The Way I See It

I'm a primary care physician—and proud of it!

Some think general medicine has lost its stature. Not this doctor.

Marc A. Ringel, MD

When I was in medical school in the early 1970s, the typical lecturer had this much to say about the whole patient:

"Of course, when treating this disease, one must address the needs of the whole patient. Now, if you'll turn your attention to the first slide, you'll see that the smooth endoplasmic reticulum . . ."

Obviously, those lectures were seldom delivered by primary care doctors. Our first physician role models were not merely specialists, they were subspecialists or researchers. These were the "real doctors" most of us patterned ourselves after.

Medical school has become a bit more appreciative of the whole patient since my day. Still, prejudice against primary care and the generalist physician who delivers it is deeply embedded in our system. This prejudice extends to society, as well, as reflected by the huge income disparity between generalist and specialist.

Medical Economics reinforced this prejudice recently in an article published in the Sept. 3, 2001, issue. Titled "Don't call me a primary care physician!" the article illustrates the devaluation of primary care among doctors—even by some of those who practice it. The author, general internist Alan Roberts, voices frustration at how his scope of practice has been whittled away, because internists have been relabeled "primary care doctors."

Since I myself am a family doctor—the ultimate primary care physician—I have spent my career coming to grips with what primary care really means.

One thing I'm sure it doesn't mean is a reduced scope of practice. I'm also sure that any barriers I bump up against aren't due to the label "primary care doctor." They're due to managed care, hospital policy, and, most often, to colleagues from other specialties fighting for turf.

Family medicine is a relatively new specialty, founded in 1968. It's the inheritor of the noble but depreciated mantle of general practice. Our field has had to be exquisitely self-conscious of its role in the subspecialist-dominated medical universe. Backed by the American Academy of Family Physicians, my colleagues have fought unceasingly for privileges to attend to patients on ventilators and to perform such procedures as endoscopies.

But there's a more important part of our battle against subspecialist domination than merely fighting for our share of the procedural pie. Family medicine is constantly struggling to redefine medical practice and the medical education system. Our goal is to get the medical establishment to truly address the whole patient (without slighting the smooth endoplasmic reticulum).

About a decade ago, the AAFP hit upon the perfect slogan: "The one doctor who specializes in you." The slogan isn't just public relations. The breadth of our medical knowledge and depth of understanding of our patients are our most important (and underappreciated) tools for healing. A good family doctor is so much more than an agglomeration of internist, pediatrician, obstetrician, surgeon, and emergency physician.

Within the field of internal medicine, I appreciate the role of a general internist. When I have a complicated adult patient with uncontrolled hypertension, borderline renal function, and dyspnea, I would much rather refer to a general internist than to a cardiologist, nephrologist, and pulmonologist. To borrow from Mark Twain, "To a man with a hammer everything looks like a nail (or heart or kidney or lung)." What I most value about a general internist is the ability to bring to the bedside a generalist's broad overview plus the internist's depth of understanding of adult medicine. General internists should work to raise public appreciation of the unique value of this merger of generalist and specialist. Rather than deny that they are primary care doctors, they should embrace this label.

In his Medical Economics article, Alan Roberts recounted the tale of Izzie, his 85-year-old diabetic stepfather, whose care was compromised by lack of a competent generalist to manage his case. Whether Roberts likes it or not, that competent generalist is what we call a "primary care physician."

The author is a family physician in Greeley, CO.

 

Marc Ringel. I'm a primary care physician--and proud of it!. Medical Economics 2002;3:61.