Why tomorrow's FP won't look like today's

September 6, 1999

The hospitalist dilemma. The midlevel provider threat. Population management. Preventive medicine. Provider report cards. Electronic medical records. They're shapingand cloudingthe future of family practice.

Cover Story

Specialty Profile: Why tomorrow's FP won't look like today's

By Neil Chesanow, Senior Editor

The hospitalist dilemma. The midlevel provider threat.Population management. Preventive medicine. Provider report cards. Electronicmedical records. They're shaping­ and clouding­the future of familypractice.

Family doctors are changing to meet the evolving needs of managed care.But people in transition are often disgruntled, so it's no surprise thatmany FPs are upset.

One fear is that broad swaths of their traditional turf may be reassignedby health plans to hospitalists and midlevel providers. If an FP's scopeof practice is further narrowed, the doctors fret, health plans may getthe idea that these physicians are overpriced--or even expendable.

At the same time, health plans are pressuring family doctors to fundamentallychange how they practice--no small challenge. Instead of spending most oftheir time diagnosing and treating disease in individual patients, FPs arenow supposed to focus on disease prevention, managing populations of chronicor at-risk patients, and on follow-up care of patients with complex illness,who are being discharged from the hospital quicker and sicker.

How will such developments affect FPs? Which threats are real and which,at least at this stage, are overblown? What challenges and opportunitieslie ahead?

Will FPs' role change for better or worse?

Primary doctors are caught in a financial squeeze. On the one hand, theirreimbursements are shrinking. On the other, their bonuses and withhold returnswill increasingly be pegged to scores on provider report cards that showhow well the doctors are meeting the new health plan mandates for populationmanagement and preventive care.

Doctors with below-average report card scores who fail to adopt healthplan-designated best practices may eventually see bonuses, even reimbursements,docked. And if that doesn't spur them to get with the program, health plandeselection is a risk. As a result, pressure is mounting not only to seemore patients a day, but also to get more patients into the office for preventivecare.

To handle this increased patient load, "many family physicians willmove toward a more supervisory role," predicts John C. McFadden, anFP in High Point, NC. "In the future, we'll spend most of our timeoverseeing midlevel providers and coordinating specialists--not treatingpatients. An FP may go through 100 charts a day but see only a few of thetoughest cases."

Family doctors who enjoy patient contact may find this prospect dismaying.But that's yesterday's thinking, McFadden asserts. "We'll need to changeour mindset and take satisfaction from caring for large groups rather thanindividuals," he says. "We'll need some patient contact--that'swhy we're FPs. But it may be only with the most complicated patients, whodon't easily fit a protocol that a midlevel could follow."

This poses a problem. Many FPs lack management and leadership skills,as midlevels and nurses amply attest. How adroitly will the doctors handlemore complex supervisory responsibilities? Another snag: Will today's FPsfind fulfillment in largely bureaucratic roles? Will tomorrow's?

The whole debate raises this overall question: What is an FP? Is familymedicine no more than a series of tasks that's done by a physician out ofconvenience? If so, why not farm out some or even all of those tasks toother, less expensive providers? Or is an FP's maestro-like orchestrationduring a patient encounter--made possible by his greater training and globalknowledge of the patient--a must for the highest-quality care?

New research suggests that this may indeed be the case. Most effortsto improve health care have been made without a full understanding of thevalue of a primary care physician's contribution. But a recent study setout to rectify that: 4,454 patient visits to 138 FPs in northeast Ohio weredirectly observed--by specially trained "research nurses"--tosee what goes on.

The study's conclusions, which were published in The Journal of FamilyPractice in May 1998: "Family physicians prioritize and delivercare according to a broad agenda based on patient needs. These needs areunderstood within ongoing relationships with the patient, family, largerhealth care system, and community. This integrative approach includes numerousavenues for affecting important patient outcomes that are unlikely to beoptimally met by less integrated models of medical care."

Farming out parts of an FP's job to other providers is clearly disintegrative.Specialty carveouts pose a similar problem, notes Patrick B. Harr, formerpresident of the American Academy of Family Physicians. "Who's lookingout for the whole patient in that situation?" he asks. "Usuallyit's nobody."

But how well do family doctors look out for the whole patient as it is?In some cases, to be sure, they're just as conscientious as their forebearswere. Take Paris E. Phillips, a solo FP in Jericho, NY. "Many patientswho come here don't really need me medically," she observes. "Butsomething is bothering them. I have them crying in my arms. 'It's okay,'I tell them. 'Let it all out.' And they feel better. I think that's medicine,too."

While more FPs are learning psychotherapy because they recognize thatfamily medicine involves more than treating somatic illness, colleaguesin heavily managed care environments are often, out of necessity, gearedfor problem-focused visits that are short and sweet. Do doctors who areinclined or pressured to be efficient have time--or even consider it partof their job--to deal with a patient's psychological problems, let alonethe emotional or physical problems of other family members? And if theydon't, are they practicing family medicine--or something less?

Something less, many doctors believe. "FPs as a whole are in a stateof grief," reflects Suzanne DeBremaecker, an osteopathic FP in Clintonville,WV. "The production-oriented environment we're being asked to workin isn't conducive to practicing good family medicine," she contends."Most doctors I talk to at family practice meetings say, 'If I couldget out, I would.' "

But not everyone agrees with this assessment. One dissenter is MichaelW. McShan, a solo FP in Kilgore, TX. McShan sees about 40 patients--includinginpatients--a day. (The median for all FPs is 25 patients a day, accordingto the annual Medical Economics Continuing Survey.) A visit in hisoffice often lasts 15 minutes. "I start out by talking about personaland family matters, then go on to what the main problems are," McShanexplains. "At the end, we discuss how to make things better and improvethe patient's physical well-being. Patient literature, much of it availablefrom the AAFP, helps me speed things along."

So it's possible to cover all the bases. Moreover, doctors who bridleat time constraints aren't powerless. Phillips, for instance, is generouswith her time--managed care be damned. While her income is now $100,000less than what it was five years ago, due to health plan reimbursement cuts,she refuses to run a turnstile practice.

"If you have a sore throat, I don't just look at your throat,"says Phillips. "I ask about your mother, your kids. That's the kindof person I am--and the kind an FP should be. It's a family situation. Youcare for the whole."

As her own boss, of course, Phillips is free to make such decisions.But even doctors who are employees may be given a choice. Says John McFaddenof the 75-doctor multispecialty group in North Carolina that he belongsto: "We cost-account everything back to the individual site. If youdon't want to see a lot of patients, that's fine. You just don't make verymuch money. This system lets doctors operate at their own comfort level.As long as they meet their overhead, anything left over is what they getto take home."

Other doctors employ more sophisticated strategies to maintain theirindependence or gain empowerment:

  • Former AAFP President Neil Brooks, who heads a four-FP practice in Rockville, CT, helped form a primary care group practice without walls. It includes 22 FPs, internists, and pediatricians who continue to work in independent practices but now have centralized management.
  • AAFP President-Elect Bruce Bagley's group of eight FPs in Loudonville, NY, is investing in electronic medical records, which Bagley expects to greatly improve the flow of work .
  • Jeffrey M. Bishop, an osteopathic FP in West Palm Beach, FL, has become an entrepreneur. He's hired a hospitalist and an acupuncturist who take referrals from outside doctors as well as from the 10 FPs in his group. An alternative medicine center is also in the works.

So despite health plan pressures to practice differently, a family doctorneed not remain passive. On the contrary, there are more opportunities thanever to find a compatible niche--or even dual niches.

"In the future, we'll see a wider diversity of practice styles thanwe have now," predicts McFadden. "How individual patients aretreated will show less variability over time. But the format in which doctorspractice will vary more and more."

McFadden foresees that "in rural areas, there will be soloists whocontinue to do everything. In urban areas, large single- and multispecialtygroups will grow in popularity. More physicians will work part time, orjust do outpatient medicine, or specialize in inpatient care. Some doctorswill switch between administrative and clinical work. There will be no onedescription for an FP."

Will hospital practice figure into FPs' future?

Some FPs fear the spread of hospitalists; others welcome it. The concernof the former is that they and their patients will be compelled to use hospitalists."Patients deliberately choose me as their personal physician,"stresses Neil Brooks. "Now, when they're put in the most vulnerablesituation of their lives--a hospital stay--they may be assigned a physicianwhom they haven't chosen and don't know."

The repercussions for primary doctors will also be profound, warn theseFPs: Without inpatients, family physicians' hospital skills will atrophy,opportunities to learn from informal encounters with specialists will diminish,and hospital privileges--often mandatory for health plan providers--maybe revoked.

"If the physician and the patient choose to have inpatient caredone by a hospitalist, that's fine. But we don't want mandatory hospitalistsystems," Bruce Bagley insists, echoing the position of every majordoctor group, including the National Association of Inpatient Physicians,the hospitalist organization.

Hospitalist systems are usually voluntary, at least at the outset. Nevertheless,studies show that at least 50 percent of FPs and about one-third of internistsbegin using hospitalists immediately. And within two to three years, mostof their colleagues voluntarily do likewise. Typically, hospitalist usethen becomes mandatory for the remaining holdouts.

This transition period gives primary care physicians time to adjust toa hospitalist system. So the process has, for the most part, occurred quietly,avoiding mass protests. But when health plans have tried to impose mandatoryhospitalist systems with no transition period, organized medicine's oppositionhas been vehement. For instance, when it looked as if Prudential HealthCarein south Florida and Cigna Health Care of Texas were going to impose mandatoryhospitalist systems earlier this year, the AMA, AAFP, American College ofPhysicians, and 20 other physician groups fired off an outraged letter tothe American Association of Health Plans decrying the moves.

Some health plans are trying to dodge opposition by introducing hospitalistsystems that are nominally voluntary. Under these systems, primary doctorswho insist on seeing their own inpatients must come close to achieving thereduced lengths of stay and lower costs that hospitalists realize. Or atthe least, these doctors must meet health plan-defined "benchmarks,"as Prudential HealthCare in south Florida put it when claiming that itshospitalist program wasn't really mandatory. But the ability of primarydoctors with busy outpatient practices to meet such benchmarks remains tobe seen.

On the other hand, primary doctors who are employees are increasinglybeing compelled to use hospitalists--with no transition period. The mandateis being issued not by health plans, the focus of fears today, but by theiremployers--hospitals and doctor groups. The employers most likely to imposemandatory systems are those with full-risk contracts that promise the doctorshandsome bonuses at year-end if inpatient costs are controlled. As a result,employed doctors aren't, for the most part, complaining. They have an economicincentive not to, and their hands are generally full just trying to meettheir outpatient production quotas.

Nor are FPs in rural areas upset when hospitalists move in, as they'reincreasingly doing. That's because the nearest hospital may be far away,and finding a doctor to take call is a constant hassle. It no longer makessense, for example, for Dwalia S. South, a family practitioner in Ripley,MS (and president of the Mississippi Academy of Family Physicians), to seeinpatients. Her local hospital is moribund, having shrunk from 120 bedsin the early 1980s to about 20 beds today, most occupied by residents ofan adjacent nursing home.

"The hospital has no specialists at all," South laments. "Itsadministrators haven't even been able to recruit an ob/gyn. It's reallya place where people go to die."

South, who sees about 35 outpatients a day, now refers her inpatientsto a hospitalist recently hired by the hospital in Tupelo, MS, about 50miles away. "I think hospitalists are great," she says. "We'regoing to see a lot more of them."

True, without inpatients, FPs' hospital skills will erode, but skillloss is inevitable without a large hospital practice. Curbside consultswith hospital specialists will be sorely missed and may pose training problemsdown the line. But for now, it's the price of progress in trying to reinin costs.

How much competition from midlevel providers?

Nurse practitioners and physician assistants maintain that they can domost of what a family doctor can do, and that they can do it just as competently,without supervision, and for less money. Since FPs often fear that anycost-cutting opportunity is irresistible to health plans, regardless ofhow it affects quality of care, many are concerned that the midlevels willbe taken at their word and permitted to become unsupervised competitors.

Adding fuel to the fire, some states are allowing NPs and PAs to be reimbursedat a higher rate. In New York, for example, health plans reimburse NPs practicingfamily medicine without supervision at the same rate as family doctors.So groups that previously would have hired an FP now have an economic incentiveto hire a midlevel provider instead. Health plan income would be unaffected,and the midlevel's lower salary would improve the group's bottom line. Ifenough groups did this, it could result in a shrinking job market for FPsand force them to accept lower salaries.

"The midlevel threat is one of the top complaints of AAFP members,although I think that fear is unfounded," concedes AAFP President-ElectBruce Bagley. "We clearly have more to offer. I don't see midlevelssupplanting FPs."

But midlevels may have a point, admits FP Suzanne DeBremaecker. "Mytraining, much of it hospital-based, makes me extremely overqualified forwhat I do," she says. "I'm geared to see a patient who's in congestiveheart failure and flagrant pulmonary edema. But it's infrequent thatI'm called on to use that intensity of training in my practice. From thatstandpoint, NPs are often well-equipped to do a lot of what we do."

Exacerbating doctors' fears is the fact that much of the guesswork isbeing eliminated from routine family care. "Right now, we're artistscreating from scratch how to treat each patient," says John McFadden."We don't have a scientific checklist yet. But when outcomes data yieldreliable pathways for the average patient, we will. It will then be easierfor someone without FP training to follow a formula."

At the moment, outside of heavily managed care states like California,evidence is scant that groups are hiring midlevels instead of FPs. In someparts of the country, however, midlevels are indeed hanging out their shinglesas solo family practitioners. "In rural areas, FPs are dying out, andnew doctors don't want to replace them," worries Dwalia South. "Instead,NPs are taking their place."

Even though NPs are moving into vacant practices new doctors don't seemto want, not competing with existing ones, South sees this as an ominousdevelopment. "FPs are giving up ob/gyn and hospital medicine. We nolonger do surgery. We've narrowed our scope," she warns. "Meanwhile,NPs have expanded theirs to the point where we're meeting in the middleand doing almost exactly the same things. One day, managed care organizationswill look from us to them, and say, 'What's the difference?' "

Moreover, midlevels in independent practice aren't just a rural phenomenon.At least one group has been formed that consists solely of unsupervisedNPs: Columbia Advanced Practice Nurse Associates, which has a tony Manhattanaddress. The practice's four NPs have had years of training equivalent toa full-fledged FP's*.

Opened in 1997, the practice has a base of 500 patients, with five toseven new patients added each week. Most are middle-aged women with multiplehealth problems who could afford their choice of doctors. They choose NPsfrom CAPNA because, as one patient put it, "it's the difference betweena four-star restaurant and McDonald's," relates Mary Mundinger, deanof the Columbia University School of Nursing, which manages CAPNA.

CAPNA providers routinely spend a half-hour or more with patients, discussingtest results, medications, therapies, preventive measures, and alternativetreatments. The tradeoff: They each see no more than 15 patients a day.

The group receives no subsidies to stay solvent, Mundinger says. CAPNAholds the same managed care contracts as physicians in the Columbia-CornellCare system, and the NPs are reimbursed at the same rate as FPs. They could,theoretically, match the doctors' income--but not by seeing 15 or fewerpatients a day. Instead, as a commitment to giving quality care, they chooseto provide longer appointments, and if they earn less, so be it.

Patients like this treatment. As a result, CAPNA is growing. In July,it opened a new office in Columbia-Presbyterian Medical Center. Its consultingarm advises NPs on how to start an independent family practice. And CAPNAhas begun to get offers from farther afield. The Connecticut legislature,for instance, recently revised a law that had required advanced-practicenurses to work under the direction of a physician. Now, the law stipulatesonly that the nurses must "collaborate with a physician." Nursesin the affluent town of Darien, CT, subsequently invited CAPNA to help themopen a practice there.

But while CAPNA bears watching, its success is a long way from heraldinga national trend, as some doctors fret. Independent midlevels aren't sweepingthe country like hospitalists are. Even the Manhattan FPs with whom CAPNAnurse practitioners directly compete are indifferent to their existence,Mundinger says. While the number of NPs and PAs nationwide is growing dramatically,making direct competition with FPs more likely in the years ahead, no oneinterviewed for this article--including current AAFP President Lanny Copeland,President-Elect Bruce Bagley, and past Presidents Neil Brooks and PatrickHarr, as well as Mary Mundinger--view this development as a global threatto family doctors.

Physician recruiter Sue Cejka of St. Louis is also unconcerned. She predictsthe market for family doctors will remain moderately bullish. "FPswon't be replaced by midlevel providers, because most patients want to seea bona fide doctor when they get sick," she asserts. "I don'tsee that changing in the foreseeable future."

As for health plans getting ideas, "if organizations like CAPNAcan succeed in attracting loyal patients and sustain themselves as businesses,opportunities for midlevels will increase," says internist Craig W.Keyes, chief medical officer of United Healthcare's New York and New Jerseyhealth plan, which has CAPNA providers on its panel. "But the jury'sstill out on what the market has to say."

"If residents see that FPs don't get respect, it hurts"

Dwalia S. South, MD, Family Medical Center, Ripley, MS

Dwalia South (above) began her medical career as a solo family practitionerseeing 40 to 50 patients a day. "You just get ground down," shesays. "You don't have partners you can depend on or bounce problemsoff of. And you must run the building, tend the yard, fix the plumbing,and pay the bills. You try to be superwoman. With time, you finally figureout that you can't."

In 1996, after losing her father, her husband, and a cousin she'd dependedon to help out with chores, South left solo practice. She became medicaldirector of a three-clinic health care organization in northeast Mississippithat includes two internists and two NPs.

The underserved rural area is predominantly African-American and Hispanic."We draw patients from about 50,000 people in five counties,"South says. "We're not the only act in town, but we're the only federallyfunded clinic, which means we can provide some free things for patients."

South now has a comparatively light load of about 35 patients a day.Sixty percent are covered by Medicare, Medicaid, or both. Twenty percenthave insurance from jobs related to furniture manufacturing, the main industry.Another 20 percent earn too much to qualify for Medicaid but not enoughto afford insurance. Charged on a sliding scale, they pay about 10 percentof the bill. The federal government covers the rest.

Recruiting FPs to underserved areas like Ripley has been a trial. South'stwo internist colleagues are international medical school graduates. "Theywon't stay," she laments. "They'll meet their J-1 visa commitmentand move on when their time is up. They haven't even moved into the community.They commute from Memphis, 70 miles away. It's hard to build community rapportif you just come in and punch a clock."

South, who's president of the Mississippi Academy of Family Physicians,sees commitment fading in FP colleagues, as well. "FPs used to be morealtruistic," she reflects. "Now they don't want to attend meetingsto solve problems unless they get paid, or get to visit some vacation spot,or earn CME credit."

This year, half of Mississippi's family practice residency openings wentunmatched. South thinks lack of status is the reason why. "When you'rein a university setting, the big bucks go to the cardiology and surgerydepartments," she observes. "Family medicine is like a red-headedstepchild. If residents see that FPs don't get respect, it hurts."

Meanwhile, NPs are moving into vacant practices and serving as FPs. Tolure more new doctors, the Mississippi Academy of Family Physicians mayrecommend that family practice residencies be shifted to community hospitalsfrom tertiary care centers. "We really don't need to be there,"South says. "Family medicine isn't an ivory tower type of practice."

"We're frustrated because our office systems are out of date"

Bruce Bagley, MD, Latham Medical Group, Loudonville, NY

Bruce Bagley, the American Academy of Family Physicians' president-elect,plans to make quality his focus when he assumes office. He's doing the samewith his practice, which includes eight FPs, two PAs, and an NP.

"Family doctors, by nature, are happy folks," Bagley reflects."But we're often frustrated by the inefficiency of our practices. Welike to blame our frustration on managed care or the Health Care FinancingAdministration, but a lot of it arises because our office procedures are50 years old and outdated."

Consider: A patient enters your office, gets checked in, sits in thewaiting room, is escorted to a room where she's weighed and measured, andis then led to an exam room, where you diagnose and treat her. The patientthen returns to the front desk to check out, pay up, and make another appointment."That's not necessarily the best way to care for populations ratherthan individuals," Bagley says, "which is what we're now beingasked to do."

That's especially true of a group like Bagley's, which derives a whopping60 percent of its revenue from capitated patients. To boost efficiency,"we're implementing electronic medical records--a major transitionfor us," Bagley says.

And a major expense. "Since we've been capitated, we've actuallydone better than with discounted fee-for-service," says Bagley. "Sowe've decided to bite the bullet and borrow the money." The estimateshis group has received for a high-end information system: nearly $500,000,or about $45,000 per practitioner.

"Maybe we've deluded ourselves," Bagley says, "but wethink the efficiencies to be gained are enormous. Every day, with everyphone call and every patient visit, we have to laboriously pull charts orenter lab results into charts by hand. Theoretically, all that will end.It won't happen on Day One, but in a year or two, all our medical recordsshould be on a compu ter hard drive."

As health plans increasingly require doctors to submit statistics onthe care of members and then issue provider report cards based on that data,electronic medical records will become a must, Bagley is convinced. "It'sthe only way we can do a quality job," he says. "Five years fromnow, we won't be able to keep up with the work we're now being asked todo without that kind of support."

Computers should also im- prove patient satisfaction in a number of ways.New patients with Internet access, for example, will be able to registerand fill out an electronic family history form by logging onto the group'sWeb site. "If you come to the office for blood work, you'll be assigneda private password that will let you access the results online as soon asthey're in," Bagley says. "We're designing that capability intoour system."

Of the AAFP members who responded to a 1998 practice profile survey,30 percent said they were in one- or two-doctor offices. Where will theyget 40 or 50 grand for an information system capable of storing and retrievingmedical records? "It's not as big a hurdle as you may think,"says Bagley. "It's easier to computerize a one- or two-doctor officethan one the size of ours, and the cost should be only about $20,000 to$25,000 per doctor. And lots of software is now available."

"Family practice is becoming customer-driven"

Jeffrey M. Bishop, DO, Western Communities Family Practice,WestPalm Beach, FL

Osteopathic FP Jeffrey Bishop (above) employs 10 FPs, three NPs, anda PA in four sites in Palm Beach County. In their office waiting rooms,patients find a TV and VCR at either end, one showing educational videosfor adults, the other for kids. A personal computer with patient educationsoftware is also available.

Bishop is one of a new breed of entrepreneurial doctors who see medicineand business converging. "Patients are also customers," he says."In the future, family practice will be customer-driven. Today, patientsatisfaction is a must to keep a practice alive."

While pleasant, modern surroundings would seem an obvious step in thisdirection, Bishop is often dismayed at the offices of colleagues he's visited."They're cluttered with books, papers, and instruments--when patientsdemand a clean environment," he says. "It's important that whena patient walks into your office, it's clutter-free, patient-friendly, anddata-rich: filled with patient education materials and aids."

Adorning the hallways of the group's clinics are informal photographsof the clinicians engaged in everyday activities. The pictures humanizedoctors and staff and create a homey atmosphere, Bishop feels. Last year,the group saw 42,000 patients, of whom 8,500 were new, and it gets 500 to700 new patients a month.

As FPs gain business savvy, Bishop sees more of them entering ancillarybusinesses--such as alternative medicine--to subsidize their incomes. That'swhat Bishop's group has done. Bishop spent six weeks in China in 1994 learningherbal medicine, anticipating that the demand for alternative medicine wouldmushroom. Two years later, he hired an acupuncturist. "Physicians fromall over Palm Beach County now send patients to him," Bishop says."We're also opening an integrative medical center, so we'll have aplace to refer patients who seek alternative care."

In addition, Bishop hired a hospitalist in 1996. This physician caresfor all group admissions and takes call roughly one weekend every othermonth, alternating with group FPs. On three half-days a week, he works inthe office, performing follow-up care on inpatients discharged within theprevious week. He then transfers the patients back to their personal physicians."Our doctors love it," Bishop says. "We're now hiring himout to other doctors in the community, as well as to managed care organizations."

The group, which has a base of 50,000 patients, is issued provider reportcards from health plans it belongs to. Surprisingly, for such a forward-thinkingdoctor, Bishop keeps track of scores the old-fashioned way: by jotting themdown in a notebook. He'd love to use electronic medical records instead."The software isn't yet right for our needs," he says, echoingthe sentiment of other doctors. "It's almost there, but not quite."

To ensure that he has a voice in the changing environment of health care,Bishop recently earned certification by the American Board of Managed CareMedicine. "Learn all you can about managed care and get involved withthe people who make the changes," he advises. "It's the best wayto have a positive impact."

Dwalia South began her medical career as a solo family practitioner seeing40 to 50 patients a day. "You just get ground down," she says."You don't have partners you can depend on or bounce problems off of.And you must run the building, tend the yard, fix the plumbing, and paythe bills. You try to be superwoman. With time, you finally figure out thatyou can't."

In 1996, after losing her father, her husband, and a cousin she'd dependedon to help out with chores, South left solo practice. She became medicaldirector of a three-clinic health care organization in northeast Mississippithat includes two internists and two NPs.

The underserved rural area is predominantly African-American and Hispanic."We draw patients from about 50,000 people in five counties,"South says. "We're not the only act in town, but we're the only federallyfunded clinic, which means we can provide some free things for patients."

South now has a comparatively light load of about 35 patients a day.Sixty percent are covered by Medicare, Medicaid, or both. Twenty percenthave insurance from jobs related to furniture manufacturing, the main industry.Another 20 percent earn too much to qualify for Medicaid but not enoughto afford insurance. Charged on a sliding scale, they pay about 10 percentof the bill. The federal government covers the rest.

Recruiting FPs to underserved areas like Ripley has been a trial. South'stwo internist colleagues are international medical school graduates. "Theywon't stay," she laments. "They'll meet their J-1 visa commitmentand move on when their time is up. They haven't even moved into the community.They commute from Memphis, 70 miles away. It's hard to build community rapportif you just come in and punch a clock."

South, who's president of the Mississippi Academy of Family Physicians,sees commitment fading in FP colleagues, as well. "FPs used to be morealtruistic," she reflects. "Now they don't want to attend meetingsto solve problems unless they get paid, or get to visit some vacation spot,or earn CME credit."

This year, half of Mississippi's family practice residency openings wentunmatched. South thinks lack of status is the reason why. "When you'rein a university setting, the big bucks go to the cardiology and surgerydepartments," she observes. "Family medicine is like a red-headedstepchild. If residents see that FPs don't get respect, it hurts."

Meanwhile, NPs are moving into vacant practices and serving as FPs. Tolure more new doctors, the Mississippi Academy of Family Physicians mayrecommend that family practice residencies be shifted to community hospitalsfrom tertiary care centers. "We really don't need to be there,"South says. "Family medicine isn't an ivory tower type of practice."

"The costliest thing in medicine isn't me--it's my pen"

Neil Brooks, MD, Rockville Family Associates, Rockville, CT

Trying to save money by reducing primary care physicians' involvementin primary care is misguided, holds former AAFP President Neil Brooks (above)."For health care to work well, we need primary care physicians at thecenter of the system--still managing the patient, but working as part ofa team," he says.

That's true, Brooks believes, even when patients clamor for open accessto specialists and health plans are eager to give it to them. As diseasemanagement programs spread, patients are also being encouraged to seek carefrom specialists that was formerly provided by primary doctors.

"But we still need an overseer who understands the dynamics of theinteractions between patients, their diseases, and the health care system,"Brooks insists. "There isn't a patient with asthma or congestive heartfailure and nothing else. When primary care is provided by nonprimary carephysicians, patients tend not to get other things they need--like immunizations."

Farming out chunks of primary care to unsupervised midlevel providersis no cost-cutting solution, either, Brooks contends. "We constantlyhear that midlevels can provide 80 to 90 percent of what FPs do for lesscost," he says. "Yet I know of no studies that show what happenswhen NPs or PAs practice independently."

Trying to save money this way is faulty logic, asserts Brooks. "Thecostliest thing in medicine isn't me--it's my pen, which I use to writeprescriptions and referrals," he says. "If you pay a midlevelhalf of what you pay me, and yet they refer patients to specialists 10 percentmore than I do, the money you save in salaries disappears, and you're inthe red."

Brooks' practice includes four FPs and one PA. In addition, his callcoverage group includes 10 FPs and four NPs. "But all the midlevelswork in a supervised setting," he stresses. "It's a very effectiveway to care for patients; the midlevels can always defer to a physician.Would referral costs increase if they couldn't? It's probable that theywould."

Brooks speaks from experience, having worked with his PA for 20 years."Two or three times a week, he brings me problems," Brooks explains."He's highly competent. Mostly I tell him that he's doing exactly whatI think he should be doing. But sometimes when he suggests that a patientsee a specialist, I take a look and may say, 'No, we can do that here.'That referral cost is then avoided."

Cutting primary doctors out of inpatient care is also a mistake, Brooksmaintains. "We don't have hospitalists at my hospital, but my inpatientsare usually seen by more than one subspecialist," he says. "YetI'm the one who understands what's going on with the patient over time.As health care grows more complex and specialized, that broad knowledgebecomes even more important in order to coordinate care. I'm also the patient'sfriend and advocate. We often forget how vital that is in a hospital setting."

Brooks thinks that groups, hospitals, and health plans are jumping thegun with their widespread and rapid adoption of hospitalists. "Willhospitalists save huge amounts of money? We don't really know," hesays. "We're changing whole systems of care without clear evidencethat it's the right thing to do."

He wishes that people who hire physicians would consider the larger ramificationsof using hospitalists. "How often do patients get rehospitalized?"Brooks wonders. "What happens to the education of physicians who nolonger have hospital access? How do they interact with colleagues? Whatabout training programs? There are lots of unresolved issues."

"Groups stress cost-effectiveness. I don't want that monkey onmy back."

Paris E. Phillips, MD, Jericho, NY

Soloists can no longer survive the competition from single- and multispecialtygroups clustered in the nation's cities and well-to-do suburbs--or so it'sthought.

But don't tell that to Paris Phillips (above, with her daughter, ArianaGodles). Even though her solo practice is located in Long Island's affluentNassau County, where she's surrounded by large groups, she's built a substantialpatient base since the mid-1980s. And while her income has nosedived inthe past five years, that's because health plan reimbursements have plungedwhile her expenses have soared, not because her patients are defecting tolarger competitors.

How does she persevere? By using midlevels to run a turnstile practice?Quite the contrary. Even though Phillips is only 43, she's thoroughly old-fashioned.A home office allows her to keep an eye on her two young children whileshe sees patients. Her mother is her receptionist. An employee keeps herbooks and helps her deal with HMOs, but she uses no nurses, NPs, or PAs.

"When patients come to the office, they want to see their personalphysician, not a midlevel or even another doctor," says Phillips. "WhenI return from vacation, patients often tell me, 'I know I could have seenyour covering doctor, but I wanted to wait for you instead.' "

That's because she gives the 75 to 100 patients she treats each weekunaccustomed empathy. "When a patient has an abnormal Pap smear andneeds a colposcopy, she's generally frightened," says Phillips. "'Don't worry,' I say. 'I've had a colpo, too. This is what happens. Here'show it feels.' By stepping off my physician pedestal and being a person,I can convey to patients that I really understand.

"That's not encouraged elsewhere. So many groups stress cost-effectiveness:Are you seeing enough patients a day? I don't want that monkey on my back."

Phillips seldom cares for inpatients anymore. "Unless you see alot of hospitalized patients each month, it's very hard to keep up withclinical issues, hospital policies, health plan policies, treatment protocols,and drug formularies," she says.

She often pays social calls, though. "Are they treating you okay?"Phillips asks her hospitalized patients. "Is there anything you wantme to say to your doctors?"

Patients appreciate this gesture. But to do more would be pointless,Phillips believes. "If a specialist is in charge, why must I say, 'Yes,I agree with what he's doing?' I then have to look at the test results.Now I've spent three hours in the hospital and haven't contributed a thing,when I could be in the office treating people whom I can help--orI could be at home, being more of a wife and mother."

Refusing to allow medicine to crowd out family time is her one concessionto modernity. "Years ago, doctors sacrificed their families to be thebest doctors they could be," Phillips observes. "But family isso important, and kids grow up very fast. I'll never compromise my patients'health, but when my child asks, 'Mommy, will you come to see me in the schoolplay?,' I'll be there."



. Why tomorrow's FP won't look like today's.

Medical Economics

1999;17:176.