It was the same years ago in residency. There was both a categorical and primary care residency track. Each had their own distinctive curriculum and rotation schedule. The outpatient track did more time in the clinic, the categorical more on the hospital wards. We trained side by side. We attended many of the same lectures. And our fellowship choices matched identically. In fact, most of my colleagues from the primary care group are now cardiologists, gastroenterologists, and pulmonologists. Even then, those in training changed their opinion midstream when they realized what their professional lives would entail.
It has become vogue to blame doctors and academic institutions for the falling number of generalists. We wag our fingers at the university behemoth who takes government money and then trains super-specialized physicians. But, if you have been in education long enough, you know that the primary care push has been going on for decades. It just hasn’t been that successful. Students and young physicians, time and again, change paths when faced with the day to day work of comprehensive primary care even though it is one of the most challenging and fulfilling jobs in medicine.
Indeed, one might say we have come here by our own careful planning. We have legislated it that way.
When you create a body that advises medicare on payment structure which is made largely of specialists and proceduralists and has no interest in protecting cognitive medicine, you have legislated a primary care crisis.
When you create electronic medical records and define how to use them meaningfully, pushing physicians to waste their precious little time in the exam room on data entry, you have legislated a primary care crisis.
When you pass a colossal healthcare reform package heavy on regulation and reporting, most of which falls on the lowly family physician toiling in the overcrowded office, you have legislated a primary care crisis.
When you fight fraud and over billing of the few, by committing the many to ornate and easily deniable paperwork that everyone but the primary care doctor refuses to fill out, you have legislated a primary care crisis.
When you tell hard working and well trained physicians that they can no longer go to the hospital, create inconceivable amounts of paperwork for those who do, and then try to replace them in their offices with nurse practitioners and physician assistants, you have legislated a primary care crisis.
And lastly, when you tell them to abandon the doctor-patient dyad, and become team leaders in charge of administratively managing groups of non-physician providers and turn them into community health gurus, you have legislated a primary care crisis.