Are Family Doctors Outdated?

“Family Physician Can’t Give Away Solo Practice.”

So heads a column written by Gardner Harris for the New York Times last week. Which raises the question: Are family doctors outdated? It's an idea that I have written about before, but because of its reappearance in the Times, and the fact that it is both an observation and an advocacy position, I want to revisit the whole basis of primary care. There is an obvious and major potential financial impact for all involved.

There are two “big ideas” here: The first is that we are seeing a shift from a small-office concept functioning independently, sprinkled unevenly around the country, to a larger group-practice form, possibly with smaller offices outlying, but all connected by a "feeder" office. The reasons for the change are numerous, including more collegiality and a more humane share-the-burden lifestyle approach. But the main driver is economic, and it is only beginning to flex its gigantic, behavior-altering muscle.

Specifically, most primary care doctors have lost the option of hanging out their own shingle. They graduate with six-figure debt, can't obtain a loan to get their businesses started, and have a pent-up desire for a long-delayed better life. And with costs so high for up-to-date technology, such as the soon to be required electronic health record system, the cost of an office-based start-up loan has become daunting -- if you can qualify for one, that is. Never mind the question of whether they’ll have the ability to repay all these loans amid the uncertainties of the managed care and Medicare marketplace.

So young doctors are opting in droves to join group practices or hospital systems, put no money into the business and earn a good salary from the start. Shared call, flexible vacation time and generous (read expensive) benefits are the cherry on top. No wonder an increasing number of established physicians are also voluntarily giving up their existing small practices and joining their younger confreres in the rush to groups.

It makes rational, organizational sense to reorganize our patchwork use of healthcare resources to a centralized form. We can then plan a more efficient means of managing our scarce resources, human and economic. Enough with the finger in the dyke approach. All reaction and no proaction make Dr. Johnny a poor boy.

Though some doctors will argue the point, better medical practices and better outcomes are the likely upshot. I cited last week that Dartmouth College’s medical school, for one, is going to a team paradigm and away from the Lone Ranger model. In this age of massive informational overload, and with new enabling tools such as the Internet and hand-held access, such a change in approach is past due. I am not the first to say that no one -- no matter how smart, how diligent, or how well-trained -- can master modern medical knowledge or, critically, its application. We all need systemic redesign to better function.

The second “big idea” is that in these new accreted groupings, much of what traditional primary care doctors do -- family practice, internal medicine, pediatrics, or even OB-GYN -- does not justify the length, depth or expense of their training. I know that I am goring my own ox here, but if those of us thus occupied were to be brutally honest about it, we are probably over-trained for the overwhelming majority of what we do every day.

I have worked with and supervised many physician assistants (PAs) and family nurse practitioners (FNPs) over the years and they do a uniformly good job handling the majority of the same patients and problems that we do. It takes a fraction of the time and expense to them, and it costs significantly less to employ them. Economics -- the best rational use of scarce resources in an increasingly sensitized marketplace -- will force us collectively to take a good hard look at ramping up these programs, in lieu of further development of primary care residencies.

In 2014 there will be at least 30 million more Americans with health insurance. Who is going to take care of them? You? Me? We're already booked. And we don't have the 10-plus years needed to get additional doctor training booted up and producing physicians by then. What we can do is get PA/FNP programs up and running, and producing trained professionals, in half the time and at a fraction of the expense.

We will still need secondary and tertiary specialists for the indefinite future of course, and we should consider bolstering some of these programs in a planned, rational way to fill in perceived gaps and reduce oversupply in other specialties. Corresponding adjustments can be made in improving distribution of these specialists, which aggregate groupings may internally facilitate.

There would also be the mutual benefit of specialists not having to do primary care functions to pay the rent, and to screen for "good cases" in areas where there are too many of specialists inappropriately concentrated. Don't scoff! I've seen it too many times to count in my over-doctored field. And the worst part of it is that, in their need and arrogance, the doctors believe they are doing an OK, or even better than OK, job of primary care, even though they were not trained to do it and their hearts aren't really in it. We do a better job for ourselves and our patients if we just stick to our knitting.

There you have it. In sum, medical training could serve its patient population better by developing a more cost-effective model; more physician extenders to do triage, prevention and simple problem-solving, instead of more time-consuming and expensive training required for a smaller number primary care docs. We could also do a better job of it in larger, centrally planned groups, using salaried extenders and niche specialists working together. What do you think?