Decline of the Family Doctor, The

Policy Review, Apr/May 2004 by Alper, Philip R

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 com-mon 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 19905, 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 coordi-nator 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 mis-led. 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 residen-cy 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 physi-cians 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 edi-tor 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 physi-cians. 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 consider-able 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. Patients were forced to change physicians without being entirely sure why. Some were dropped when their doctors decided to limit their practices to a specialty, but others with ongoing diseases had to find a different specialist when their doctor decided to register with a given HMO as a primary physician. Such decisions were, and continue to be, made specifically with each insurance carrier. Thus, where formerly the doctor filled both roles, a confusing matrix of practice limitations resulted. Sometimes physicians were in effect required to continue to do both jobs, but to be paid for only one.

The quest for price and volume efficiency by managed care has brought an increasing number of nurse practitioners and physician extenders into the role of "primary care providers." The three-way relationship between physicians, these non-physician providers of care, and patients is unusual. They are well-accepted by patients, and they help busy physicians. But they also create competition for physicians and probably lower their earnings to the degree that professionals with less expensive training can replace them. Though consumers surely appreciate a brake on fee increases, non-physician providers can't really offer the full range of services for which physicians are qualified. How this complicated relationship will work out over time is uncertain and not often discussed.