by Pepi Granat, MD
Yesterday, and every day, in my office we had one or two patients we call our “Oldie Goldies”.
People who have been with us since 1971 when I opened my practice, 39 years ago. People whose progress, medical and personal, I’ve shared, and who share mine. We know their parents, kids and cousins either because they call us in crisis, or they’re our ongoing patients. And every day we see at least one, and sometimes more new patients, usually sent by friends, who say at the end of the visit: “I’m so glad I found you, I’m so sick of seeing specialists who don’t really know or care about all these details and don’t pull it all together.”
Every day in my office I do some procedure which others might refer: punch biopsy, flexible sigmoidoscopy, ear lavage, endometrial biopsy, breast cyst aspiration etc. Specialists do them with equal, not better skill. But my patient is served better (and cheaper) by me, because I also address other problems often in many organ systems, without restricting myself to the “code” of the visit’s description.
Generalism in medicine is especially valuable now, with burgeoning and confusing information abounding on the Internet. Especially now, when the “baby-boomer generation” is coming of age. Its women are entering menopause; its men are facing prostate risks. These savvy people want preemptive comprehensive knowledge and management from their physicians when well. They want judgment and careful diagnosis and choice of specialists when sick. No one but the family doctor sees that as his/her role. The gynecologists are not that interested in heart disease, hypertension and diabetes and are not up on the drugs, except in their field. The general internists often don’t do procedures and few want to get into gynecology, and the urologists have no interest in anything but plumbing, though they’re very good at it.
Family doctors obsolete? Not on your life. Public wants specialists? You bet. So do we. When we/they need them. Not before. The specialists are becoming increasingly narrow in their scope and abilities. The patients know this. It is proper and understandable as special procedures advance. An important position we could take is to advocate against enabling specialists to capitalize on their exalted positions, with our aiding and abetting, by hiring “physician extenders” whose scope of practice exceeds the specialists’ abilities to “supervise” them. I am referring to the vascular surgeon who hires a nurse practitioner to “cover” all the medical problems for his patients which he himself not only hasn’t kept up with, but never knew in the first place (drugs for hypertension, diabetes, etc.). Or the cardiac surgeon who hires a PA , allowing him to round on his patients, expecting him, for example, to pick up things like confusion resulting from overdose of lidocaine combined with hyponatremia, causing a patient to pull out a femoral line, which is beyond his expertise.
Unfortunately, it may be other physicians and large groups who, for their own agendas, attempt to devalue the family doctor. Unless we oblige them and become triage officers, losing our knowledge and action edge, we do not have to comply with their judgments. Some of us feel depressed when devalued by others and are made to feel unneeded. Others of us know our own value, and are proud of it. Our patients know it for sure, as long as we deliver that value in their service, which is our job.
This debate is very akin and pertinent to the one on hospitalists. It comes at a time when studies are cited charging multiple medication errors in hospitals. This is a time when countless pressures conspire to abolish careful and caring medicine. No matter which specialist admits a seriously ill or traumatized patient, or even a routine surgical patient, often there will be multisystem disease, much of it outside the specialist’s field. Then either another specialist is called, who himself does not see his role as overseer of the whole patient, or nursing staff is depended upon to know and obtain a comprehensive view of the patient. Nurses are wonderful, but change every 8 hours. They can alert to ominous signs but are not trained to spot early emerging pathology based on vast knowledge of disease processes.
Rather than removing the family doctor from the hospital or claiming his obsolescence, he/she should be utilized as the generalist needed to fill the bill, involving one in every hospital and ICU case. Perhaps calling one in as consultant, if the patient did not have a family doctor before, but not attempting to displace him/her by someone who trains and stays only in hospital.
Nurses, even well-trained “extenders”, are not physicians; specialists are not generalists. Two true statements which, when understood with their full implications, bolster the role of the family doctor, both in office and hospital.
Often I describe to patients the family doctor’s role as the hub of a wheel, the spokes of which lead to specialists when needed, returning to the hub for ongoing care. If the family doctor were ever to be unwisely edged out of patient care, that would be one wheel that would need reinvention.
Pepi Granat is a family physician.
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