Academic journal article Policy Review

The Decline of the Family Doctor

Academic journal article Policy Review

The Decline of the Family Doctor

Article excerpt

A "DENNIS THE MENACE" cartoon shows a little girl and her friend asking two little boys whether they want to play "primary health-care provider." This curious bit of insurance company jargon that has been substituted for "doctor"--a phrase that internists and family physicians find so demeaning and depersonalizing--has now reached the comics pages and become common parlance. In a way, the joke made about primary care is emblematic of the crisis in which primary care now finds itself. The issues are important not only to physicians. To the degree that people are patients or consumers (however the two may differ), the outcome of the turmoil in primary care will determine what to expect at the most basic level of health care in the future.

Stephen Schroeder, a recent president of the $8 billion Robert Wood Johnson Foundation, notes that primary care has been on a roller coaster. In the early 1990s, managed care attempted to use primary physicians and nurse practitioners to improve access and quality while, at the same time, keeping costs down. There was talk of the primary physician as the coordinator of all medical care. It didn't work, and the backlash resulted in a decline in prestige, job satisfaction, and income for primary physicians. Many of the young physicians who flocked to the field felt cheated and misled. At the same time, the average medical student's educational debt has climbed to just under $110,000 today. More than 25 percent of students are burdened with a debt greater than $150,000--a figure that further affects career choice for the next generation of physicians.

Graduates of American medical schools filled only 47 percent of residency training positions in family practice in 2002, a drop from 73 percent six years earlier. Similar trends are present in general internal medicine. The reduction in satisfaction that affects most branches of medicine is worst in primary care, according to Schroeder and others. Both the public and physicians in training are fascinated by new technology, and this is increasing interest in medical and surgical specialties at the expense of primary care. Income differentials are considerable and increasing.

These details are of more than academic interest, even though, as an editor once put it to me, "The public has trouble empathizing with physicians because it is difficult to identify with them." Nevertheless, walking the proverbial mile in the moccasins of both primary and specialty physicians can provide insights available no other way.

"Anatomy of an Internist"

SPEAKING OF "my doctor" typically has meant a primary physician with generalist training. In the United States, however, patients with such diseases as arthritis, diabetes, lung disease, or heart disease would often choose corresponding medical specialists--rheumatologists, endocrinologists, pulmonologists, or cardiologists--as their principal physicians. Since all medical specialists have had training in internal medicine, they often came to fill the dual role of specialist and generalist, most often for patients with ongoing illnesses in their specialties. This brought considerable depth and expertise into primary care. It also narrowed the specialist/generalist divide that is characteristic of medicine in the rest of the world.

Managed care managed to disrupt this arrangement. Whereas specialists predominate in the United States by a margin of 2-1 (the reverse of the ratio in most other Western countries), managed care typically forced physicians to declare themselves either specialists or generalists, and it was easier and more lucrative to be a consultant rather than a jack-of-all-trades.

What began as a desire for administrative simplicity by health insurance carriers (and no doubt as a way to obtain care more cheaply, since specialists tend to use more resources) had the perverse effect of weakening primary care and contributing to a reduction in the work force. …

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