Family medicine established itself as a specialty in 1969 at a time when medical specialties were proliferating and physicians started diverting away from general practice to more specialized fields. Many of the early giants of family medicine believed medicine had become too technological and scientific, treating organs rather than the person and looking only at mass data rather than the individual. This is not to say family medicine exists as a Luddite specialty focused on emotions and subjective experiences; the founders simply wanted to return focus back to looking at the person as a whole. Over the last 50 years since its founding, family medicine has evolved along with the healthcare system as a whole. Today there are two models of family medicine, the Referral Mill and the Rural Doc, which show how family medicine has evolved over time and raise interesting questions on the role of the family doctor.
THE RURAL DOC
Physicians in rural areas can do it all, or at least have earned the perception of having a wide variety of skills and a incredible wealth of clinical knowledge. They do so largely out of necessity as often they are the only physician for 100 miles¹. When asking the question “What can a generalist do?”, look at the Rural Doc who constantly pushes the bounds of the answer to this question.
THE REFERRAL MILL
Opposite to the Rural Doc in almost every way, the Referral Mill usually exists in an urban setting, surrounded by specialists and hospitals. One of the more unfortunate outcomes of our healthcare system is the push to see more patients per day in the clinic setting. As a result, the generalist has less time to think critically about complex illness, and thus becomes a Referral Mill. Heart problem? Refer to cardiology. Back pain? Refer to orthopedic surgery. Woman? Refer to OB/GYN. The Referral Mill leaves the wide the question “What does a generalist do?”
FAMILY MEDICINE TODAY
The Rural Doc shows us what family doctors can do, the Referral Mill makes us wonder what do family doctors do. While most primary care practices fall somewhere between the two extremes, primary care physicians should strive to embody the Rural Doc, referring only when:
- The patient requires a procedure reserved for specialists (major surgery, endoscopy)
- The patient has a rare disease or needs an unusual workup
- The patient has failed standard therapy for a disease (E.g. uncontrolled diabetes maxed out on insulin, resistant hypertension maxed out on medicines)
Having a well functioning primary care system with competent physicians practicing broad spectrum medicine maximizes benefits for the entire healthcare system, including decreased costs and better outcomes. Unfortunately, our current system pushes physicians more towards becoming Referral Mills.
From a financial standpoint, referring a patient in order to see two patients makes more money² compared to taking time to work through the issue. Furthermore, on average, physicians only have about 10 minutes to spend with patients, half of which is spent looking at their EMR³. Spending more time with a patient means staying later after the office closes to finish charting and/or to falling behind seeing all the other patients.
The other force is an unfortunate, ugly truth driven by low compensation and high administrative burden. Family Medicine does not attract the best and brightest. In fact, Family Medicine has consistently in the past few years matched students with the lowest objective markers (such as board scores) compared to other specialties⁴. Higher functioning physicians can and, arguably, are more willing to handle more issues themselves. As the brain drain continues in Family Medicine, the value of primary care will subsequently decrease.
Recent studies show primary care makes a notable positive impact on mortality⁵ and overall value based care⁶. These results are largely buoyed by currently practicing primary care physicians who trained and practiced at a time when primary care looked more like a Rural Doc’s practice than today’s Referral Mill office. If things continue the way they do now, more people will ask “what do primary physicians do?”. Already patients are noticing⁷. The erosion of what a family physician does and can do has also provided ammo for Nurse Practitioner (NP) organizations pushing for independent practice without physician oversight; something already legal in 23 states and gaining traction⁸. On paper, if all a physician does is treat the common cold and refers pretty much everything else out, then health systems and insurers have every right to replace primary care physicians with primary care nurse practitioners. The outcomes of primary care will worsen regardless of independent NP or Referral Mill physician, but at least it’ll get worse cheaper with NPs.
From the beginning of family medicine as a specialty to now, Rural Docs have answered “What can primary care physicians do?” and Referral Mills have raised the question “What do primary care physicians do?”. In order to address the future of primary care, the question “What should primary care physicians do?” needs to be addressed during every conversation on the topic from medical education to payment reform. Different players in the healthcare landscape will answer the question based on their own interests, so its up to all primary care physicians to answer the question for themselves and join the conversation to help bring out the full potential of a functional primary care system.
Sources:
- https://www.washingtonpost.com/national/out-here-its-just-me/2019/09/28/fa1df9b6-deef-11e9-be96-6adb81821e90_story.html
- https://www.ama-assn.org/system/files/2018-11/medicare-pay-levy.pdf
- https://www.jwatch.org/fw111995/2016/09/06/half-physician-time-spent-ehrs-and-paperwork
- https://www.nrmp.org/wp-content/uploads/2018/06/Charting-Outcomes-in-the-Match-2018-Seniors.pdf
- Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of primary care physician supply with population mortality in the United States, 2005–2015. JAMA Intern Med 2019;179:506–514.
- Levine DM, Landon BE, Linder JA. Quality and experience of outpatient care in the United States for adults with or without primary care. JAMA Intern Med 2019;179:363–372.
- https://www.nytimes.com/2017/10/12/well/live/why-i-almost-fired-my-doctor.html
- https://www.aanp.org/advocacy/state/state-practice-environment
