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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  • Kristy Sokoloski

    This piece is a very interesting response to Dr. Brooks’ article. Unfortunately, there are a lot of people who have such strong opinions about what the role of NPs should be when it comes to the issue of Primary Care. Three months ago I had an experience where I had to make use of a Nurse Practicioner. While I am glad that she spent the amount of time that she did with me and we had a nice visit I know that for me when it comes to management of my health issues I am more comfortable with my doctor. But when it comes to needing to see someone else other than my doctor for more urgent situations I am more comfortable with the PA. Just my personal preferences.
    On the issue of Internists vs Family Medicine doctors, I tried using an Internist a few times several years back and I found that I was more comfortable with the Family Medicine doctor. My current Primary Care Physician and some of the other doctors I have had throughout my life including as an adult have been Family Medicine doctors. I have also read the number of articles that have stated that more Medical students that choose to go in to Internal Medicine tend to do more subspeciality training. I found that to be very interesting as well.
    There is still much work that needs to be done in order to fix all the issues that need fixing when it comes to healthcare. This is an issue that affects one and all, and we all need to work together (yes, patients included) in order to help make this happen, not against each other. In the mean time the costs of giving and receiving healthcare continue to rise making it harder on all of us. This is definitely a very long and winding road that we all have to travel.

    • Michael Chen

      To answer your question about internal medicine and going into subspecialty training: Internal medicine has many subspecialities for which residents who are going into internal medicine can chose from after they complete their residencies. Family medicine does not, unless you decide to go back into internal medicine and then go into subspeciality (which most won’t do because of the cost of medical school debt and that there is enough “payoff” at the end). Obviously, the monetary payoff for family practice is so poor, it’s no question that there is a strong incentive for student doctors to go into subspeciality practice. It’s the way our payment structure (through the RUC) has incentivized subspeciality care versus primary care in the United States.

    • drg

      If it is urgent, why would you think the PA is as equipped and is better to deal with the problem than the doctor?

  • Dike Drummond MD

    IMHO there will always be room for generalist doctors in healthcare. The challenge at the moment is what their role will be in the years ahead.

    Realize that Dr. Brooks is specialty physician who makes his living off procedures. He is a “partialist” in every sense of the term. Primary care doctors get in the way of him operating and making the big bucks. Off course he would see piles of sense (from a very personal and selfish viewpoint) to getting rid of primary care and simply inserting a smooth referral process.

    And orthopedic surgeons routinely abandon their patients to generalist physicians – including hospitalists – at the merest whiff of a complication. I never allow my patients to get orthopedic surgery without bird dogging their hospital stay and rounding on them. Primary care is vital to optimum coordination of care and cost effective management of the majority of patient symptoms and concerns.

    And the popularity of concierge medicine shows that patients want a personal relationship with “my doctor” to survive.

    Dike Drummond MD

  • win89

    In 2007, the AAFP launched their TranforMed Model of Care Demonstration project. I had just become a patient of Dr. X when clinic where she practiced chose to be part of that demonstration.

    I stayed with the clinic for 18 months before seeking care elsewhere. For one of the medical problems that emerged during this time I saw 5 different providers, including nurse pratitioners and physicians assistants. I don’t know how much Dr. X was involved, but in the end, I was referred to a specialist. This was a very frustrating and painful experience. When I developed a gynecological problem, I couldn’t stand the idea of being passed around the office so I sought the services of a nurse practitioner who had her own practice. It was nice to feel cared for.

    I think it’s valuable to have a provider who knows who you are, and can use that information to facilitate a diagnosis, determine an optimal treatment plan and keep you healthy. That is not what I experienced at the TranforMed clinic…the Future of Family Medicine? In this model of care, I became a chart that anyone could treat. If continuity of care means having access to a patient chart, all one really needs is an integrated health care system.

    And if I am not a chart, why have family physicians embraced a model of care that fragments the primary care experience? I would rather see the same provider, even if it’s a nurse practitioner, than be passed around the office.
    So it seems to me that the AAFP is fulfilling Dr. Brook’s prediction…

    • southerndoc1

      I’m sure that most of the time you were sick and wanted to see your physician, she was in the back of the office glued to a computer doing population management, pre-visit planning, care plan reconciliation, and writing agendas for tomorrow’s team huddle.

      The vast majority of practicing family physicians regard PCMH/TransFormed as a sick joke that will be used to deliver the coup-de-grace to primary care in this country.

      Sorry you were scammed like that.

      • ProudOkie

        Well said Southern……

    • Kevin Bernstein, MD

      That’s an interesting generalization. At our PCMH, our patients see their assigned provider over 70% of the time and their assigned team close to 100% of the time. And this is in a residency program. TransforMED helped with our transformation as well. Anytime one of my patients is seen by another provider, that provider talks to me about what they were seen for. We plan to continue to function this way despite how others perceive PCMH.

      • win89

        From the results of the demonstration project;

        ‘In contrast, there were no significant improvements in patient-rated outcomes, including ratings of the 4 pillars of primary care (easy access to first-contact care, comprehensive care, coordination of care, and personal relationship over time), global practice experience, patient empowerment, and self-rated health status. There were trends for very small decreases in coordination of care (P = .11), comprehensive care (P = .06), and access to first-contact care (P = .11) in both groups.”

        Four doctors left this practice duing the TransforMed demonstration project.

        • Kevin Bernstein, MD

          Well aware of the data and well aware that we are seeing the exact opposite.

  • tmcgill

    The original article makes the same mistake the entire recent American health care model makes: the faulty assumption that health care is composed entirely of a series of a la carte treatments. If that were the case, sure, why not provide those treatments as inexpensively as possible? The real tragedy of the missing family physician is not that there’s nobody to remove someone’s stitches or order blood tests; it is that there is nobody left who can integrate the entirety of a person’s health picture.

    Who is left, in the maze of specialists, to understand how the different pieces fit together, to know which specialists to see, and be able to gauge effectively when a particular specialist’s proposed diagnoses or treatments are coming from a view of possible health concerns that isn’t broad enough, because a specialist is, by definition, narrowed to a subset of the things which go on in a human body? Who remains to do the work of estimating which things from different systems or from a patient’s history may be relevant to which other issues and which are not likely to be? The patient, that’s the only person left to do this under the current model, and the patient isn’t trained to do that.

    The issue isn’t who provides services, it is who coordinates them, understands them, and has a higher-level view of the patient’s overall history and current condition, and can make recommendations and give explanations based on that understanding. I think hospitals sometimes assemble cross-disciplinary teams to deal with a patient, under the overall direction of a single doctor whose specialty is that patient, but in day-to-day, outpatient medicine, I think this essentially never happens. There is a reason why construction projects have a “general contractor” who runs the overall show and coordinates the activities of the workers from each trade. Yet even though the human body is a lot more complicated than any construction project, we are mostly left serving as our own general contractor with respect to our health. This is absurd and counterproductive. We clearly need to find a way to expand, not contract, the presence of family physicians in our health care.

    • ProudOkie

      And again – NPs do that every day all over the country – we have already proven we are up to the task. And it does happen every day in outpatient practice – every single day…..just because one doesn’t mention it or refuses to believe it is irrelevant. This is starting to take on a circus flavor. Family practice/primary care physicians are not the only ones capable of these tasks. Keep repeating it friends – in the meantime, there are 17 states where NPs coordinate care to the full extent of their practice authority.

      • ProudOkie

        crazy…dissenting truthful opinions get a thumbs down. Best march in lockstep to be liked!

      • tmcgill

        A circus flavor? My whole point is that if you are reducing medicine to a series of “tasks”, as does the original essay which both this article and my comment are disputing, you’re already on the wrong track. You’re saying NP’s are doing this all over the place; I’m saying _nobody_ is doing this for most people. NP, MD, in most cases either one having a consistent, ongoing, thorough knowledge of a person’s health and well-being would be a clear step up from the kind of coordinated care most people aren’t getting. Medicine isn’t just a dispatching and delivery mechanism for treatments. It isn’t even wise to treat automobile maintenance like that, much less human bodily maintenance, like just something that occurs when something breaks and thus consists of nothing more than a series of independent broken thing-fix, broken thing-fix events. My objection is not to the professionalism of NP’s, PA’s, or anyone else. My objection is to the idea that “because most of our health care is just menial treatments, most of it can be done by people who aren’t doctors.” I disagree with the premise, and I disagree with any answer that results in doctors being brought in at the tail end, with no ongoing familiarity with their patients, to swoop in, quickly scan the situation and pronounce some answer, as regularly happens in today’s medical care system. I should have a doctor whose specialty is me.

        • ProudOkie

          I thought you were saying that without the physician, there is nobody to perform these tasks (your first paragraph). I was pointing out that, even if one chooses not to mention it, there are others (NPs) who do this every day, all over the country. It sounded like you had the feeling that the FP was the end all, be all, of patient management. Two of every ten office visits are seen by NPs. And this does not include the “hidden” visits that are billed as physician visits even though the NP was completely in charge and managed everything. One can easily interpolate that at least 3 out of 10 visits are performed by NPs alone – that is 30%. That is alot – more than a lot for sure. So these tasks are (or aren’t) getting done by NPs almost as much as they are by physicians. I apologize for misunderstanding you, if, in fact, I did.

      • Jason Simpson

        We tried your experiment in New Mexico and it didnt work!! NPs have full independence in that state yet the number of rural health clinics is EXACTLY the same!

        NPs wan to run off to the big cities like the doctors do! They also want 9-5 workhours and dont want the stress of running their own business!

        • ProudOkie

          Hi Jason,
          Thanks for the comment! A few things:
          1) I would venture to say that New Mexico is not your typical state geographically or from a population based or rural/urban based standpoint. I;m not sure it is a good state to use as a representative of the rest of the country. I have never been there and have lots of preconceived ideas of the statel such as – it’s a GIANT DESERT and rural is REALLY rural. Perhaps it’s difficult to garner a big enough population base to run a clinic? I do not know. But this I do know, it is not your typical state so it is a bad example.
          2) I notice that New Mexico is the ONLY example used by physician groups. Why? If indepedence laws did not help at all, what about the other 18 states? Any mention of the success in those states? I know in my state, there are privately owned, NP only clinics all over the place. I can name 10 of them, all on the outskirts of Oklahoma County in rural areas easily. They are successful and provide a HUGE service to residents in these rural areas. There is no physician involvement in these clinics aside from the requirements by the BON, which are minimal at best. Oklahoma should really be a state where NPs practice to the full extent of their authority, as they are only tethered to a physician by prescriptive authority. There are many many more dangerous ways to harm a customer aside from writing a prescription and we are completely independent in all other areas.
          3) How about examples like Washington State? Oregon? And many others – there are many successful “private” NPs in all of these states.
          4) NP practice without physician involvement really changes very little concerning actual NP practice. What is DOES change is the purely financial need from an NP standpoint for a private business agreement with a physician to prescribe in my state. Take Texas for example, a recent NP article confirmed that physicians charge NPs as much as $2,000 per month to supervise them. The new Texas law, which does very little to help patients in Texas, also increases the number of NPs a physician may supervise from 4 to 7. This amounts to seven signatures and the collection of $14,000 a month from NPs simply trying to increase access to care. This is a travesty and restraint of trade on its very face. In many states, the supervisory requirement is a monthly meeting (for what?) and the review of 20 charts. We see 500-600 patients per month in my clinic. 20 charts means nothing and if I need help, I will ask a colleague. I have cell phone numbers for an internist, cardiologist, pulmonolgist, ENT, etc., you get it. The supervision issue is slowly being exposed from what it is – $$$$$$.
          5) I always hear physicians say “If NPs want to practice alone, then let them buy their own liability insurance!” Well, number one, I already do! For me, and all of the licensed employees in my clinic! Number two, yes! let us! We want to be judged on our own. Rid yourselves of us and “the worries” our liability places on you. I have never figured out this self defeating argument.
          6) And finally, Full practice authority does not hinder AAFP healthcare goals at all: a) we can still practice in physician led teams, PCMHs, ACOs, ABCs, EFGs, whatever new acronym you want to call it, if we choose to do so, b) the ability to practice in a team as an independent provider, completely on our own license, relieves the physician of that “much touted worry about liability.” EVERYTHING we would do would be on our own license – better for everyone involved! c) It would NOT change any scope of practice laws – those are already strictly regulated by our BONs. We couldn’t start performing appendectomies or anything else by relieving the physician of responsibility for us.
          So, the arguments by organized medicine are slowly becoming less and less relevant as patients and other health care providers gain a better understanding about who we are and what we do. They are really about economics and control. I do not blame family practice physicians for trying to protect their turf. But there are other answers to society’s healthcare needs as well – and those answers have already been proven and are already working every day on their own merits.
          Please excuse any typos! Sorry so long!!! Wow!!

  • doc99

    Paying Primary Care Physicians for the time spent with the patient instead of CPT codes would truly be transformational.

    • Michael Chen

      It’s not even the time spent, it’s the rate of pay that is not in line with the rate of pay for procedures.
      I’m sure that there are primary care doctors who have been managing chronically ill patients that bill by time-based coding, but even then, the E&M codes are woefully undervalued compared to procedures. It does not truly reflect the amount of coordination of care, time spent listening to the patient to truly understand patient behavior that could lead to positive outcomes and adherence to treatment.

    • Beau Ellenbecker

      Exactly my thoughts. I was working on a blog on this very concept. My time and issues delt with should control payment. Not home many body systems I recorded at least two findings in….

  • Brad Banko

    I work in a vertically integrated medical system and you could consider many urban centers to be similar… the effect of malpractice liability is to give the primary care practitioner little choice but to refer most specialty issues to specialists, and hospital systems will like this, because it generates more revenue, but the care becomes fragmented and the outcomes worse.

    I have been surprised on a number of occasions to find that fairly reliable patients with diabetes are following with an endocrinologist and seem to have little guidance or oversight on their blood sugar management.

  • Virginia Scanlan

    My dad was a GP for 50 years. He served his internship at Cook County Hospital and then spent five years in the Pacific Theater during World War II and became a surgeon there. He delivered babies, did appendectomies, removed tonsils, made hernia repairs, and practiced general medicine. Yes, he made house calls. He worked seven days a week. When he died at 82, hundreds of patients attended his funeral. This is what they talked about: He listened to them. He settled family disputes. If they were very worried about something, he’d help them think it through. He gave hell to errant husbands and naughty children and they listened. He threw their bills in the trash if they couldn’t pay him. My father delivered many of the people who attended the funeral and their children. You could understand why they were devoted to him. When he sat down to talk to you, he immediately grabbed your wrist as if he was taking your pulse. You had his complete attention. At the bedside, he’d hang on while he talked to you.”When Dr. Clem came to the house, then we knew that everything would be OK,” a patient said.This is not a romanticized version of his life. This was my Dad. He had moral authority.He was passionate. He lived his oath, and loved medicine. Patients want and need one thing — somebody to really care about them and to know them intimately throughout their lives. If you do not want to do that, quit. If you do want to do it, do not let anyone — your college, the government, hospital bureaucrats, EMR purveyors, or anyone else stop you. You have more power than you think you have. By the way,
    no one from Blue Cross will attend your funeral.

    see more

  • Charlie Buscemi

    Just another bitter MD who has come to realize her practice has become irrelevant among physicians. Go and specialize and leave NPs alone!

    • Jason Simpson

      You go ahead and be happy being seen by quacks with 1/4th the training of a real doctor!

      You’d better make sure that the person who introduces herself as “Dr Smith” is really a doctor and not a nurse who got her “medical degree” out of a cracker jack box!

  • sdietrich17

    Well said. As a recently retired, full scope of practice FP, I agree completely. And the research backs us up!!

  • Yul Ejnes, MD, MACP

    Well written column, but I have a question about one of the statistics, the “98 percent of internal medicine graduates indicate they will go on to become subspecialists” figure. That seems very high, so what’s the source of that number? Is it possible that you confused the oft-cited JAMA study by clerkship directors from a few years ago that indicated that 2% of medical students surveyed said that they would go into general internal medicine? The surveyed group was medical students, not internal medicine graduates. I believe the number of IM residents who eventually subspecialize is more like 75-80%, still higher than desirable, but less than what you cite.

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