cause serious effects on one’s health. ACEs are “potentially traumatic events that occur between 0-17 years of age.” ACEs include things like directly or indirectly experiencing abuse or neglect, instability in the home through divorce, separation, or imprisonment, or household substance use. The CDC calculates that 61% of adults have at least 1 ACE and 16% have 4 or more ACEs. With ACEs being linked to chronic health disorders, substance use, as well as having a negative impact on education and careers, the CDC recommends 6 categories to help prevent ACEs; among them are mentoring programs, enhanced community support, and enhanced primary care. They further explain their vision of “enhanced primary care” as providing “brief screening assessments” followed by “referral to intervention services and support.” This quick screen and referral make sense when considering that PCPs are overworked and do not have time to provide the time needed to tease out the layers that comprise the social situation. I argue that PCPs are in a unique position to better assess the social situations that are linked to the health disparities attributed to ACEs if they have the proper time. The PCPs are well acquainted with the patient and their health concerns. They have a rapport with the patient and can better link the social aspects with the health history that is already known. 

Practices that have direct payment models like direct primary care (DPC) practices often have lower patient panel sizes and spend a great deal more time with patients than high volume traditional clinics. These DPC practices have great rapport with their patients and are able to dive into the social aspects that make up a patient’s health. I argue that these practices are able to provide a better version of “enhanced primary care” that is able to assess for ACEs, link it to the health disparities, and also take the extra time to tailor the healthcare to meet the needs the individual patient needs. I believe that the greater satisfaction that DPC physicians have in their job provides them with drive and inspiration to meet the other aspects the CDC calls for to prevent ACEs: mentoring programs and enhanced community support. I have seen DPC physicians have close relationships with their communities. They often give back to their communities with their free time. The high rates of burnout in the gunslinging, high volume, traditional clinics are estimated at 78% with 46% considering changing career paths according to the 2018 physician survey.2 These high rates of burnout discourage physicians from giving back to their communities with the limited free time they acquire. The happiness that DPC physicians experience allows them to provide the mentor programs and community development as well as the enhanced primary care the CDC calls for to prevent ACEs.

The push to provide enhanced primary care is better suited for those in the direct pay model of DPC than for the cowboys of the high-volume traditional clinics. The DPC physicians may provide more time with patients better assessing their social aspects, identifying ACEs, and then linking that to their well-known medical history. They are further able to prevent ACEs by giving their free time to community and mentoring programs. So, I encourage you to choose ACEs over cowboys.

1. https://www.jabfm.org/content/jabfp/29/4/496.full.pdf
2. https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf
3. https://www.cdc.gov/violenceprevention/aces/index.html

Ben Hauter is a PGY1 at SIU Family Medicine in Springfield, IL. He was inspired to pursue primary care by
his parents whose small-town practices had great impact on their community. Ben’s passion for DPC led
to his parents exit from fee for service and creation of their DPC clinic: Central Illinois Direct Care. Ben
plans to finish his family medicine residency and start his own DPC practice. He Lives with his wife,
Brittany, who works as an occupational therapist, and their two dogs.

10140cookie-checkACEs over Cowboys by Ben Hauter, MD PGY-1

By Kenneth Qiu, MD

Dr. Qiu will be moderating our Resident and Student section. Kenneth Qiu, MD is a PGY-3 family medicine resident who is opening a DPC practice in the Richmond area July 2021. He has been involved with the DPC community since medical school and has worked to increase awareness of DPC for medical students and residents across the country. He’s presented at two previous DPC Summits, serves as a steering member of the DPC Coalition, and is also an innovation consultant to the AAFP.

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