The country doctor is alive and well

In a recent New Yorker article about him, Dr. Mehmet Oz was paraphrased as saying that “Marcus Welby — the kindly, accessible, but straight-talking television doctor — is dead.” If he believes that, Dr. Oz needs to get out of New York.

At 51-years-old, I’m a little too young to remember the television show Marcus Welby, M.D, that aired on ABC from 1969 to 1976. A colleague told me the show was pretty schmaltzy and that it implied Welby could make a living on long conversations with two patients per day, which has never been a reality in primary care, not even then.

Perhaps a better nostalgic model of family medicine is Dr. Ernest Ceriani, a rural Colorado general practitioner and the subject of an extensive photo essay in Life Magazine in 1948. In the essay, Ceriani delivers babies, makes house calls, reads x-rays, splints fractures, tends to elderly patients, flushes out waxy ears, cares for patients after a heart attack, amputates a gangrenous leg, and is called away from a Saturday morning at a trout stream to care for a little girl who has been kicked in the head by a horse. He repairs the facial laceration, but has to tell her parents to take their daughter to Denver for surgery to remove the eye that was damaged beyond repair.

The writer of the article concluded, “His income for covering a dozen [medical] fields is less than a city doctor makes by specializing in just one, but Ceriani is compensated by the affection of his patients and neighbors, by the high place he has earned in his community and by the fact that he is his own boss. For him, this is enough.” Clearly, fair pay for comprehensive primary care is not a new issue. We see this issue threaten our field with every medical school graduating class.

But the country doctor is still alive. Dr. Ceriani’s spirit lives on in my family medicine residency and others. I am on the faculty of the John Peter Smith (JPS) Family Medicine Residency in Fort Worth, TX. We are the largest family medicine program in the country, and in spite of our location in the fourth-largest metropolitan area in the country, we have trained more rural family physicians than any other program in America.

We were one of the participants in a program called Preparing the Personal Physician for Practice (P4), which was an experiment in family medicine residency curriculum that started in 2007. We were allowed to revamp our curriculum in the way we felt best prepared young family physicians for future practice. Our curricular innovation comes in two layers:

  1. We allow residents to stay for a fourth year of training to do just about anything they want (within reason).
  2. We take their vocational passion, delivering babies, for example, and try to make the training experience as longitudinal as possible. We increase the residents’ exposure to maternity care throughout all four years of training, not just in a fourth-year fellowship. By far, our most popular extra training request has been a combination of maternity care and rural or global rotations. Sports medicine and geriatrics are also commonly sought, and we’ve had a few residents create experiences in hospital care, general surgery, and emergency medicine.

The final data are just now being collected, but preliminary results show that of the people who chose the maternity care track, 80 percent deliver babies in practice, and of those, all do their own C-sections. They average 106 deliveries per year.

And they’re not just watered down obstetricians. They do so much more than maternity care. They address numerous needs in their communities.  Ninety percent of them care for newborns and children in the hospital. All of them see elderly patients. Eighty percent feel comfortable providing end-of-life care. Eighty percent care for hospitalized adults. All of them place IUDs and perform endometrial biopsies. About a third do colonoscopies and EGDs.

Our graduates provide these services in a variety of underserved settings such as a remote jungle valley in Papua, New Guinea, the African savannah, and small towns across Texas and many other states. Because they provide comprehensive care to complex patients and they are able to provide a full basket of procedures, their local health care infrastructure is strengthened.

A great example of this phenomenon is Randy Lee, MD, a graduate from the pre-P4 days who has served his rural hometown of Hamilton, TX, for nearly 20 years. When he first arrived in Hamilton, the county hospital ER saw less than 100 patients per month, had an average daily inpatient census of less than five, and was about to close. Now Dr. Lee has seven family physician partners that have helped increase the hospital’s capacity. Besides ambulatory care, they provide hospital care, ER coverage, colonoscopies, EGDs, and other minor surgeries. The ER now sees 600 patients per month, and the daily inpatient census ranges from 15 to 30. The hospital operates in the black and community support is strong.

Although the CMS fee schedule allows Dr. Oz to make more in a two-hour surgery than family physicians make in an entire day, the spirit of altruism and service is still strong enough to carry many of our graduates to fulfilling careers in underserved populations. If primary care physicians are ever paid fairly for providing comprehensive care to complex patients, our ability at JPS to train even more young family physicians to serve vulnerable populations will grow, and so will family physicians’ visibility and accessibility.

And maybe then, enough Americans will have an accessible and trusted comprehensive generalist physician, so that the parochial opinions of Dr. Oz will forever fade from our collective memories.

Richard Young is a family physician who blogs at American Health Scare. This article originally appeared in Primary Care Progress.

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  • Paul Simmons

    Thank you, Dr Young, for saying what needs to be said repeatedly: that a well-trained comprehensive family physician can do much, do it well, do it efficiently, and is what patients want. We could save American health care, if given a chance.

    • Richard_Young_MD

      Paul,

      I wrote a reply earlier, I guess it didn’t go through. Thanks for your kind support. Do you have any pull with anyone at CMS?

      • Paul Simmons

        I wish! I don’t have any pull with my pets, much less CMS.

  • Patient Kit

    I admittedly live in NYC, which can be quite expansive since I routinely meet people here from all over the world and from all over the country from many different backgrounds. When it comes to medicine though, I think we live in a bit of a bubble in NYC because we have so many docs, hospitals and options.. One of the great things about KMD is that it really puts me in better touch with how our healthcare system is experienced outside of places like NYC, in small towns and rural areas. We have our share of underserved people here too but, if you are poor enough, there are good medical options here. It’s very difficult in NYC though to be not quite poor enough to be eligible for help and many people live in that zone. We don’t all live in Dr Oz’s world.

    That said, it is really hard for me to imagine any of my primary care docs doing c-sections, colonoscopies, sports medicine, etc for me. I’m not at all sure that I want one doctor who does almost everything. I really adore some of my specialists, some of who are kind, accessible and straight-talking and really really good at what they do. I really don’t want my primary care doc to even be my GYN, let alone be my surgeon.

    • Richard_Young_MD

      Patient Kit,

      Thanks for your honest reflections.

      Let me challenge you to think even farther away from NYC. In countries such as England, Sweden, Canada, Australia, etc., their people wouldn’t think of going anywhere but to see their GP for most of their ailments and concerns. There are no pediatricians who provide routine child care, no internists to provide outpatient care, and no OB/GYNs to provide care for most women’s heath concerns (I’m speaking of the 90+% of the time, not a few percent exceptions in each country).

      In Australia, the rural family docs have broken themselves out as a separate specialty. In the U.S., there are a handful of family medicine residencies that have distinguished themselves as providing outstanding training for their graduates to provide all the services you listed. It takes either more intense training, or longer, or a combination of both to create these full-service comprehensive family physicians.

      But the narrow-mindedness of Medicare, Medicaid, and the insurance companies does not pay these outstanding physicians for the breadth of services they provide. If you want to be involved in improving America’s health, than picking up the sword to help us fight to reverse the primary care payment bigotry built into the system would be very helpful.

      One final thought. If you want better health at a lower cost for you and all Americans, then you absolutely want your family physician to be your “GYN”. He or she will be able to exercise common-sense judgment reflected in a patient-care culture that is different from the doctors who only worry about one body part. Care in these family physicians’ hands becomes less invasive and more a process of negotiation between your desires and the realities of your medical situation.

      A better healthcare system is possible. It just takes imagining a world that doesn’t exist in NYC.

      • Patient Kit

        First, Dr Young, I do value and respect good primary care doctors and think they should be paid more fairly for what they do. Personally, I do not value procedures over critical thinking and a good doctor-patient relationship.

        That said, I don’t want my “generalist” doc to do almost everything for me. To me, it sounds like there are a lot of turf battles going on in the US healthcare system between primary care docs and specialists and between doctors and NPs and PAs. And, unless I’m misunderstanding you, it sounds like you’re advocating for primary care docs to take back some of the procedures that specialists now do.

        I think moving away from specialists will be a hard sell to patients. We’ve had it drummed into us that outcomes are better when procedures are done at hospitals and by doctors who do a lot of that kind of procedure — not by doctors who do a little of everything.

        My GYN is not only not a primary care doc but he is a GYN oncologist (ovarian cancer survivor here). I would not have wanted a primary care doc or even a regular OB/GYN to do my surgery. My subspecialist is not only very good at what he does in the OR, he talks to me and treats me like a whole person. I have a better doc-patient relationship with him than I’ve had with any primary care doc.

        Are you, at heart, advocating for fewer specialists in our system? I’m all for better primary care and better treatment of primary care docs, but not if that means eliminating specialists for most patients.

        Re healthcare systems in the other countries you mentioned, are you saying that specialists have a much smaller role in those countries? I was not aware of that but will have to do some research and reading about that.

        It’s always a pleasure discussing these complex healthcare system issues with doctors here on KMD. I’ve learned much from the good conversations her and certainly do not pretend to have all the answers.

        BTW, I can get my head outside of my beloved NYC. I wish I was in my beloved Mexico right now. ;-). I have lived in NYC forever and get all my healthcare here so I just wanted to acknowledge the bubble that living in a place with so many medical options can be. But I do know that there is life outside of NYC. ;-). I’m not even Manhattan centric. Brooklyn girl here.

        • Dr. Drake Ramoray

          Generally speaking their are fewer specialists in other countries than in the United States. Also typically the pay gap is significantly smaller between primary care docs and specialists. Lastly, most countries don’t use nurse practitioners or PAs (at least in the endocrine world) although in OB there is a lot more midwife care etc.

          As for primary care docs doing more. I believe the universal answer is yes. I can say it is for Canada, Australia, New Zealand, and the UK. I have looked into international work (actual employment/expatriate not medicine without borders type volunteer gigs) from time to time and for Aus and NZ in particular one of the limiting factors for me was the requirement to provide primary care as there was not a perceived need for solely Endocrine services.

          • Patient Kit

            I’m definitely in favor of dealing with the widening pay gap between primary care docs and specialists in the US. Not only would it value primary care properly but maybe it would help get PCPs and specialists on the same side and focused on the real enemy.

            Interesting that there are fewer specialists in other countries’ systems. Not sure how I feel about that. I do love my specialists. At any rate, currently in the US, we have a lot of primary care docs who have not been doing a lot of those procedures. So, even if we moved in that direction, that change would take time.

          • Richard_Young_MD

            Patient Kit,

            Your comments demonstrate exactly why recent attempts at fixing our healthcare system, such as Accountable Care Organizations, Patient-Centered Medical Homes, etc., are doomed to fail. None of them demand that American patients change their attitudes about what a healthcare system should look like or how it should be used. The American people have been scared into believing that the best care is given by multiple trips to multiple body part doctors, which is an extraordinarily expensive fallacy.

            If you don’t mind what you’re paying for healthcare, and you feel you can afford yearly insurance inflation greater than general inflation don’t change a thing. If you want healthcare to become more humane and affordable, you and most other Americans need to spend some mental and emotional energy imagining a better healthcare world founded on family physicians.

          • Patient Kit

            Dr Young,

            I can hear your frustration in your response to me that I’m not instantly embracing what you’re saying as the answer to all our healthcare system problems.

            As someone who was diagnosed with ovarian cancer while I was uninsured (for the first time after decades of being well insured), I can assure you that I know what fear of not being able to access much-needed healthcare feels like and I do care very much about reforming our system so that healthcare is affordable and accessible to all. If you care about that too and truly believe that more comprehensive family med docs is the way, you will be open to hearing and understanding the resistance so that our issues can be addressed. If you want to change things radically, it helps to sincerely understand what you are up against.

            The fact is that, for decades, many of U’s have never experienced anything close to what you’re describing from our primary care docs. So, it’s kind of hard to imagine that kind of comprehensive care coming from the PCPs we have been seeing. I can see training more for the future but that will take time. And right now, I don’t see the existing primary care docs being able to be my oncologist or my orthopedist.

            Before I was diagnosed with cancer and experienced serious injury (ruptured Achilles tendon), I wasn’t one to run to my PCP for every little thing. I’m much more inclined to run to the local YMCA, where I workout 5x a week (an important part of my healthcare plan). Most minor things, I can treat myself. I just had a bad sore throat. I blame the walk-in refrigerators on wheels that we call buses in NYC. But my sore throat resolved itself in 24 hours. I could feel my immune system kick in and fight. All I had to do was soothe it and wait. No antibiotic or PCP necessary.

            If you truly think that more comprehensive family medicine is the big answer, then I would ask you to think about how to explain how we get there to resisters like me, who have never experienced what you describe. How many existing PCPs in the US do you think are currently capable of providing the kind of care you describe? Certainly not many of the older PCPs who haven’t done these things for decades. And, not the current primary care residents at the teaching hospital where I currently receive care, who refer to specialists like crazy. Also, I imagine you should expect some pushback on your vision from the specialists you would replace.

            I can see what you envision but not how you plan to get there.

  • EmilyAnon

    Now that I think back, when my brothers and I were growing up in L.A. we had only one doctor. He delivered the babies, set broken bones, took out tonsils among other things like dealing with fevers, rashes and the like. There were no yearly check-ups or blood draws if you showed no symptoms. He wore many hats, pediatrician, obstetrics, orthopedist, hand holder, etc. I don’t remember any bad endings. And there was no insurance back then, you paid cash. But somehow my blue collar parents could afford it.

    For comparison I checked back 2 years to see how many doctors I visited. The list: gyn-oncologist. med-oncologist, PCP, gyn, breast specialist, derm, geneticist, general surgeon, ophthalmologist, ENT, gastro. Except for the surgeons and oncologists, the other specialists were for screening only. I’m sure I’m one of those patients adding to the healthcare crisis. but once you are diagnosed with cancer, you fear it lurking in every other body part and want to seek out assurances from the specialists. Maybe having insurance helps facilitate this over indulgance.

    • Richard_Young_MD

      EmilyAnon,

      I appreciate your honest reflections. Never having had cancer myself, I certainly can’t say I know what if feels like (though I’ve cared for many patients with cancer).

      While it’s more than understandable how anyone in your shoes would be concerned about feelings and symptoms that arise after your original cancer diagnosis, I submit to you that if you had a well-supported family physician who you trusted, you could discuss your concerns and fears with him/her and save yourself 10 trips a year. You just have to imagine a healthcare delivery world different from the dysfunctional system you’ve grown up in.

  • leslie fay

    Yes, I’m old but I remember fondly having just one family practitioner for everything. It was simple, handy and you didn’t have to explain what another doctor had done. I had that type of doctor up until my employer’s insurance required I do otherwise. One of my favorite memories was a female physician that lived upstairs with her office on the first floor. One time she saw me dressed in her housecoat!

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