Destroying the family physician: An AAFP member responds

A response to The creative destruction of the American family physician.

Dr. Brooks’ column shines a bright light on the misconception that some subspecialists have about the core of primary medical care and family medicine. As a former nurse practitioner and current family physician, I’d like to point out the flaws of his argument.

At a time when the health care community is working to end the fragmentation, duplication and gross inefficiencies of our health care system, Brooks’ recommends further splintering care by relying on nurse practitioners who can “at least refer to a supervising internist” or subspecialists when a health condition goes beyond an NP’s education and training. This is disingenuous.

High-quality health care goes beyond performing the “services and tasks” available from a nurse practitioner. Comprehensive health care goes beyond the adult-only focus of general internists. Cost-efficient health care ends the fragmentation of multiple referrals to subspecialists, inevitable duplication of tests and other services, and risk of medical errors.

The American Academy of Family Physicians practice profile demonstrates that, in addition to comprehensive preventive and chronic care, today’s family physicians provide pediatric care, newborn and neonatal care, minor surgery, colposcopy, and formal interpretation of EKGs in hospitals and in their offices. They cover intensive care and the emergency department.

Data from the National Ambulatory Medical Care Survey show that 35 percent of visits for circulatory conditions are to family physicians, 27 percent of visits for musculoskeletal problems are to family physicians, 44 percent of visits for respiratory conditions are to family physicians, 40 percent of visits for endocrine issues are to family physicians, and 22 percent of visits for digestive issues are to family physicians.

Nurse practitioners are extremely valuable members of the patient-care team. But with 3,500 hours of clinical training, they do not have the same breadth and depth of medical knowledge as family physicians, who complete 11,000 hours of clinical training. Yes, they can refer to subspecialists when their patients’ conditions require medical expertise beyond nurse practitioner training. But research consistently demonstrates such an approach harms the quality of care and increases the cost. Barbara Starfield’s research, for example, concluded, “Lower primary care physician supply and higher specialist-to-population ratios were associated with higher overall age-adjusted mortality, mortality from heart disease, mortality from cancer, neonatal mortality, life span, and low-birth weight ratios.”

Her research echoes that of others. Elliott Fisher and his colleagues studied care to the U.S. Medicare population and found higher surgery rates, greater performance of procedures, higher expenditures, and worse outcomes with a higher the ratio of specialists per population.

Confirming these findings, Katherine Baicker and Amitabh Chandra showed a “significant increase” in the quality of care with an increase of general practitioners per 10,000 population, while increasing the number of specialists was associated with poorer quality and higher costs.

Moreover, Brooks ignores the fact that 98 percent of internal medicine graduates indicate they will go on to become subspecialists, further limiting patients’ access to internal medicine, and fails to acknowledge the more limited training that internists receive. Again, Starfield’s studies have shown that having a general internist as a primary care physician is “associated with more different specialists seen” and greater use of brand-name over generic prescriptions.

Relying on a nurse practitioner’s nursing education and referrals to subspecialists for medical care that can be provided by a family physician not only worsens the fragmentation and duplication of services, but also increases costs. Far from solving the primary care shortage, poor quality of fragmented care and skyrocketing costs, Brooks’ approach worsens every problem our nation is trying to solve.

LaDona Schmidt is a family physician and former nurse practitioner.

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