Paul M. Fischer
After an exciting and challenging day of caring for patients and teaching students, a third-year medical student on his family medicine rotation says to me, “I really like what you do, but I just cannot afford to go into family practice.” I realized that by “afford,” he was referring not only to finances but also to the expectations of his parents, friends, and medical school. After spending 35 wonderful years as a family doctor, I have been “dissed’ by a kid who wants to become a dermatologist.
So I am of two minds. Part of me is fulfilled by being needed, loved, and respected by my patients.
Over time, they have increasingly looked to me to diagnosis, advise, reassure, and guide them through a complex healthcare environment in which few others offer them help. Another part of me sees that what I do is increasingly devalued by forces outside the exam room ― those who pay for health care, those who question the “medical necessity” of each test I order or drug I prescribe, and those in medicine who are more likely to know a procedure’s CPT code than a patient’s name.
We are in this position because we have failed to define ourselves, instead allowing others to perpetuate myths about what we do. The first such myth is that what we do is easy. Nothing can be further from the truth. In about 15 minutes, we are asked to treat a long list of chronic problems (e.g., diabetes, obesity, hypertension), resolve a few new problems (eg cough, headache), address preventative health recommendations (eg, smoking, flu shot), integrate the psychosocial issues that impact the patient’s health, and figure out how to get it all paid for by an insurance company using codes that don’t really match either my patient’s problems or the care I provide. Oh, and by the way, can you look at this rash and fill this prescription for my husband? Recent research has shown that an average primary care visit is 50% more complex than a visit to a cardiologist and five times more complex than one to a psychiatrist. So no, it is not easy.
The second myth is that it requires less training than other medical specialties. This has resulted in some assuming that primary care can be left to “midlevel” clinicians. While physician assistants and nurse practitioners can work effectively in primary care settings, it is a mistake to believe that they provide equivalent care to patients with complex problems, and we have suffered by the wide acceptance of this assumption. OR techs can work effectively in an operating room, but no one suggests that they replace surgeons.
A third myth is that all we diagnose is colds. Patients present with a vast sea of undifferentiated complaints. Most of these are diagnosed in primary care. After all, most patients’ cancers are diagnosed before the patient gets to the oncologist, and someone has already figured out that the problem is renal before a visit to the nephrologist. For a cardiologist, the biggest diagnostic dilemma is really whether the patient has or does not have coronary disease. There are, in fact, few medical specialties other than primary care where the doctor doesn’t know the disease before opening the door to meet the patient. And many common complaints are complex. Consider for example, “I’m tired all the time.” Does the patient need a TSH, a cardiac echo, an SSRI, or a little time and reassurance? Sorting all this out is beyond the talents of the endocrinologist, cardiologist, or psychiatrist. It requires a good family doctor.
A final myth is that we function as “gatekeepers.” The image here is that the good stuff is behind the gate and family physicians are barriers blocking patients’ access to it. This obnoxious concept was perpetrated by managed care organizations, which did a great deal to misrepresent the value we bring to healthcare. My goal is to match the right patient with the right treatment at the right time. In this day of unnecessary heart caths and back surgeries, patients need someone they can trust to have their best interest at heart.
These myths and others have resulted in devaluing the image of primary care at a time when it is needed most. Thirty million Americans will be added to the insurance rolls by 2014 and state Medicaid budgets will go broke. It did not have to be so bad, but my student became a dermatologist instead.
Paul Fischer is a family physician at the Center for Primary Care in Augusta.
Care And Cost 
Healthcare Independence Means Primary Care Empowerment
From my 30 plus year perspective in healthcare, Dr. Fischer’s comments are very telling. The forces behind the myths and perceptions Dr. Fischer describes are becoming increasing nervous about losing control over a very profitable “status quo”. Much like “energy independence” would impact energy revenue for those who profit from high costs of certain forms of energy, the type of healthcare independence that would be created from primary care empowerment would naturally reduce the demand for the more expensive forms of healthcare service.
A major component of establishing value for primary care is allowing these practices to invest in a meaningful amount of time and effort in improving the healthcare literacy of their patients. Only primary care can offer this type of support for their patients given the fact this “information therapy” must be whole person oriented to be truly relevant to the individual. The dispensing of patient centered information must be part of the compensation in a way that recognizes and rewards the quality of the effort.
Overcoming the forces behind maintaining the status quo will take a concerted and sustained “partnership” between primary care physicians, patients, and the employers (both public and private) who sponsor the benefit plans that imply the value of primary care. While this notion may suggest creating an “us vs them” with the rest of the healthcare industry, it need not. Anyone able to translate restoring value to primary care into their own “enlightened self interest” should be welcome to join the partnership. The “enlightened self interests” for the current partnership mean primary care physicians able to fulfill their true potential, patients who are able to improve their overall health status, and employers who are able to effectively lower the cost of employing people. Finding the “enlightened self interest” for those who’s current business model requires healthcare dependence will be difficult, but I believe it can and must be done. Otherwise we’ll never achieve primary care parity, let alone establish its true value.
Jed
Paul: A wonderful, and wonderfully accurate set of comments. I went in to family medicine in 1980, after an internship of one year. After serving in the National Health Service Corps and nine years in my own private practice in McAllen, TX, I moved to Chapel Hill, NC, to finish a residency in family medicine at UNC so that I could become board certified in our specialty. So, in 1990, at age 40, I felt as though I was the oldest resident in Christendom! I also encountered a new generation of medicine (the AIDS epidemic made us all fearful of blood and bodily fluids ) and new attitudes about family medicine and family practice. What I heard from the medical students was the attitude that not only was family practice not going to pay well, but that is was TOO HARD! You would have to know all that medical and surgical information, about all those many conditions and problems you were going to treat! Much easier to focus on the skin — dermatology — the gut — gastroenterology — the hips — orthopedic surgery. The profession of medicine has suddenly, it seemed to me, about choosing which organ to serve. Not how to serve people or communities.
My sense is that this change was multi-factorial in its origins. Society was pushing for specialization, as were the insurance companies and the pharmaceutical companies. Being a “generalist” was a derogatory term that implied knowing just a little about many things, while knowing nothing in particular, and applied to other professions beyond medicine and health care.
Whatever the reasons, the ideal of taking care of whole human beings in communities, and of “specializing in all of you” became terribly tarnished in the 1990s and well into the 2000s. I am glad to see you writing about these myths, and hope that we can see a reversal of these wrong-headed ideas soon.
Kind regards, DCK
Paul, you are right on target here and if anything, your case is understated. The fragmentation of our system into a situation in which “partialists” dominate reflects science and systems that are decades old. That organization represents an era when the rotary phone and the retailing of the local hardware store were the “new thing”. The metabolic underpinnings of hypertension, high cholesterol, adult onset diabetes, arterial disease, heart attack, stroke, and kidney failure are all interrelated. Coordinating and integrating the science and systems to deliver optimal medical therapy to these patients with multiple chronic conditions is incredibly complex work. In the adult onset diabetic patient with renal disease, the kidney function can actually improve when the pressure, glucose and cholesterol are aggressively managed with lifestyle and carefully selected medications using modest resources. The number of patients going on to dialysis can be reduced 6-fold. ONLY primary care can deliver that kind of treatment today and that care has very high value. Thanks for calling our attention to this very important issue.