It’s been thirty years since Dr. Pete shook my hand on graduation day and slapped my back, his gravelly voice mumbling a wisecrack that couldn’t quite hide his emotions. I was the first foreign medical school graduate in our small residency program and he had trusted me, just as I had trusted him, through three years of hard work and many challenges.
Our residency program was only a few years old, and my specialty was only twelve when I started. Family practice had begun with the realization in the 1950s that fewer and fewer medical school graduates chose to enter general practice after their internship year, but instead went on to specialize. With the knowledge explosion of the twentieth century, the need for well-trained generalists gained acceptance and the void left by retiring GPs was filled by the graduates of three-year family practice residencies focusing on 1) first-contact care; 2) continuous care; 3) comprehensive care; 4) personal care (Caritas); 5) family care; and, 6) competency in scientific general medicine.
Medicine has changed a lot, and America is not the same as when I first came here. Primary care is more complex, with more demands from forces outside the physician-patient-family constellation we thought and talked so much about thirty years ago.
In the early 1980s CT scanning had just been introduced, but there were no MRIs in our state yet. We didn’t have EMRs, there were no prior authorizations, no direct-to-consumer drug advertising; we didn’t even have the Internet.
What we did have when I started out was a generation of young doctors with a shared passion for clinical, albeit low-tech medicine, and for taking care of patients and families in their small communities.
My generation had sit-ins over minor injustices in high school. We wore bell bottoms and sang songs about love, peace, and justice. We wanted to make the world a better place. Those of us who wanted to become doctors watched Marcus Welby, MD — I did, as an exchange student, on a large console TV in my Massachusetts host family’s suburban living room. My determination from a year of illness in early childhood to become a doctor gelled right then, in 1971, into a vision of what I have been fortunate to actually be doing for the last thirty years.
I have better tools now than Marcus Welby had, and the technical standard of care has made huge leaps since my residency days. But something has gone missing. The idealism and passion of physicians have become worn and frayed as a result of the paradigm shift toward the manufacturing view of health care. Health care is now becoming impersonal. It is organized, delivered and measured like industrial output in automobile plants. It is mass produced and valued by its consistency and conformity, even though no two patients are exactly alike.
Most of our patients still come to us looking for personalized care, but they feel the pinch of our newly imposed agendas in their fifteen minutes with us. We are more and more put in the role of public health officials, collecting data for government and insurance companies and promoting their population-based agendas.
But when we really engage with our patients we can see the power of the traditional doctor-patient relationship that many others in health care have tried to negate.
The passion and commitment of doctors have been devalued as we are instead building entire systems to do what Marcus Welby and his nurse did, day in and day out, when they practiced their professions and held themselves to their standards and ideals.
But no system can replace human effort and commitment. Doctors, nurses and everybody else in health care need to be at the center, side by side and face to face with their patients and the “system” needs to capture, rekindle and support their passion, not suppress and replace it.
Family physicians were trained to be capable in areas where our ability to keep up is now challenged, just like the general practitioners’ sixty years ago. Fewer and fewer primary care doctors now set fractures, deliver babies or perform even minor surgeries and procedures.
Increasingly, we are instead taking on the role that the journal Canadian Family Physician calls “broker of choices.” With the Internet and all the media exposure about medical issues, we are no longer patients’ primary source of medical information, but we are the ones that are best suited to help them sort out information and compare alternatives.
This actually builds on our specialty’s founding principles. We are still the glue that holds the parts together, even when other specialties are involved. We provide the first contact, the continuity, the personal focus and the family view of the patient and their support system; it requires our solid competency in general scientific medicine; and it is comprehensive in the ancient meaning of the word as it derives from “comprehendere” — to grasp mentally — we help our patients with the big picture while we attend to their everyday medical needs.
“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.