I worry…

As I talk to medical students about their futures…I still worry that I cannot recommend family medicine as wholeheartedly as I once did…

Don’t get me wrong.  I happen to think Family Medicine is what all primary care physicians should be.  I really don’t think the world needs internists, pediatricians and non-surgical OB-GYNs.  I don’t think physician extenders should do primary care.  I think we need well trained physicians – educated about all ages and conditions doing the routine health maintenance and disease management stuff for a majority of the population.  I think we should provide maternity care for routine deliveries.  I don’t think we should provide hospital care, especially nowadays, when people are sicker, stays are shorter and efficiency is demanded.  Family physicians, well-trained in office systems, preventive care, diagnosis, and chronic care management, can use extenders to deliver routine, protocol driven primary care in non-traditional interactive ways, and can reserve patient visits for the stuff that we’re good at – evaluating undifferentiated illness, monitoring for severe disease/need for referral, assiting with behavior change information, etc.

Several problems have emerged recently, however, to make my ideal a non-reality in the US:

1.  Many people in America think they’re smarter than a primary care physician, and consider themselves ill-served if they don’t consult a specialist for whatever they think they’re problem is.  I’m sure that our specialty reinforces that to some extent with inattentive prescribing, referral and a general patient-machine mentality so that we can earn an income.  We are also victims of the logical fallacy that given the same number of years, internists and pediatricians will be better at primary care than family doctors because they spend more time doing their relative specialty (adults or kids) as opposed to family doctors (who do adults, kids, surgery and maternity/womens’ care all in the same three years).  We’re not allowed to make definitive judgements by patients, because the patients know that there’s someone out there (a specialist) that’s "more focused" on that particular condition, and if they’re paying for a "service" (ugh…), then they ought to get the most out of that service.

2.  My impression is that internists, pediatricians and "women’s health specialists" (the OB-GYN’s have even forgsaken their names…) are appealing to this specialty focus, and we (family doctors) are abandoning our focus on family systems and dynamics, and just trying to pass ourselves off as excellent primary care physicians.  This is too dilute a message in comparison with the messages from the others…they can be considered just as good at primary care in the other specialities…

3.  The public doesn’t value, and sometimes considers a threat, the idea of a single physician for everyone in the family.  Privacy issues, ickiness factor…whatever.  People seem to not appreciate that any longer.  I try to bring out the value of that to all the students that rotate with me (even the current one…going into "med-peds"…AARGH!), but I’m not sure it’s helping.

So, I sometimes get discouraged.  I know family doctors can be a boon to any community they’re placed in.  The Navy certainly felt that way (at least when I was in).  We would certainly be valued in developing countries.  Why not here?