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CommentaryHealth Care PolicyPrimary Care

The Disappearing Family Doctor

By April 23, 2011February 21st, 2020No Comments

Re: “Family Physician Can’t Give Away Solo Practice” by Gardiner Harris, NY Times, p.1, 4.23.11

What a sad commentary: “A centuries-old intimacy between doctor and patient is being lost.” True, and so unnecessary and so wrong. The intense pressure to limit the time of general medical appointments is purely economic and results from prolonged systematic underpayment by insurers for primary care medical services.

The underpayment, by which primary care physicians (internal medicine, family practice) earn 50-60% less than specialty colleagues such as cardiologists, radiologists and orthopedists (published figures validated from many sources), has been the policy of major medical insurance companies following the lead of Medicare for about the past two decades. Inadequate primary care resources (staff, computers, time to see patients) in turn leads to medical error and, perversely, to high cost, as Dr. Rothman disdains. But it wasn’t inevitable.

Does anyone remember any public discussion that “We need to pay our primary care physicians much less money so that we can all have unreasonably restricted face time with our doctor when we can even get a timely appointment at all?” Is anyone happy with rushed, impersonal contacts with doctors in large groups who look at their computers rather than you for your appointment? Clearly this is not the outcome the public wants.

Where Is My Doctor?

The public is right to want personal physicians who actually know who you are. Dr. Welby’s critical advantage was an intimate knowledge of his patients over many years. When put in a modern setting (even with just a few physicians) with sufficient well-trained clinical and administrative staff and modern data systems, I experience and others know as well that such personal knowledge is of immense utility both to physician and patient and results in much more effective, safer, less costly, and less scary medical interactions.

That is why I left my overburdened primary care role at a major Boston teaching hospital almost five years ago and established Orchard Health Care, a membership practice (unfortunately a.k.a. “concierge” practice) where a much smaller number of patients pay additional money each year so that our practice of two experienced internists can practice high quality, high-tech, cost-effective care with ample time for each patient’s appointment and easy communication between patient and doctor as well by phone or e-mail or Skype. The membership payments by our patients enable the total revenue for our practice to be comparable to the typical gastroenterology or orthopedic practice. All of a sudden, personal medical care is again possible.

We work hard on quality of care. Each day our staff collectively review outstanding patient problems, tests, and anyone who is sick at home or in hospital or recovering from surgery. We contact patients to check on them. We make house calls. We badger our specialty colleague’s offices electronically and by phone to insure proper communications. We try to ensure that there are no medical cracks for our patients to fall through. This takes staff and time, and people who know who you are. Data systems are a support, not a substitute for personal knowledge. We are privileged to have the resources to do this. Everyone should, but doesn’t.

Medical Homes Coming

I wish I could be more enthusiastic about the various models for “medical homes” that are supposed to replace Dr. Welby. They are predicated on trained but non-physician personnel, such as nurse practitioners, being the direct contact with the patient, with adequate support staff for them, robust data systems, and a supervising doctor.

Will that work? I have supervised excellent nurse practitioners. Even the best trained non-physicians require more specialty consultation than the skilled internist. Reading other people’s medical notes, even computerized, is time consuming and not as immediate as reviewing your own notes and recalling the details. And will insurers, after underfunding primary care for two decades, suddenly start to provide enough money to enable these teams to work?

In addition, having for years personally cared for 2,000 active patients, I know that the supervising doctor responsible for several times that number of patients under the medical home model will only rarely develop the intimate knowledge of individual cases that is required for best medical advice.

So I fear that the future with medical homes actually holds care that will be even less personal, require more time for multiple visits and specialty consultations, and ultimately will be more costly and less effective.

We certainly are in a primary care mess now. But we made it, by our reimbursement policies. Paying for primary care as we pay for specialty care (try gastroenterology) would promptly change the landscape. Personal physicians are desirable and attainable for every American. Modern Dr. Welby’s, with adequate resources, could provide better, safer and cheaper care in a fashion that people actually want. Think on that, and talk to your Congressman.

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